Brookhaven Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for contaminated sharps disposal bins, attached to one (300 Hall MA Medication Cart) of one 300 Hall MA Medication Cart and one (300 Hall Nurse Medication Cart) of one 300 Hall Nurse Medication Cart reviewed for hazards. <BR/>MA B failed to ensure contaminated sharps in the sharps bin attached to the 300 Hall MA Medication Cart, were below the full line. <BR/>MA B failed to ensure medications found on the sharps bin insert lid on the 300 Hall MA Medication Cart, were disposed of properly. <BR/>RN C failed to ensure contaminated sharps in the sharps bin attached to the 300 Hall Nurse Medication Cart, were below the full line. <BR/>These failures placed residents at risk of being exposed to contaminated sharps, possible bloodborne pathogens, and access to unprescribed medications. <BR/>Findings included:<BR/>An observation on 01/30/2024 at 10:07 AM, revealed the plastic insert contained inside the sharps bin attached to MA B's 300 Hall MA Medication Cart was past the full line. Sharps (needles, blades [such as scalpels] and other medical instruments that are necessary for carrying out healthcare work and could cause an injury by cutting or pricking the skin) in the insert blocked the insert's lid from closing completely. Eight pills were observed, stuck between the plastic insert and the insert's lid which contributed to the lid from closing properly. <BR/>In an interview on 01/30/2024 at 10:08 AM, MA B stated she was not aware the sharps in the bin were past the full line because she did not use it. She said the lid on the sharps bin insert should be free to close to ensure staff and resident safety. She said she did not see the medications on the lid of the sharps insert but could see they were preventing the lid from closing completely. She said all staff were responsible to ensure the sharps bin inserts were not filled past the full line however only the nurses had keys to the sharps bins attached to the carts. She said medications should not be disposed of in the sharps bin. She said the full bin and medications posed a hazard for residents and staff. <BR/>In an interview on 01/30/2024 at 10:20 AM, ADON A said the sharps bins should never be filled past the fill line to prevent possible injury to staff or residents. When asked about the medications stuck on the lid of the sharps bin insert, he said medications should not be disposed of in the sharps bin and did not know why the medications were on the sharps bin lid. He stated the medications appeared to be blocking the lid from closing properly. He stated the nurses had keys to the bins and were responsible to ensure the bins were not filled past the full line. He said the medications could be accessible to residents and posed a potential hazard as residents. He said he would find the keys to MA B's cart and change the sharps bin and remove the medications from the lid. <BR/>An observation on 01/30/2024 at 10:30 AM, revealed the plastic insert in the sharps bin, attached to RN C's 300 Hall Nurse Medication Cart to be past the full line. She said it should not be past the full line because the lid would not close properly which posed a potential hazard. She said the nurses had keys to the sharps bins and should ensure the inserts were not filled past the full line. <BR/>In an interview on 01/30/2024 at 1:50 PM, the Administrator said the sharps bin inserts should never be filled past the full line because it posed a potential risk of harm to staff and residents. She said they could be stuck by a needle if the lid did not close properly. She said she expected nursing staff to ensure this was done and nursing management to monitor it. She said medications should not be disposed of in the sharps bins and should not be on the lid of the bins where residents could have access to them. She said many of the residents in the facility tend to wander and could have consumed the medications. <BR/>In an interview on 01/30/2024 at 3:31 PM, the DON said the sharps bins should never be filled past the full line. He said the lid does not close properly when sharps are above the full line which could cause a risk of staff or residents getting stuck with a needle. He said a staff member was recently stuck in this manner and in servicing was conducted. He said medications should be disposed of properly and not placed in the sharps bin. He said he changed out MA B's sharps insert and disposed of the pills that were on the lid. He said he did not feel the medications were accessible because they were in a groove at the back of the insert lid. He said none-the-less the medications should not be there and since the insert lid could not close properly, there was a potential hazard to residents if they were able to get the medications. He said staff are trained on how to dispose of medication properly. <BR/>Record review of the facility's undated policy titled, Safety and Supervision of Residents, reflected, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation - Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. 3. When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. 5. The QAPI Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 2 (Resident # 15 and #20) of 3 residents reviewed for pharmacy services.<BR/>MA B failed to administer medications timely as ordered by physician to Resident # 20<BR/>LVN D failed to administer medications timely as ordered by physician to Resident # 15<BR/>The deficient practice could place residents at risk of not receiving the therapeutic effects from their medications as intended by the prescribing physician order.<BR/>The findings included:<BR/>Record review of Resident #15's face sheet dated 01/30/24 revealed an [AGE] years old female, admitted to the facility on [DATE] with diagnoses that included hypertension (blood pressure that is higher than normal), hypothyroidism (happens when the thyroid gland doesn't make enough thyroid hormone) and malignant neoplasm of unspecified site of right female breast (breast cancer) <BR/>Record review of Resident #15's physician order summary dated 01/30/24 reflected metoprolol succinate ER oral tablet extended release 24-hour 25 mg (metoprolol succinate) give 50 mg via g-tube two times a day for hypertension. <BR/>Record review of Resident #15's medication administration record dated 01/30/24 reflected Metoprolol ER 50 mg 1 tablet scheduled at 9 am. <BR/>Observation on 01/30/24 at 11:25 a.m., revealed LVN D administered Resident #15the following medications: Ferrous sulfate 5 cc, Magnesium 400 mg 1 tablet, Potassium chloride 15 cc, Vitamin B-12 1000 mcg 1 tablet and Metoprolol ER 50 mg 1 tablet <BR/>Record review of Resident #20's face sheet dated 01/30/24 revealed a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses that included insomnia, constipation, gastro-esophageal reflux disease without esophagitis, angina pectoris, vitamin d deficiency, major depressive disorder, Parkinson's disease, and type 1 diabetes mellitus.<BR/>Record review of resident's #20's physician orders summary dated 01/30/24 reflected, Keppra tablet 500 mg (levetiracetam) give 1 tablet by mouth two times a day for seizures, methocarbamol oral tablet 750 mg (methocarbamol) give 1 tablet by mouth three times a day for muscle spasms and pain, Norco oral tablet 7.5-325 mg (hydrocodone-acetaminophen) give 1 tablet by mouth two times a day for pain, Topamax oral tablet 25 mg (topiramate) give 1 tablet by mouth two times a day for migraines, trospium chloride tablet 20 mg give 1 tablet by mouth two times a day for incontinence/frequency/urgency, <BR/>Record review of Resident #20's medication administration record dated 01/30/24 reflected Hydrocodone 7.5 - 325 mg 1 tablet was scheduled at 9 am and 9 pm, methocarbamol 750 mg 1 tablet scheduled at 9am, 2 pm and 9 am, Topiramate 25 mg 1 tablet scheduled at 9 am and 9 pm, levetiracetam 500 mg 1 tablet scheduled at 9 am and 9 pm, trospium chloride 20 mg 1 tablet scheduled at 9 am and 9 pm. <BR/>Observation on 01/30/24 at 11:54 a.m., revealed MA B administered the following medications to Resident #20, Hydrocodone 7.5 - 325 mg 1 tablet, methocarbamol 750 mg 1 tablet, Topiramate 25 mg 1 tablet, levetiracetam 500 mg 1 tablet, trospium chloride 20 mg 1 tablet, <BR/>Interview on 01/30/24 at 11:58 a.m., MA B revealed she still had about three more resident to administer medications that were scheduled to be administered in the morning. MA B stated she was late to administer medications because she was assigned more resident because another medication aide called off. MA B stated she was supposed to administer the medications per orders and within the one-hour window which was one hour before and one hour after the scheduled time. MA B stated medications were supposed to be administered timely because other medications that were scheduled more than once a day could be administered too close to each to other which could have a negative effect on the resident. <BR/>Interview with LVN D on 01/30/24 at 1:40 p.m., revealed she was a charge nurse and she mainly worked on the night shift, and she had been requested to assist on the 6-2 shift. She acknowledged administering medication to Resident # 15 late. LVN D stated the resident's assignment had changed after one of the staff members called off. LVN D stated the resident's medications was to be administered timely within the one-hour window to prevent any negative effects if the medications were scheduled more than one time per day which could be administered to close to each other. <BR/>Interview with the DON on 01/30/24 at 3:50 p.m., he stated the charge nurse and medication aide were to administer medication per the orders and per the scheduled time. The DON stated the staff were late because one of the medication aide had called off leaving one medication aide to administer the medications. The DON stated the medications were not supposed to be administered late because some of the medications that were scheduled more than once a day could be administered too close to each other which could lead to a negative effect and at times not being effective if they were pain medications. The DON stated the staff had been in-serviced on medication administration. <BR/>Record review of the facility policy undated titled Administering oral medications, Purpose. The purpose of this procidure is to provide guidelines for the safe administartions of oral medications. The policy did fcnot indicate the times the mediactions were to be administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay that included diagnoses, course of treatment, pertinent labs, a final summary of the resident's status and reconciliation of all pre-discharge medications with the resident's post-discharge medications for 1 of 5 residents (Resident #1) reviewed for closed records.The facility failed to ensure Resident #1 was discharged from the facility with a discharge summary that included an accurate and current description of the clinical status of the resident.The facility failed to provide the required notice to the Office of the long-term Care Ombudsman regarding the discharge of Resident#1.This failure could place residents at risk for not receiving appropriate and timely care due to confusion among various facilities, agencies, practitioners, and caregivers involved with the resident's care.Findings Included: Record review of Resident #1's MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE]. Diagnoses included: Schizophrenia (a chronic mental health condition characterized by a combination of cognitive symptoms that significantly impair a person's daily functioning), anemia (a condition in which there is an abnormally low number of red blood cells (RBCs) or hemoglobin in the blood), hypertension (a condition in which the force of blood against the artery walls is consistently too high). Further review of the Resident #1's MDS, dated [DATE], revealed there was no documented BIMS score. Resident #1's MDS section E0200. Behavioral Symptom - Presence and Frequency reflected Resident#1 had Physical behavioral symptoms directed toward others (this behavior occurred once), Verbal behavioral symptoms directed toward others (this behavior occurred 4-6 times but less than daily). Record review of Resident #1's DISCHARGE - Recapitulation of Stay reflected one dated 10/02/2025 discharge to [hospital name 2]. There was no documented Discharge - Recapitulation of Stay for 10/03/2025 when Resident one went to the hospital. Record review of Resident #1's Physician orders dated 10/03/2025 revealed the following: Send to hospital for further evaluation and treatment. Interview with Ombudsman on 11/04/2025 at 10:09 AM revealed on 10/3/2025 the facility contacted her to get a list of suitable facilities for Resident#1's alternative placement. She stated SW B told her Resident#1 was going for treatment but did not specify the facility. She stated in immediate discharges the facility must provide clinical discharge summary of the residents to the receiving facility, and the notice of discharge to the Ombudsman manager which was not done. Attempted interview with FM 2 on 11/04/2025 at 1:43 PM was unsuccessful. A voicemail was left with a call back number. Attempted interview with FM1 on 11/04/2025 at 1:45 PM was unsuccessful. The surveyor left a voicemail with a call back number. Interview with LVN A on 11/04/2025 at 4:30PM revealed she was the nurse when Resident#1 was transferred to. She stated that she was not aware if he signed a discharge notice. Interview with SW B on 11/04/2025 at 4.45pm revealed that she did not send clinical documents or complete discharge summary because the former Administrator and the DON oversaw the transfer. Interview with SW C on 11/04/2025 at 2:10PM revealed she was the geriatric social worker at behavioral hospital. She stated the hospital was an acute stay behavioral hospital that stabilized behavior then discharged patients and it was not for long-term placement. She stated that Resident#1 was transferred to the hospital to evaluate and establish a medication regimen that would regulate his behavior and there was no clinical discharge summary provided. Interview with the DON on 11/04/2025 at 3:55pm revealed that she had been employed for a month. When asked if there was a clinical discharge summary or documentation dated 10/03/2025 the DON stated she could not find any documentation. She stated that the last week of October 2025 there was an email that SW C had gotten everything that she needed to find Resident#1 a new facility. She stated it was necessary to provide clinical discharge summary to the receiving hospital for continuum of care. Interview with LVN A on 11/04/2025 at 4:30PM revealed she was the nurse when Resident#1 was transferred to. She stated that she was not aware if he signed a discharge notice. She stated that she did not complete a discharge summary or the E-interact (a set of dashboard checklists, and automatic triggers designed to work together to assist care teams to reduce acute care transfers) because it was a busy day. She stated that failure to provide discharge summary to the admitting facility could result in the residents not receiving the care they deserve. Interview with MD on 11/04/2025 at 4.40pm revealed he called the ER and gave report to the ER Doctor and spoke with case management staff and notified them the resident would not be returning to the facility. He stated whenever a Resident transferred to the ER from the nursing home, the facility called and gave report to the receiving hospital. He stated that he did not make a discharge summary, because his duty was to call the hospital and give reports of what was going on with the residents. He stated that the nurse was responsible for the discharge summary. Interview with SW B on 11/04/2025 at 4.45pm revealed that she did not send clinical documents or complete discharge summary because the former Administrator and the DON oversaw the transfer. She stated it was important to provide the admitting facility with proper documentation such as clinical discharge summary so the residents can be cared for appropriately. Interview with Administrator on 11/04/2025 at 4:56PM revealed he was newly hired, and he was not part of the discharge and that he could not speak on how it was overseen. He stated even in an immediate transfer there is procedure and protocol to ensure the receiving facility had enough information to care for the resident. He stated that his expectation was there would be a time and record of when the resident signed and accepted the discharge notice. Record review of the facility's Transfer or Discharge, Emergency policy, latest revision dated 08/2018, stated the following: If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented.Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures:a. Notify the resident's Attending Physician.b. Notify the receiving facility that the transfer is being made.c. Prepare the resident for transfer.d. Prepare a transfer form to send with the resident.e. Notify the representative (sponsor) or other family members.f. Assist in obtaining transportation; andg. Others as appropriate or as necessary.5. Should it become necessary to transfer residents during emergency or disaster situations, transfer procedures outlined in our disaster plan will be implemented.6. The resident's medical record must be forwarded to the Medical Records office within twenty-four (24) hours of the transfer or discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from neglect for 1 (Resident #1) of 9 residents reviewed for neglect. 1. The facility failed to ensure Resident #1 was not neglected when she fell from her bed and remained on the floor beside her bed for approximately 4 hours on 07/30/25. 2. The facility failed to ensure RN A and CNA B did Routine Resident Checks every 2 hours on Resident #1 during their shift on 07/30/25. The non-compliance was identified as past non-compliance. The facility corrected the non-compliance before surveyor's entrance. These failures could place residents at risk for humiliation, fear, shame, agitation, decreased quality of life and possibly death. Findings included:Record review of Resident #1's admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included: hypokalemia (condition where the potassium levels in the blood are lower than normal), cerebral infarction (occurs when blood flow to the brain is interrupted, leading to brain tissue damage), depression, hypertension (high blood pressure), gastro-esophageal reflux disease (GERD) without esophagitis (a condition where stomach acid flows back into the esophagus without causing inflammation or damage to the esophageal lining), constipation, osteoarthritis in the right knee (joint disease that causes pain, stiffness, and swelling in the joints), and age-related osteoporosis without current pathological fracture (a condition that weakens bones, making them more prone to fractures), and dementia. Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected she had severe cognitive impairment with a BIMS score of 2. Resident #1 used a wheelchair and walking cane for assistance with mobility and was independent and did not require any assistance with rolling left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer, or toilet transfer. Resident #1 needed assistance with setup or clean-up with tub/shower transfer, walking 10 feet, walking 50 feet with two turns, and walking 150 feet. Resident #1 did not have any falls prior to being admitted to the facility. Record review of Resident #1's Care Plan reflected the following entries:An entry dated 06/29/2025 and revised on 08/26/2025 reflected: Focus: [Resident #1] was at risk for falls related to impaired balance/gait, weakness and use of psychotropic medications.Goal: [Resident #1 will have decreased risk for serious injury or hospitalization as a result of falling through the next assessment review period. Date Initiated: 08/29/2025, Revision on: 08/17/2025, Target Date: 07/30/2025 .Interventions: Discuss/review fall(s) at morning meetings, IDT/QA meetings, and as indicated.Date Initiated: 06/29/2025 Encourage locking of brakes on Wheelchair.Date Initiated: 06/29/2025 Encourage resident to voice needs as well as to seek/await staff assist with transfers.Date Initiated: 06/29/2025 Encourage use of self-help devices as indicated.Date Initiated: 06/29/2025 Ensure glasses are clean, in good repair and worn appropriately.Date Initiated: 06/29/2025 Ensure resident wears appropriate, well-fitting footwear to minimize the risk ofSlipping.Date Initiated: 06/29/2025 Fall risk quarterly and prn per facility policy.Date Initiated: 06/29/2025 Keep call light within reach.Date Initiated: 06/29/2025 Keep environment clear of unnecessary objects. Keep bed locked and in lowest position unless otherwise ordered/indicated.Date Initiated: 06/29/2025 Nursing staff will monitor for side effects/adverse reactions to medications.Date Initiated: 06/29/2025 Refer to therapies and/or restorative, as indicated.Date Initiated: 06/29/2025 Safety training, retraining and education as needed.Date Initiated: 06/29/2025 An entry dated 08/26/2025 reflected: Focus: [Resident #1] was at risk for skin breakdown due to decreased mobility.Goal: [Resident #1] will have no skin breakdown in the next 90 days. Date Initiated: 08/26/2025 and Target Date: 07/30/2025. There were no Interventions in place. Record review of Resident #1's Skin Assessment for 07/30/25 at 5:00 AM due to an un-witnessed fall revealed, that Resident #1 had a small scrape on her upper right arm and denied pain. Record review of Resident #1's Neurological Check on 07/30/25 at 6:14 AM, revealed that she was complaining of vomiting and diarrhea. [Resident #1] denied any pain or discomfort or emotional distress. Record review of Resident #1's X-rays on 07/31/25 revealed that impressions were taken of the skull, hips, and chest and the findings revealed that there was no evidence of any fractures present in all areas. Record review of the facility's Admissions List for 02/01/25 to 08/26/25 revealed that Resident #1 was admitted to the facility from an acute care hospital on [DATE]. Record review of the facility's Incident Logs for 02/26/25 to 08/26/25 revealed on 07/30/25 at 5:00 PM, Resident #1 had an unwitnessed fall. Record review of the facility's In-service Training Log reflected that the staff's previous training on Resident Rights was conducted by Administrator on 07/23/25. The In-Service Training Logs reflected the staff were trained on the facility's policies and procedures on Resident Rights. The In-Service Training Attendance Roster reflected that the trainings were attended by all staff except RN A and CNA B. Record review of the facility's Staff Schedule for 07/29/25, revealed that RN A and CNA B were assigned to the evening shift on the 200 Hall where Resident #1 resided. Record review of the facility's In-service Training Log dated 07/30/25, reflected that the trainings were conducted by Administrator. The In-Service Training Logs reflected the staff were trained on the facility's policies and procedures on Abuse/Neglect, Resident Rights, Routine Round Checks, Call Lights, and Fall Preventions. The In-Service Training Attendance Roster reflected that the trainings were attended by all staff except RN A and CNA B. Record review of the employee files for RN A and CNA B revealed on 07/30/25 both staff members were suspended pending the facility's investigation of Resident #1's fall during the evening shift on 07/29/2025. Both staff members were terminated on 07/30/25 due to policy/procedure violation, prohibited conduct, safety violations, and unsatisfactory job performance which led to Resident #1's unwitnessed fall on 07/30/25. Both employee files did not reveal any other infractions or disciplinaries regarding resident neglect. Record review revealed on 07/30/25, the facility conducted Safe Surveys with the residents in the facility, and all stated that their needs were being met at the facility and did not have any concerns regarding abuse and neglect. Record review of the facility's Provider Investigation Report dated 08/06/25 revealed, RN A was the Charge Nurse on duty and CNA B was also on duty assigned to the 200 and 300 halls during the evening shift on 07/30/25, which was from 6 PM to 6 AM. On 07/30/25 at approximately 4:30 AM, [Resident #1] was observed by FM to have fallen and remained on the floor or an extended period of time. FM voiced concerns regarding the night shift doing routine checks during their shifts. [Resident #1] had a head-to-toe assessment which revealed a skin tear to her upper right arm. RN A and CNA B were immediately suspended and later terminated due to not following the facility's Routine Round Check Policy. The finding of Founded due to the neglect of RN A and CNA B. In a telephone interview with RN A on 08/26/25 at 4:25 PM revealed, that she was employed at the facility for 2 years as of 07/30/25. RN A stated that she worked the 6P-6A shift on 07/30/25. RN A stated that CNA B worked the 6P-6A shift on 07/30/25. RN A stated that herself and CNA B were assigned 2 hallways on 07/30/25. She stated at the beginning of her shift, she would do her rounds and check on residents to see how they were doing. RN A stated that Resident #1 was independent but needed some assistance with her ADL's due to her having some muscle weakness. RN A stated that Resident #1 appeared to be fine and did not appear to be in any distress or discomfort when she checked on her at the beginning of her shift. RN A stated that Resident #1 did not like to be awakened during the night and preferred to keep her door ajar or closed. RN A stated that if Resident #1's door was opened throughout the night, she would become disturbed in her sleep. RN A stated that during her shift on 07/30/25, Resident #1 had nausea and was vomiting due to her having some health issues. RN A stated that she did not Check-In with Resident #1 during her shift because she became busy with tasks such as assisting other residents and passing medications to residents. RN A stated that she was doing her rounds around 4:30 AM on 07/30/25, she heard some noise and observed Resident #1 on the floor beside her bed. She stated that Resident #1 stated that she had fallen on the floor after self-ambulating herself to the bathroom. RN A stated that Resident #1 did not know how long she remained on the floor after her fall. RN A stated that Resident #1 had a camera in her room that recorded the resident's fall on 07/30/25. RN A stated that after she observed Resident #1 on the floor, she contacted CNA B and told her that Resident #1 had fallen out of the bed and they picked up Resident #1 and placed her on her bed. RN A stated that Resident #1 complained of dizziness after the fall, and she was given a head-to-toe assessment. Resident #1's head-to-toe assessment revealed a small tear on Resident #1's right elbow. RN A stated that she took Resident #1's vital signs and everything looked good. RN A asked Resident #1 if she needed anything to drink and/or eat and she told her no, she wanted to go to sleep. RN A stated that after the fall, she did not observe any bruises on Resident #1. RN A stated that the x-ray technician came to the facility and gave Resident #1 an x-ray, which revealed no injuries. RN A stated that Resident #1 also received a Neurological Check, which revealed no concerns. She stated that after x-ray technician left Resident #1's room, she went to sleep. RN A stated that after Resident #1's fall, she notified the FM, physician and called the DON and she made an incident report. She stated that she called Resident #1's FM and left a voicemail message informing her about Resident #1's fall. RN A stated that prior to 07/30/25, Resident #1 did not have any history of falls. RN A stated that she could not remember the last In-Service she received on abuse, neglect, falls, and routine resident checks but she had taken the Trainings at least once or twice a week. RN A stated that neglect was when a resident has their Call Light on and the Call Light remains on for a long amount of time and no one answers the Call Light. RN A stated that she was told by the DON and Administrator that she would be suspended from working at the facility pending the facility's investigation on the incident. RN A stated that she was notified by the Administrator that her employment was terminated due to not following the facility's policy, Routine Resident Checks, which stated that Routine Resident Checks should be done on every shift at least every 2 hours. RN A stated that there was a potential risk of Resident #1 being on the floor for 4 hours without any assistance. RN A stated the Resident #1 could have been harmed by being unconscious, have serious injuries and fractures bones. Record review of CNA B's undated statement, Fall Incident Statement revealed, Upon the return from her 45-minute lunch break on 07/30/25 at approximately 4:00 AM, RN A called her to come to [Resident #1's] room because she needed assistance. CNA B stated that she entered the room and observed [Resident #1] on the floor. Resident #1 told CNA B that she went to the bathroom and became dizzy. RN A and CNA B assisted [Resident #1] by placing her into her bed. CNA B gave [Resident #1] the call light and advised her not to attempt to go to the bathroom without assistance. [Resident #1] told CNA B that she called for help verbally. CNA B stated that she told [Resident #1] that no one heard her and to use the call light for assistance. CNA B stated that [Resident #1] typically walked with the assistance of her walking cane and she was unsure if [Resident #1] used her walking cane when she walked to the bathroom. CNA B stated that [Resident #1's] cane was observed near her bed rail. CNA B stated that [Resident #1] asks for her door to remain shut at all times and she had not entered [Resident #1's] room for a couple of hours during her shift and was unsure how long [Resident #1] was on the floor. [sic] During an observation of Resident #1's room on 08/26/25 at 4:01 PM, revealed that the Call Light was operable and was in reach. Resident #1's wheelchair was observed beside her bed. Resident #1 was not in her room. In a telephone interview with [Resident #1's] FM on 08/26/25 at 4:50 PM, she stated that she was [Resident #1's] RP/FM. The FM stated that Resident #1 was admitted to the facility on [DATE] for Long Term Care. The FM stated that Resident #1 had a camera in her room. The FM stated on 07/30/25 at 5:09 AM, she received a voicemail from RN A stating that she was making rounds throughout the facility and found [Resident #1] sitting on the floor. RN A stated that when she asked [Resident #1] what happened, she said that she was going to the bathroom and she felt dizzy and decided to sit down on the floor. RN A stated that [Resident #1] had some bruising on her right hand and nowhere else. The FM stated that she was asleep when RN A telephoned her and left the voicemail message. The FM stated that she got up around 8:00 on 07/30/25, listened to the voicemail message and thought that it was weird that [Resident #1] would get out of her bed and just sit on the floor because she had never done anything like that in the past. The FM stated that she decided to look at the video camera footage on the day of the incident. The FM stated that the video camera footage revealed that [Resident #1] had a fall on 07/30/25 around 12:30 AM and remained on the floor until about 4:30 AM until RN A seen her and CNA B assisted [Resident #1] with getting back into her bed. The FM stated that she felt like the facility staff were negligent due to no one checking in on her mom for 4 hours. The FM stated that [Resident #1] initially sustained a tear on her right arm near her elbow after the fall. She stated that a couple of days later, Resident #1 had a bruise to her check, left lower leg. The FM stated that Resident #1 had not had any falls prior to being admitted to the facility. The FM stated that she did not want to get anyone at the facility into any trouble, but she felt like the staff were negligent by not checking in on [Resident #1] during the evening shift on 07/30/25. An observation of video footage sent to HHSC Surveyor from Resident #1's FM on 08/26/25 at 5:22 PM revealed the following: On 07/30/25 at 00:56 (12:56 AM) Resident #1 was observed sitting on the edge of her bed upright, with both of her feet on the floor. Resident #1 was observed leaning towards her headboard and grabbing her cane. Resident #1 was observed then standing up, Resident #1 appeared to be unbalanced and attempted to regain her balance. Resident #1 was then observed to take about 10 steps forward when she falls forward and out of view of the camera. The floor was free of any obstacles. Resident #1 did not vocalize anything such as pain or for help. Resident #1 was observed in the bottom corner of the camera getting on her knees then the video ends. On 07/30/25 at 4:38 AM Resident #1 was observed sitting on her buttocks near the middle/bottom half of her bed, her legs are not able to be seen as they are out of view of the camera. Resident #1's cane was observed near her pillow propped up against the bed. Audio can be heard of [RN A] stating she needs help another lady's voice [CNA B] asks, with what and [RN A] says she's on the floor. On 07/30/25 at 4:39 AM, [RN A and CNA B] were observed entering Resident #1's room. RN A was heard stating she's never done this before she can walk and then telling Resident #1 Okay we need to get you up and asks Resident #1 How you feeling? to which Resident #1 was heard saying Good, I think. Both staff members were observed assisting Resident #1 from the floor to the bed, Resident #1 was observed telling CNA B that she was going to the bathroom. On 07/30/25 at 4:41 AM, CNA B was observed placing the call light within reach of Resident #1 and both staff [RN A and CNA B] tell Resident #1 to call and to use her call light and they will come help her and Resident #1 replied, Yes I know. On 07/30/25 at 4:42 AM RN A was observed taking Resident #1's vital signs and noted that Resident #1 was hurt on her elbow and asked Resident #1 if she got hurt to which Resident #1 stated yes and CNA B asked her if she hit her head and Resident #1 stated No and shook her head. CNA B then tells Resident #1 that she will be back to clean her elbow. On 08/26/25 at 10:28 AM, an attempted telephone call to CNA B was unsuccessful. In an interview with CNA C on 08/27/25 at 11:50 AM, he stated that he had been employed at the facility for 14 years. CNA C stated that he was not on duty when Resident #1 had a fall on 07/30/25. CNA C stated that he had taken In-Service Trainings on Abuse, Neglect, Falls, Fall Prevention and Routine Resident Checks sometime last month. CNA C stated that In-Service Trainings were conducted by the Abuse Coordinator who is the Administrator. CNA C stated that In-Service Trainings are ongoing and are done every time an incident happened at the facility, such as an allegation of abuse, neglect and resident falls, and call lights. CNA C stated that Routine Resident Checks are to be done every 2 hours or as needed depending on the resident's needs. CNA C stated that if he observed a resident on the floor, he would make sure that the resident was safe and then he would notify his Nurse and inform him/her what happened. CNA C stated that if a resident was left alone on the floor for 4 hours it was resident neglect. He stated that residents should not be on the floor and left unattended for that amount of time, which was excessive. CNA C was able to define and provide examples of resident neglect and was able to provide a detailed understanding of each. CNA C stated that the risk of a resident remaining on the floor for a long period of time can affect a resident's psychological well-being and cause harm such as injuries and fractured bones. In an interview with the CNA D on 08/27/25 at 11:57 AM, she stated that she had been employed at the facility for 5 years. CNA D stated that she was not on duty when Resident #1 had a fall on 07/30/25. CNA D stated that she had taken several In-Service Trainings on Abuse, Neglect, Falls, Fall Prevention and Routine Resident Checks during her tenure at the facility. CNA D stated that In-Service Trainings were conducted by the Abuse Coordinator who is the Administrator, and the DON. CNA D stated that In-Service Trainings are always being done with all staff every time an incident happened at the facility, such as an allegation of abuse, neglect and resident falls, and call lights. CNA D stated that Routine Resident Checks are to be done every 2 hours or as needed, such as if a resident turns on their Call Light. CNA D stated that if she observed a resident on the floor, she would talk to the resident to ensure that the resident was safe and did not need any emergency medical attention. CNA D stated that she would then notify her Charge Nurse and inform him/her what happened. CNA D stated that if a resident is left alone on the floor for 4 hours it is resident neglect. CNA D stated that she was not aware of any residents being abused or neglected at the facility. CNA D stated that if she suspected that a resident was being abused or neglected, she would notify the Abuse Coordinator/Administrator. CNA D stated that a resident should not be on the floor and left unattended for 4 hours, which was too long. CNA D was able to define and provide examples of resident neglect and was able to provide a detailed understanding of each. CNA D stated that the risk of a resident remaining on the floor for a long period of time is that the resident could be seriously hurt or injured, which meant that the resident needed emergency services. In an interview with the Administrator on 08/27/25 at 1:49 PM, he stated that the DON was not available due to being ill and out on Leave. The Administrator stated that on 07/30/25, Resident #1 had a fall during the evening shift and was found on the floor by RN A. He stated that RN A and CNA B assisted Resident #1 back to her bed. He stated that RN A asked Resident #1 what happened and how did she fall? He stated that RN A stated that Resident #1 told both staff members [RN A and CNA B] that she got out of the bed and felt dizzy and had fallen on the floor. RN A checked the resident for s/s of any injuries, bruises and marks via a head-to-toe assessment. RN A stated that Resident #1 stated that she was dizzy and the head-to-toe assessment revealed that Resident #1 had a small skin tear on her upper right arm near her elbow. The Administrator stated that Neurological Checks, X-rays, and Skin Assessments were completed on 07/30/25, which revealed that the resident did not have any serious injuries including fractures. He stated that Resident #1's RP and physician were notified after the incident. The Administrator stated that he was informed by Resident #1's FM that a voicemail was received from RN A on the early morning of 07/30/25, which stated that resident had a fall. The FM notified the Administrator and DON and provided video camera footage that revealed that Resident #1 was on the floor for an excess of 4 hours. The Administrator stated that he suspended and later terminated both RN A and CNA B due to them not abiding by the facility's policy for Routine Resident Checks, which were to be done on residents every 2 hours. The Administrator stated that both staff members [RN A and CNA B] admitted that they did not perform routine resident checks during their shift on 07/30/25, which led to Resident #1 being left on the floor unattended. He stated that himself and the DON viewed the videos and stated that both staff members were negligent for leaving the resident on the floor after her fall on 07/30/25. The Administrator stated that he immediately began In-Service Trainings with all staff on Reporting Abuse, and Neglect, Abuse and Neglect, Falls, Falls Prevention, Call Lights, and Routine Resident Checks. The Administrator stated that he also conducted Safe Surveys with residents in the facility, which revealed that the sampled residents did not have any concerns regarding their safety and the care they were receiving at the facility. The Administrator stated that all the In-Service Trainings will be ongoing for all staff monthly. The Administrator stated there was a risk when a resident is left alone unattended on the floor for 4 hours, which meant that the staff did not perform routine resident checks while Resident was on the floor. He stated that there are risks included the resident not having their medical needs and concerns taken care of. The Administrator stated that harm included psychological and mental well-being and serious injuries. On 08/27/25 at 2:47 PM attempted Telephone Calls to RN A and CNA B were unsuccessful. During an observation on 08/27/25 at 2:51 PM, Resident #1 was observed in the Dining Room, sitting alone in a chair with a walking cane beside her. She was well-dressed and groomed and was participating in an activity with other residents. The activity was being conducted by the Activity Director. During an observation and interview with Resident #1 in the dining room on 08/27/25 at 3:15 PM, Resident #1 was observed sitting at a table by herself. There were approximately six residents still sitting in the Dining Room. Resident #1 stated that she had 1 fall since she had been admitted to the facility. Resident #1 stated that on the day of the incident in the middle of the night, she had to use the restroom and attempted to get out of her bed and her legs were weak and she had a fall. Resident #1 stated that she was unable to crawl to her bed to press the call light for help. She stated that she was on the floor for a long period of time, but she was unable to provide a timeframe of how long she was on floor. Resident #1 stated that she did not remember hitting her head on anything during or after her fall from the bed. Resident #1 reported that she had a scrape on her right arm and a bruise on her left leg after she fell. She stated that after she fell onto the floor, she did not yell for help and remained on the floor. She stated that she was not in any pain or distress after she fell on the floor. She stated that she keeps her door cracked throughout the day and night. She stated that RN A saw her on the floor and then CNA B assisted RN A with placing her onto her bed. Resident #1 stated prior to her fall on 07/30/25, she had not had any issues in the past getting out of her bed and self-ambulating to the restroom. She stated that she did not recall any staff coming into her room to check on her when she was sleeping. She stated that she does not like to be awakened at night. Resident #1 stated that she feels safe at the facility, and she did not have any concerns regarding the care she was receiving at the facility. An observation of Resident #1 and interview on 08/27/25 at 4:03 PM, revealed that there was a small approximately 1-inch scrape to her upper right forearm and a pink bruise on her left calf. Resident #1 stated that she did not have any other injuries on her body, including her face and head areas after the fall on 07/30/25. Resident #1 stated that she had not had any falls prior to being admitted to the facility. Resident #1 stated that she had not had any falls at the facility since her fall on 07/30/25. Record Review of the voicemail sent to HHSC Surveyor from Resident #1's FM on 08/27/25 at 4:41 PM revealed the following:[RN A] telephoned the FM and stated, Hi [FM} this is the Nurse from [the facility] and this is about [Resident #1]. RN A stated, while making rounds, she was found on the floor in a sitting position. When resident was asked what happened, resident stated that she was going to the bathroom, she felt dizzy so she sat down on the floor and she did not get hurt or anything, just a little bruise on her right hand and nothing else, it was not bleeding just a little scratch and I gave her two medications and I just wanted to let you know, thank you. The Timestamp on the voicemail recording was 07/30/25 at 5:09 AM. On 09/02/2025 at 2:48 PM, an email was received from the Administrator which included a Statement from the DON about Resident #1's fall on 07/30/25. The DON's Statement stated, [DON} was notified by the Nurse, [RN A] that [Resident #1] had fallen in her room. [RN A] was making her rounds when she had [sic] calling for help. [DON] instructed [RN A] to do head-to-toe assessment on [Resident #1] and note any injury, any complaint of pain, any skin swelling or skin breakdown. [DON] also instructed her to inform the family, inform MD and request for x-ray to any body part, and initiate neuro-checks on [Resident #1]. All of the above instructions were carried out by the Nurse [RN A]. In the IDT meeting the next morning, we reviewed the fall and noted that the resident ambulated independently using a cane and liked for her door to be closed when she was in her room, including at nighttime. The x-rays were done and were negative for any injuries for [Resident #1]. The Nurses on each shift were advised to continue monitoring [Resident #1] for pain and emotional distress. The DON's Statement of Fall incident Report on 07/30/20245 was signed by the DON. Record review of facility's policy for Resident Rights, undated, reflected, Policy StatementEmployees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation1.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect.2. Staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents. Record review of facility's policy for Abuse Prevention Program, undated, reflected, Policy StatementOur residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from.involuntary seclusion, verbal, mental.Policy Interpretation and ImplementationAs part of the resident abuse prevention program, the administration will:1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff.or any other individual.3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.4. Require staff training/orientation programs that include such topics as abuse prevention, identification andreporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.5. Implement measures to address factors that may lead to abusive situations, for example:a. Provide staff with opportunities to express challenges related to their job and work environment.6. Identify and assess all possible incidents of abuse;7. Investigate and report any allegations of abuse within timeframes as required by federal requirements;8. Protect residents during abuse investigations;9. Establish and implement a QAPI [VT15] review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse; and10. Involve the resident council in monitoring and evaluating the facility's abuse prevention program. Record review of facility's policy for Routine Resident Checks, dated 2001, revised July 2013, reflected, Policy StatementStaff shall make routine resident checks to help maintain resident safety and well-being.Policy Interpretation and Implementation1.To ensure the safety and well-being of our residents, nursing staff shall make a routine check on each unit at least once every 2 hours and as needed.2.Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify and change in the resident's condition, identify if the resident has any concerns, and if the resident is sleeping, needs toileting assistance, etc.3.The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs.4.The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time, identify of the person making checks, and any outcomes of each check. (Note: CNA's may also record this information and provide it to the Nurse Supervisor/Charge Nurse).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from neglect for 1 (Resident #1) of 9 residents reviewed for neglect. 1. The facility failed to ensure Resident #1 was not neglected when she fell from her bed and remained on the floor beside her bed for approximately 4 hours on 07/30/25. 2. The facility failed to ensure RN A and CNA B did Routine Resident Checks every 2 hours on Resident #1 during their shift on 07/30/25. The non-compliance was identified as past non-compliance. The facility corrected the non-compliance before surveyor's entrance. These failures could place residents at risk for humiliation, fear, shame, agitation, decreased quality of life and possibly death. Findings included:Record review of Resident #1's admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included: hypokalemia (condition where the potassium levels in the blood are lower than normal), cerebral infarction (occurs when blood flow to the brain is interrupted, leading to brain tissue damage), depression, hypertension (high blood pressure), gastro-esophageal reflux disease (GERD) without esophagitis (a condition where stomach acid flows back into the esophagus without causing inflammation or damage to the esophageal lining), constipation, osteoarthritis in the right knee (joint disease that causes pain, stiffness, and swelling in the joints), and age-related osteoporosis without current pathological fracture (a condition that weakens bones, making them more prone to fractures), and dementia. Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected she had severe cognitive impairment with a BIMS score of 2. Resident #1 used a wheelchair and walking cane for assistance with mobility and was independent and did not require any assistance with rolling left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer, or toilet transfer. Resident #1 needed assistance with setup or clean-up with tub/shower transfer, walking 10 feet, walking 50 feet with two turns, and walking 150 feet. Resident #1 did not have any falls prior to being admitted to the facility. Record review of Resident #1's Care Plan reflected the following entries:An entry dated 06/29/2025 and revised on 08/26/2025 reflected: Focus: [Resident #1] was at risk for falls related to impaired balance/gait, weakness and use of psychotropic medications.Goal: [Resident #1 will have decreased risk for serious injury or hospitalization as a result of falling through the next assessment review period. Date Initiated: 08/29/2025, Revision on: 08/17/2025, Target Date: 07/30/2025 .Interventions: Discuss/review fall(s) at morning meetings, IDT/QA meetings, and as indicated.Date Initiated: 06/29/2025 Encourage locking of brakes on Wheelchair.Date Initiated: 06/29/2025 Encourage resident to voice needs as well as to seek/await staff assist with transfers.Date Initiated: 06/29/2025 Encourage use of self-help devices as indicated.Date Initiated: 06/29/2025 Ensure glasses are clean, in good repair and worn appropriately.Date Initiated: 06/29/2025 Ensure resident wears appropriate, well-fitting footwear to minimize the risk ofSlipping.Date Initiated: 06/29/2025 Fall risk quarterly and prn per facility policy.Date Initiated: 06/29/2025 Keep call light within reach.Date Initiated: 06/29/2025 Keep environment clear of unnecessary objects. Keep bed locked and in lowest position unless otherwise ordered/indicated.Date Initiated: 06/29/2025 Nursing staff will monitor for side effects/adverse reactions to medications.Date Initiated: 06/29/2025 Refer to therapies and/or restorative, as indicated.Date Initiated: 06/29/2025 Safety training, retraining and education as needed.Date Initiated: 06/29/2025 An entry dated 08/26/2025 reflected: Focus: [Resident #1] was at risk for skin breakdown due to decreased mobility.Goal: [Resident #1] will have no skin breakdown in the next 90 days. Date Initiated: 08/26/2025 and Target Date: 07/30/2025. There were no Interventions in place. Record review of Resident #1's Skin Assessment for 07/30/25 at 5:00 AM due to an un-witnessed fall revealed, that Resident #1 had a small scrape on her upper right arm and denied pain. Record review of Resident #1's Neurological Check on 07/30/25 at 6:14 AM, revealed that she was complaining of vomiting and diarrhea. [Resident #1] denied any pain or discomfort or emotional distress. Record review of Resident #1's X-rays on 07/31/25 revealed that impressions were taken of the skull, hips, and chest and the findings revealed that there was no evidence of any fractures present in all areas. Record review of the facility's Admissions List for 02/01/25 to 08/26/25 revealed that Resident #1 was admitted to the facility from an acute care hospital on [DATE]. Record review of the facility's Incident Logs for 02/26/25 to 08/26/25 revealed on 07/30/25 at 5:00 PM, Resident #1 had an unwitnessed fall. Record review of the facility's In-service Training Log reflected that the staff's previous training on Resident Rights was conducted by Administrator on 07/23/25. The In-Service Training Logs reflected the staff were trained on the facility's policies and procedures on Resident Rights. The In-Service Training Attendance Roster reflected that the trainings were attended by all staff except RN A and CNA B. Record review of the facility's Staff Schedule for 07/29/25, revealed that RN A and CNA B were assigned to the evening shift on the 200 Hall where Resident #1 resided. Record review of the facility's In-service Training Log dated 07/30/25, reflected that the trainings were conducted by Administrator. The In-Service Training Logs reflected the staff were trained on the facility's policies and procedures on Abuse/Neglect, Resident Rights, Routine Round Checks, Call Lights, and Fall Preventions. The In-Service Training Attendance Roster reflected that the trainings were attended by all staff except RN A and CNA B. Record review of the employee files for RN A and CNA B revealed on 07/30/25 both staff members were suspended pending the facility's investigation of Resident #1's fall during the evening shift on 07/29/2025. Both staff members were terminated on 07/30/25 due to policy/procedure violation, prohibited conduct, safety violations, and unsatisfactory job performance which led to Resident #1's unwitnessed fall on 07/30/25. Both employee files did not reveal any other infractions or disciplinaries regarding resident neglect. Record review revealed on 07/30/25, the facility conducted Safe Surveys with the residents in the facility, and all stated that their needs were being met at the facility and did not have any concerns regarding abuse and neglect. Record review of the facility's Provider Investigation Report dated 08/06/25 revealed, RN A was the Charge Nurse on duty and CNA B was also on duty assigned to the 200 and 300 halls during the evening shift on 07/30/25, which was from 6 PM to 6 AM. On 07/30/25 at approximately 4:30 AM, [Resident #1] was observed by FM to have fallen and remained on the floor or an extended period of time. FM voiced concerns regarding the night shift doing routine checks during their shifts. [Resident #1] had a head-to-toe assessment which revealed a skin tear to her upper right arm. RN A and CNA B were immediately suspended and later terminated due to not following the facility's Routine Round Check Policy. The finding of Founded due to the neglect of RN A and CNA B. In a telephone interview with RN A on 08/26/25 at 4:25 PM revealed, that she was employed at the facility for 2 years as of 07/30/25. RN A stated that she worked the 6P-6A shift on 07/30/25. RN A stated that CNA B worked the 6P-6A shift on 07/30/25. RN A stated that herself and CNA B were assigned 2 hallways on 07/30/25. She stated at the beginning of her shift, she would do her rounds and check on residents to see how they were doing. RN A stated that Resident #1 was independent but needed some assistance with her ADL's due to her having some muscle weakness. RN A stated that Resident #1 appeared to be fine and did not appear to be in any distress or discomfort when she checked on her at the beginning of her shift. RN A stated that Resident #1 did not like to be awakened during the night and preferred to keep her door ajar or closed. RN A stated that if Resident #1's door was opened throughout the night, she would become disturbed in her sleep. RN A stated that during her shift on 07/30/25, Resident #1 had nausea and was vomiting due to her having some health issues. RN A stated that she did not Check-In with Resident #1 during her shift because she became busy with tasks such as assisting other residents and passing medications to residents. RN A stated that she was doing her rounds around 4:30 AM on 07/30/25, she heard some noise and observed Resident #1 on the floor beside her bed. She stated that Resident #1 stated that she had fallen on the floor after self-ambulating herself to the bathroom. RN A stated that Resident #1 did not know how long she remained on the floor after her fall. RN A stated that Resident #1 had a camera in her room that recorded the resident's fall on 07/30/25. RN A stated that after she observed Resident #1 on the floor, she contacted CNA B and told her that Resident #1 had fallen out of the bed and they picked up Resident #1 and placed her on her bed. RN A stated that Resident #1 complained of dizziness after the fall, and she was given a head-to-toe assessment. Resident #1's head-to-toe assessment revealed a small tear on Resident #1's right elbow. RN A stated that she took Resident #1's vital signs and everything looked good. RN A asked Resident #1 if she needed anything to drink and/or eat and she told her no, she wanted to go to sleep. RN A stated that after the fall, she did not observe any bruises on Resident #1. RN A stated that the x-ray technician came to the facility and gave Resident #1 an x-ray, which revealed no injuries. RN A stated that Resident #1 also received a Neurological Check, which revealed no concerns. She stated that after x-ray technician left Resident #1's room, she went to sleep. RN A stated that after Resident #1's fall, she notified the FM, physician and called the DON and she made an incident report. She stated that she called Resident #1's FM and left a voicemail message informing her about Resident #1's fall. RN A stated that prior to 07/30/25, Resident #1 did not have any history of falls. RN A stated that she could not remember the last In-Service she received on abuse, neglect, falls, and routine resident checks but she had taken the Trainings at least once or twice a week. RN A stated that neglect was when a resident has their Call Light on and the Call Light remains on for a long amount of time and no one answers the Call Light. RN A stated that she was told by the DON and Administrator that she would be suspended from working at the facility pending the facility's investigation on the incident. RN A stated that she was notified by the Administrator that her employment was terminated due to not following the facility's policy, Routine Resident Checks, which stated that Routine Resident Checks should be done on every shift at least every 2 hours. RN A stated that there was a potential risk of Resident #1 being on the floor for 4 hours without any assistance. RN A stated the Resident #1 could have been harmed by being unconscious, have serious injuries and fractures bones. Record review of CNA B's undated statement, Fall Incident Statement revealed, Upon the return from her 45-minute lunch break on 07/30/25 at approximately 4:00 AM, RN A called her to come to [Resident #1's] room because she needed assistance. CNA B stated that she entered the room and observed [Resident #1] on the floor. Resident #1 told CNA B that she went to the bathroom and became dizzy. RN A and CNA B assisted [Resident #1] by placing her into her bed. CNA B gave [Resident #1] the call light and advised her not to attempt to go to the bathroom without assistance. [Resident #1] told CNA B that she called for help verbally. CNA B stated that she told [Resident #1] that no one heard her and to use the call light for assistance. CNA B stated that [Resident #1] typically walked with the assistance of her walking cane and she was unsure if [Resident #1] used her walking cane when she walked to the bathroom. CNA B stated that [Resident #1's] cane was observed near her bed rail. CNA B stated that [Resident #1] asks for her door to remain shut at all times and she had not entered [Resident #1's] room for a couple of hours during her shift and was unsure how long [Resident #1] was on the floor. [sic] During an observation of Resident #1's room on 08/26/25 at 4:01 PM, revealed that the Call Light was operable and was in reach. Resident #1's wheelchair was observed beside her bed. Resident #1 was not in her room. In a telephone interview with [Resident #1's] FM on 08/26/25 at 4:50 PM, she stated that she was [Resident #1's] RP/FM. The FM stated that Resident #1 was admitted to the facility on [DATE] for Long Term Care. The FM stated that Resident #1 had a camera in her room. The FM stated on 07/30/25 at 5:09 AM, she received a voicemail from RN A stating that she was making rounds throughout the facility and found [Resident #1] sitting on the floor. RN A stated that when she asked [Resident #1] what happened, she said that she was going to the bathroom and she felt dizzy and decided to sit down on the floor. RN A stated that [Resident #1] had some bruising on her right hand and nowhere else. The FM stated that she was asleep when RN A telephoned her and left the voicemail message. The FM stated that she got up around 8:00 on 07/30/25, listened to the voicemail message and thought that it was weird that [Resident #1] would get out of her bed and just sit on the floor because she had never done anything like that in the past. The FM stated that she decided to look at the video camera footage on the day of the incident. The FM stated that the video camera footage revealed that [Resident #1] had a fall on 07/30/25 around 12:30 AM and remained on the floor until about 4:30 AM until RN A seen her and CNA B assisted [Resident #1] with getting back into her bed. The FM stated that she felt like the facility staff were negligent due to no one checking in on her mom for 4 hours. The FM stated that [Resident #1] initially sustained a tear on her right arm near her elbow after the fall. She stated that a couple of days later, Resident #1 had a bruise to her check, left lower leg. The FM stated that Resident #1 had not had any falls prior to being admitted to the facility. The FM stated that she did not want to get anyone at the facility into any trouble, but she felt like the staff were negligent by not checking in on [Resident #1] during the evening shift on 07/30/25. An observation of video footage sent to HHSC Surveyor from Resident #1's FM on 08/26/25 at 5:22 PM revealed the following: On 07/30/25 at 00:56 (12:56 AM) Resident #1 was observed sitting on the edge of her bed upright, with both of her feet on the floor. Resident #1 was observed leaning towards her headboard and grabbing her cane. Resident #1 was observed then standing up, Resident #1 appeared to be unbalanced and attempted to regain her balance. Resident #1 was then observed to take about 10 steps forward when she falls forward and out of view of the camera. The floor was free of any obstacles. Resident #1 did not vocalize anything such as pain or for help. Resident #1 was observed in the bottom corner of the camera getting on her knees then the video ends. On 07/30/25 at 4:38 AM Resident #1 was observed sitting on her buttocks near the middle/bottom half of her bed, her legs are not able to be seen as they are out of view of the camera. Resident #1's cane was observed near her pillow propped up against the bed. Audio can be heard of [RN A] stating she needs help another lady's voice [CNA B] asks, with what and [RN A] says she's on the floor. On 07/30/25 at 4:39 AM, [RN A and CNA B] were observed entering Resident #1's room. RN A was heard stating she's never done this before she can walk and then telling Resident #1 Okay we need to get you up and asks Resident #1 How you feeling? to which Resident #1 was heard saying Good, I think. Both staff members were observed assisting Resident #1 from the floor to the bed, Resident #1 was observed telling CNA B that she was going to the bathroom. On 07/30/25 at 4:41 AM, CNA B was observed placing the call light within reach of Resident #1 and both staff [RN A and CNA B] tell Resident #1 to call and to use her call light and they will come help her and Resident #1 replied, Yes I know. On 07/30/25 at 4:42 AM RN A was observed taking Resident #1's vital signs and noted that Resident #1 was hurt on her elbow and asked Resident #1 if she got hurt to which Resident #1 stated yes and CNA B asked her if she hit her head and Resident #1 stated No and shook her head. CNA B then tells Resident #1 that she will be back to clean her elbow. On 08/26/25 at 10:28 AM, an attempted telephone call to CNA B was unsuccessful. In an interview with CNA C on 08/27/25 at 11:50 AM, he stated that he had been employed at the facility for 14 years. CNA C stated that he was not on duty when Resident #1 had a fall on 07/30/25. CNA C stated that he had taken In-Service Trainings on Abuse, Neglect, Falls, Fall Prevention and Routine Resident Checks sometime last month. CNA C stated that In-Service Trainings were conducted by the Abuse Coordinator who is the Administrator. CNA C stated that In-Service Trainings are ongoing and are done every time an incident happened at the facility, such as an allegation of abuse, neglect and resident falls, and call lights. CNA C stated that Routine Resident Checks are to be done every 2 hours or as needed depending on the resident's needs. CNA C stated that if he observed a resident on the floor, he would make sure that the resident was safe and then he would notify his Nurse and inform him/her what happened. CNA C stated that if a resident was left alone on the floor for 4 hours it was resident neglect. He stated that residents should not be on the floor and left unattended for that amount of time, which was excessive. CNA C was able to define and provide examples of resident neglect and was able to provide a detailed understanding of each. CNA C stated that the risk of a resident remaining on the floor for a long period of time can affect a resident's psychological well-being and cause harm such as injuries and fractured bones. In an interview with the CNA D on 08/27/25 at 11:57 AM, she stated that she had been employed at the facility for 5 years. CNA D stated that she was not on duty when Resident #1 had a fall on 07/30/25. CNA D stated that she had taken several In-Service Trainings on Abuse, Neglect, Falls, Fall Prevention and Routine Resident Checks during her tenure at the facility. CNA D stated that In-Service Trainings were conducted by the Abuse Coordinator who is the Administrator, and the DON. CNA D stated that In-Service Trainings are always being done with all staff every time an incident happened at the facility, such as an allegation of abuse, neglect and resident falls, and call lights. CNA D stated that Routine Resident Checks are to be done every 2 hours or as needed, such as if a resident turns on their Call Light. CNA D stated that if she observed a resident on the floor, she would talk to the resident to ensure that the resident was safe and did not need any emergency medical attention. CNA D stated that she would then notify her Charge Nurse and inform him/her what happened. CNA D stated that if a resident is left alone on the floor for 4 hours it is resident neglect. CNA D stated that she was not aware of any residents being abused or neglected at the facility. CNA D stated that if she suspected that a resident was being abused or neglected, she would notify the Abuse Coordinator/Administrator. CNA D stated that a resident should not be on the floor and left unattended for 4 hours, which was too long. CNA D was able to define and provide examples of resident neglect and was able to provide a detailed understanding of each. CNA D stated that the risk of a resident remaining on the floor for a long period of time is that the resident could be seriously hurt or injured, which meant that the resident needed emergency services. In an interview with the Administrator on 08/27/25 at 1:49 PM, he stated that the DON was not available due to being ill and out on Leave. The Administrator stated that on 07/30/25, Resident #1 had a fall during the evening shift and was found on the floor by RN A. He stated that RN A and CNA B assisted Resident #1 back to her bed. He stated that RN A asked Resident #1 what happened and how did she fall? He stated that RN A stated that Resident #1 told both staff members [RN A and CNA B] that she got out of the bed and felt dizzy and had fallen on the floor. RN A checked the resident for s/s of any injuries, bruises and marks via a head-to-toe assessment. RN A stated that Resident #1 stated that she was dizzy and the head-to-toe assessment revealed that Resident #1 had a small skin tear on her upper right arm near her elbow. The Administrator stated that Neurological Checks, X-rays, and Skin Assessments were completed on 07/30/25, which revealed that the resident did not have any serious injuries including fractures. He stated that Resident #1's RP and physician were notified after the incident. The Administrator stated that he was informed by Resident #1's FM that a voicemail was received from RN A on the early morning of 07/30/25, which stated that resident had a fall. The FM notified the Administrator and DON and provided video camera footage that revealed that Resident #1 was on the floor for an excess of 4 hours. The Administrator stated that he suspended and later terminated both RN A and CNA B due to them not abiding by the facility's policy for Routine Resident Checks, which were to be done on residents every 2 hours. The Administrator stated that both staff members [RN A and CNA B] admitted that they did not perform routine resident checks during their shift on 07/30/25, which led to Resident #1 being left on the floor unattended. He stated that himself and the DON viewed the videos and stated that both staff members were negligent for leaving the resident on the floor after her fall on 07/30/25. The Administrator stated that he immediately began In-Service Trainings with all staff on Reporting Abuse, and Neglect, Abuse and Neglect, Falls, Falls Prevention, Call Lights, and Routine Resident Checks. The Administrator stated that he also conducted Safe Surveys with residents in the facility, which revealed that the sampled residents did not have any concerns regarding their safety and the care they were receiving at the facility. The Administrator stated that all the In-Service Trainings will be ongoing for all staff monthly. The Administrator stated there was a risk when a resident is left alone unattended on the floor for 4 hours, which meant that the staff did not perform routine resident checks while Resident was on the floor. He stated that there are risks included the resident not having their medical needs and concerns taken care of. The Administrator stated that harm included psychological and mental well-being and serious injuries. On 08/27/25 at 2:47 PM attempted Telephone Calls to RN A and CNA B were unsuccessful. During an observation on 08/27/25 at 2:51 PM, Resident #1 was observed in the Dining Room, sitting alone in a chair with a walking cane beside her. She was well-dressed and groomed and was participating in an activity with other residents. The activity was being conducted by the Activity Director. During an observation and interview with Resident #1 in the dining room on 08/27/25 at 3:15 PM, Resident #1 was observed sitting at a table by herself. There were approximately six residents still sitting in the Dining Room. Resident #1 stated that she had 1 fall since she had been admitted to the facility. Resident #1 stated that on the day of the incident in the middle of the night, she had to use the restroom and attempted to get out of her bed and her legs were weak and she had a fall. Resident #1 stated that she was unable to crawl to her bed to press the call light for help. She stated that she was on the floor for a long period of time, but she was unable to provide a timeframe of how long she was on floor. Resident #1 stated that she did not remember hitting her head on anything during or after her fall from the bed. Resident #1 reported that she had a scrape on her right arm and a bruise on her left leg after she fell. She stated that after she fell onto the floor, she did not yell for help and remained on the floor. She stated that she was not in any pain or distress after she fell on the floor. She stated that she keeps her door cracked throughout the day and night. She stated that RN A saw her on the floor and then CNA B assisted RN A with placing her onto her bed. Resident #1 stated prior to her fall on 07/30/25, she had not had any issues in the past getting out of her bed and self-ambulating to the restroom. She stated that she did not recall any staff coming into her room to check on her when she was sleeping. She stated that she does not like to be awakened at night. Resident #1 stated that she feels safe at the facility, and she did not have any concerns regarding the care she was receiving at the facility. An observation of Resident #1 and interview on 08/27/25 at 4:03 PM, revealed that there was a small approximately 1-inch scrape to her upper right forearm and a pink bruise on her left calf. Resident #1 stated that she did not have any other injuries on her body, including her face and head areas after the fall on 07/30/25. Resident #1 stated that she had not had any falls prior to being admitted to the facility. Resident #1 stated that she had not had any falls at the facility since her fall on 07/30/25. Record Review of the voicemail sent to HHSC Surveyor from Resident #1's FM on 08/27/25 at 4:41 PM revealed the following:[RN A] telephoned the FM and stated, Hi [FM} this is the Nurse from [the facility] and this is about [Resident #1]. RN A stated, while making rounds, she was found on the floor in a sitting position. When resident was asked what happened, resident stated that she was going to the bathroom, she felt dizzy so she sat down on the floor and she did not get hurt or anything, just a little bruise on her right hand and nothing else, it was not bleeding just a little scratch and I gave her two medications and I just wanted to let you know, thank you. The Timestamp on the voicemail recording was 07/30/25 at 5:09 AM. On 09/02/2025 at 2:48 PM, an email was received from the Administrator which included a Statement from the DON about Resident #1's fall on 07/30/25. The DON's Statement stated, [DON} was notified by the Nurse, [RN A] that [Resident #1] had fallen in her room. [RN A] was making her rounds when she had [sic] calling for help. [DON] instructed [RN A] to do head-to-toe assessment on [Resident #1] and note any injury, any complaint of pain, any skin swelling or skin breakdown. [DON] also instructed her to inform the family, inform MD and request for x-ray to any body part, and initiate neuro-checks on [Resident #1]. All of the above instructions were carried out by the Nurse [RN A]. In the IDT meeting the next morning, we reviewed the fall and noted that the resident ambulated independently using a cane and liked for her door to be closed when she was in her room, including at nighttime. The x-rays were done and were negative for any injuries for [Resident #1]. The Nurses on each shift were advised to continue monitoring [Resident #1] for pain and emotional distress. The DON's Statement of Fall incident Report on 07/30/20245 was signed by the DON. Record review of facility's policy for Resident Rights, undated, reflected, Policy StatementEmployees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation1.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect.2. Staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents. Record review of facility's policy for Abuse Prevention Program, undated, reflected, Policy StatementOur residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from.involuntary seclusion, verbal, mental.Policy Interpretation and ImplementationAs part of the resident abuse prevention program, the administration will:1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff.or any other individual.3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.4. Require staff training/orientation programs that include such topics as abuse prevention, identification andreporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.5. Implement measures to address factors that may lead to abusive situations, for example:a. Provide staff with opportunities to express challenges related to their job and work environment.6. Identify and assess all possible incidents of abuse;7. Investigate and report any allegations of abuse within timeframes as required by federal requirements;8. Protect residents during abuse investigations;9. Establish and implement a QAPI [VT15] review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse; and10. Involve the resident council in monitoring and evaluating the facility's abuse prevention program. Record review of facility's policy for Routine Resident Checks, dated 2001, revised July 2013, reflected, Policy StatementStaff shall make routine resident checks to help maintain resident safety and well-being.Policy Interpretation and Implementation1.To ensure the safety and well-being of our residents, nursing staff shall make a routine check on each unit at least once every 2 hours and as needed.2.Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify and change in the resident's condition, identify if the resident has any concerns, and if the resident is sleeping, needs toileting assistance, etc.3.The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs.4.The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time, identify of the person making checks, and any outcomes of each check. (Note: CNA's may also record this information and provide it to the Nurse Supervisor/Charge Nurse).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 2 of 19 residents (Residents #7 and Resident #48) reviewed for quarterly assessments. 1. The facility did not ensure Resident #7's Quarterly MDS Assessment, dated 03/12/2025, was completed within 90 days of the previous assessment. 2. The facility did not ensure Resident #48's Quarterly MDS Assessment, dated 03/19/2025, was completed within 90 days of the previous assessment. These failures could place residents at risk of not having their assessments completed timely.Findings included:1. Record review of Resident #7's admission Record, dated 07/23/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #7's annual MDS assessment dated [DATE] revealed he had diagnoses including Hypertension (a condition in which the force of the blood against the artery wall is too high), Anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), Orthostatic Hypotension (form of low blood pressure that happens when standing after sitting or lying down), Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar, the body doesn't produce enough insulin or it resists insulin), Cerebral Palsy (a neurological disorder that affects movement and muscle coordination, caused by abnormal brain development or damage to the developing brain), Anxiety Disorder (disorder characterized by feelings of worry, anxiety, or fear that are enough to interfere with one's daily activities), Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), Schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and Autistic Disorder (neurological and developmental disorder that affects how people interact with others, communicate, learn and behave).Record review of Resident #7's EHR revealed quarterly MDS assessment dated [DATE] reflected the status was In-Progress and had not been completed or transmitted to the CMS system. His most recent completed assessment was a Quarterly MDS assessment completed on 12/14/2024.2. Record review of Resident #48's admission Record dated 07/23/2025 revealed she was a [AGE] year-old female admitted to the facility on [DATE].Record review of Resident #48's quarterly MDS assessment dated [DATE] revealed she had diagnoses including Multiple Sclerosis (a chronic autoimmune disease that affects the central nervous system, leading to a range of neurological symptoms due to damage to the myelin sheath that insulates nerve fibers), Anxiety Disorder (disorder characterized by feelings of worry, anxiety, or fear that are enough to interfere with one's daily activities), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Psychotic Disorder (severe mental health conditions characterized by disruptions in thought processes, perceptions, and emotional responses, often leading to a loss of touch with reality), Arthritis (the swelling and tenderness of one or more joints), Osteoporosis (causes bones to become weak and brittle), and Muscle Weakness (a symptom of many conditions, ranging from muscle injuries to fatigue).Record review of Resident #48's EHR revealed her quarterly MDS assessment dated [DATE] reflected the status was In-progress and had not been completed or transmitted to the CMS system. Her most recent completed assessment was a quarterly MDS assessment dated [DATE].During an interview on 07/23/2025 at 1:30 PM, the DON stated the VP of Reimbursement is responsible for completing MDS assessments until an MDS coordinator is hired. The DON stated the risks for late assessments included not getting the most up-to-date information needed during their IDT meetings and it could also affect their reimbursement.During an interview on 07/23/2025 at 2:43 PM, the Administrator stated the VP of Reimbursement was responsible for completing MDS assessments until an MDS coordinator is hired. The Administrator stated he was aware some of MDS assessments were late, and they were working to resolve the matter. He stated risks for late assessments included the resident's information may not be updated timely and they could miss a change in condition. He stated the facility's reimbursement could be impacted as well. In an interview on 07/23/2025 at 3:00 PM, VP of Reimbursement stated the facility had not completed Resident #31 and Resident #48's quarterly MDS assessments due to the facility not having an MDS coordinator. VP of Reimbursement stated he was responsible for completing the assessments until an MDS coordinator is hired. VP of Reimbursement stated the risk of late or missed assessments could affect the residents plan of care, continuity of care, and affect reimbursement.Record review of the facility's undated policy and procedure titled Electronic Transmission of the MDS, identified as current by the Administrator, reflected the following: All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. MDS electronic submissions shall be conducted in accordance with current OBRA regulations governing the transmission of such data.

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (300 Hall MA Medication Cart) of six of six medication carts reviewed for medication storage. <BR/>MA B failed to ensure medications found on the sharps bin insert lid on the 300 Hall MA Medication Cart, were disposed of properly. <BR/>This failure placed residents at risk for unauthorized access to the medication cart and a harmful medication can be consumed placing residents at risk for administration of harmful medication. <BR/>Findings included:<BR/>An observation on 01/30/2024 at 10:07 AM revealed, MA B's 300 Hall MA Medication Cart, had eight pills stuck between the plastic insert of the sharps (needles, blades [such as scalpels] and other medical instruments that are necessary for carrying out healthcare work and could cause an injury by cutting or pricking the skin) container and the lid, which prevented the lid from closing properly. Residents were observed self-ambulating through the hall in thier wheelchairs. <BR/>In an interview on 01/30/2024 at 10:08 AM, MA B stated she did not see the medications on the lid of the sharps insert but could see they were preventing the lid from closing completely. She denied that she disposed of the medication but could not say who may have. She said all staff were responsible to ensure medications were secured and disposed of properly. She said medications should not be disposed of in the sharps bin. She said the medications posed a hazard for residents as they could have access to medications not prescribed to them. <BR/>In an interview on 01/30/2024 at 10:20 AM, ADON A said the medications stuck on the lid of the sharps bin insert should not be disposed of in the sharps bin and did not know why the medications were on the sharps bin lid. He stated the medications appeared to be blocking the lid from closing properly. He said the medications could be accessible to residents and posed a potential hazard as residents. He said he would find the keys to MA B's cart and remove the medications from the lid. <BR/>In an interview on 01/30/2024 at 1:50 PM, the Administrator said medications should not be disposed of in the sharps bins and should not be on the lid of the bins where residents could have access to them. She said many of the residents in the facility tend to wander and could have consumed the medications. She said she expected the nursing management to monito this and ensure staff were trained on facility policy. <BR/>In an interview on 01/30/2024 at 3:31 PM, the DON said medications should be disposed of properly and not placed in the sharps bin. He said he changed out MA B's sharps insert and disposed of the pills that were on the lid. He said he was not able to identify what the pills were. He said he did not feel the medications were accessible because they were in a groove at the back of the insert lid, however, the medications should not be there and since the insert lid could not close properly, there was a potential risk to residents consuming the medications if they were able to get the medications. He said staff are trained on how to dispose of medication properly but did not recall when the last training was. <BR/>Record review of the facility's undated policy, titled, Storage of Medications, reflected, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper. or incorrect labels are returned to the pharmacy for proper labeling before storing. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 6. Hazardous drugs shall be clearly marked as such and shall I be stored separately from other medications. 7. Compartments containing drugs and biologicals are locked when not in use. 8. Unlocked medication carts are not left unattended

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for contaminated sharps disposal bins, attached to one (300 Hall MA Medication Cart) of one 300 Hall MA Medication Cart and one (300 Hall Nurse Medication Cart) of one 300 Hall Nurse Medication Cart reviewed for hazards. <BR/>MA B failed to ensure contaminated sharps in the sharps bin attached to the 300 Hall MA Medication Cart, were below the full line. <BR/>MA B failed to ensure medications found on the sharps bin insert lid on the 300 Hall MA Medication Cart, were disposed of properly. <BR/>RN C failed to ensure contaminated sharps in the sharps bin attached to the 300 Hall Nurse Medication Cart, were below the full line. <BR/>These failures placed residents at risk of being exposed to contaminated sharps, possible bloodborne pathogens, and access to unprescribed medications. <BR/>Findings included:<BR/>An observation on 01/30/2024 at 10:07 AM, revealed the plastic insert contained inside the sharps bin attached to MA B's 300 Hall MA Medication Cart was past the full line. Sharps (needles, blades [such as scalpels] and other medical instruments that are necessary for carrying out healthcare work and could cause an injury by cutting or pricking the skin) in the insert blocked the insert's lid from closing completely. Eight pills were observed, stuck between the plastic insert and the insert's lid which contributed to the lid from closing properly. <BR/>In an interview on 01/30/2024 at 10:08 AM, MA B stated she was not aware the sharps in the bin were past the full line because she did not use it. She said the lid on the sharps bin insert should be free to close to ensure staff and resident safety. She said she did not see the medications on the lid of the sharps insert but could see they were preventing the lid from closing completely. She said all staff were responsible to ensure the sharps bin inserts were not filled past the full line however only the nurses had keys to the sharps bins attached to the carts. She said medications should not be disposed of in the sharps bin. She said the full bin and medications posed a hazard for residents and staff. <BR/>In an interview on 01/30/2024 at 10:20 AM, ADON A said the sharps bins should never be filled past the fill line to prevent possible injury to staff or residents. When asked about the medications stuck on the lid of the sharps bin insert, he said medications should not be disposed of in the sharps bin and did not know why the medications were on the sharps bin lid. He stated the medications appeared to be blocking the lid from closing properly. He stated the nurses had keys to the bins and were responsible to ensure the bins were not filled past the full line. He said the medications could be accessible to residents and posed a potential hazard as residents. He said he would find the keys to MA B's cart and change the sharps bin and remove the medications from the lid. <BR/>An observation on 01/30/2024 at 10:30 AM, revealed the plastic insert in the sharps bin, attached to RN C's 300 Hall Nurse Medication Cart to be past the full line. She said it should not be past the full line because the lid would not close properly which posed a potential hazard. She said the nurses had keys to the sharps bins and should ensure the inserts were not filled past the full line. <BR/>In an interview on 01/30/2024 at 1:50 PM, the Administrator said the sharps bin inserts should never be filled past the full line because it posed a potential risk of harm to staff and residents. She said they could be stuck by a needle if the lid did not close properly. She said she expected nursing staff to ensure this was done and nursing management to monitor it. She said medications should not be disposed of in the sharps bins and should not be on the lid of the bins where residents could have access to them. She said many of the residents in the facility tend to wander and could have consumed the medications. <BR/>In an interview on 01/30/2024 at 3:31 PM, the DON said the sharps bins should never be filled past the full line. He said the lid does not close properly when sharps are above the full line which could cause a risk of staff or residents getting stuck with a needle. He said a staff member was recently stuck in this manner and in servicing was conducted. He said medications should be disposed of properly and not placed in the sharps bin. He said he changed out MA B's sharps insert and disposed of the pills that were on the lid. He said he did not feel the medications were accessible because they were in a groove at the back of the insert lid. He said none-the-less the medications should not be there and since the insert lid could not close properly, there was a potential hazard to residents if they were able to get the medications. He said staff are trained on how to dispose of medication properly. <BR/>Record review of the facility's undated policy titled, Safety and Supervision of Residents, reflected, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation - Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. 3. When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. 5. The QAPI Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of the resident needs for 2 (Resident #6, and Resident #83) of 5 residents reviewed for resident rights. <BR/>The facility failed to ensure Resident #6 and Resident #83's call light was placed within reach. <BR/>These failures could place residents at risk of injuries and unmet needs. <BR/>Findings included:<BR/>Review of Resident #6 Quarterly MDS assessment dated [DATE] revealed resident was admitted on [DATE] with readmission on [DATE], diagnoses of cerebral infarction (stroke), dementia (loss of cognition cognitive communication deficit), unsteadiness on feet, difficulty in walking, generalized muscle weakness, and a BIMS score of 7 (severely impaired cognition). <BR/>Review of Resident #6 Care Plan dated initiated 04/04/2023 and revised 05/03/2024 reflected resident had a history of falls and had a fall with injury to his forehead on 04/04/2024 due to an unsteady gait with the intervention to remind resident to call for help before he got up. Review of Care Plan dated initiated 08/22/2018 and revised on 04/11/2023 reflected Resident #6 had an ADL self-care performance deficit and limited mobility due to a stroke with the intervention of Encourage resident to use bell to call for assistance. <BR/>Observation on 06/04/2024 at 11:02 AM of Resident #6 revealed resident was laying in a low bed watching television with his call light hanging off the right side of his bed rail. <BR/>Interview on 06/04/2024 at 11:03 AM with Resident #6 revealed he was alert and slightly confused, he did not know where his call light was and did not know how to find it and stated he could not reach it. <BR/>Interview on 06/04/2024 at 11:15 AM with CNA O revealed she had worked at the facility for a year and was familiar with Resident #6. CNA O stated that Resident #6 was at risk for falls and stated that his call light was out of his reach which put the resident at risk of having a fall by not being able to call for assistance first. CNA O stated call lights are important to be kept within reach of residents because if a resident fell they would not be able to call for assistance. CNA O placed call light next to resident on the bed. <BR/>Interview on 06/05/2024 at 3:51 PM with ADON A revealed Resident #6 was at facility for long term care and had dementia, a history of falls and was on fall precautions which included keeping his bed at a low level, ensure the resident was positioned correctly, and had call light within reach. ADON A stated that she would be concerned if Resident #6's call light was not within reach because even though he was forgetful it was important he had the ability to use the call light. ADON A stated the risk to a resident to not have a call light within reach was that a resident would not be able to call when they need help and could fall. <BR/>Review of Resident #83 Quarterly MDS assessment dated [DATE] revealed resident was admitted on [DATE] and had the diagnoses of osteoarthritis (disease of the joints), pain in unspecified hip, muscle weakness, unsteadiness on feet, and a BIMS of 6 (severely impaired cognition). <BR/>Review of Resident #83's Care Plan dated initiated 01/10/2024 and revised on 01/31/2024 reflected resident was at risk for falls due to a history of falls and had an unsteady gait with the intervention of keep call light within reach. Review of Care Plan dated initiated 05/07/2024 reflected Resident #83 was on hospice services and was at risk of decline in mental and physical conditions with an intervention of call light in reach and answer promptly. <BR/>Observation on 06/04/2024 at 10:50 AM revealed Resident #83 was awake lying in bed, wearing pajamas, with a stuffed animal under his arm and his call light was out of reach, looped and hung on the wall behind the resident's bed.<BR/>Interview on 06/04/2024 at 10:51 AM with Resident #83 revealed he was not sure where his call light was located. <BR/>Interview on 06/04/2024 at 10:59 AM with CNA D revealed he had worked at the facility for 13 years and stated that the call light should be placed within reach next to Resident #83 and was not sure why it was on the wall. CNA D placed call light next to resident on bed. CNA D stated that Resident #83 was at risk of falls and should always have his call light within reach to be able to call for assistance to get out of bed or to be able to call for help if he did fall. CNA D stated that he was not sure who assisted the resident last because hospice services had also been to visit with resident and that any staff member who previously assisted Resident #83 was responsible to ensure the call light was within reach. CNA D stated the risk to a resident by not having a call light within reach is risk of injury, falling, or not having their needs met. <BR/>Interview on 06/05/2024 at 3:53 PM with ADON A revealed Resident #83 had dementia, a history of falls, was ambulatory and liked to walk around in his room by himself. ADON A stated that Resident #83 should always have his call light within reach. ADON A stated the risk to a resident who did not have a call light within reach would be they would not be able to get assistance or could fall and not be able to receive assistance. ADON A stated any staff member who assisted residents was responsible for ensuring call lights were placed within their reach and it was important to ensure residents had their needs met and prevent possible injury.<BR/>Interview on 06/06/2024 at 10:30 AM with DON revealed he had worked at the facility for about 2 months and was familiar with Resident #6 and Resident #83. DON stated that Resident #6 ambulates himself with a wheelchair and had difficultly expressing himself verbally. DON stated Resident #6 was at a high risk of falls because his gait was unsteady and that his call light should always be within his reach so he could ask for assistance. DON stated that Resident #83 was alert but confused and currently was on hospice services and should always have call light within reach so resident could call for assistance if needed. DON stated any staff member including CNAs or RNs are supposed to ensure the call lights were within reach when they round and provide care to residents. DON stated that having a call light within reach of residents was important for safety reasons, so residents are able to call for assistance and have their needs met. <BR/>Interview on 06/06/2024 at 12:56 PM with Administrator revealed she was familiar with Resident #6 and Resident #83 and stated they were both at high risk of falls and should always have their call light within reach. Administrator stated it was important that all residents had their call lights within reach because it was their policy and a safety precaution and ensured residents received assistance that they needed. <BR/>Facility policy on resident call lights was requested on 06/05/2024 and facility provided safety policy titled Safety and Supervision of Residents. Review of safety policy reflected: Systems Approach to Safety . facility-oriented and resident-oriented approaches to safety are used to gather to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to resolve a grievance in a timely manner for 1 of 5 (Resident #44) residents reviewed for grievances. <BR/>1.The facility failed to make prompt efforts to ensure Resident #44's grievance was initiated, reported, and resolved in a timely manner. <BR/>These failures could affect the Resident's ability to file a grievance without the fear of discrimination, reprisal or retribution and their right to have their grievances resolved in a timely manner.<BR/>Findings Included:<BR/>Record Review of Resident #44's Quarterly MDS with an ARD of 07/13/24 revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #44's active diagnoses included: Unspecified Dementia, Unsteadiness on feet, muscle wasting and atrophy (loss of muscle leading to its shrinking and weakening) and unspecified glaucoma (progressive eye condition that can cause blindness). Resident #55 had a BIMS score of 9, indicating a moderately impaired cognition. <BR/>Record Review of the facility's March 2024 Grievance Log revealed 3 logged grievances, none of which revealed a grievance filed for Resident #44.<BR/>Record Review of the facility's April 2024 Grievance Log revealed 0 logged grievances.<BR/>Record Review of the facility's June 2024 Grievance Log revealed 4 logged grievances, none of which revealed a grievance filed for Resident #44.<BR/>Record Review of the facility's May 2024 Grievance Log revealed 1 logged grievances, none of which revealed a grievance filed for Resident #44.<BR/>Record Review of the facility's July 2024 Grievance Log revealed 1 logged grievances, grievance filed was not filed by Resident #44. <BR/>All grievances were dated as resolved.<BR/>Record Review of the facility's August 2024 Grievance Log revealed 0 logged grievances.<BR/>Interview with Resident #44 on 08/28/24 at 10:23AM revealed that her current wheelchair was not in working condition that was comfortable for her or met her needs . Resident #44 revealed that she filed a grievance with ADON A a few months ago and the Maintenance Assistant came by to fix the wheels, but the wheelchair was still not in working condition or comfortable for her. Resident #44 revealed that nobody came back from the facility to check and see if the wheelchair was working or comfortable for her after it was serviced by the facility Maintenance Assistant. Resident #44 revealed that she relies on the wheelchair to move around the facility and go out with her family. Resident #44 revealed her current wheelchair makes daily tasks harder for her such as coming and going from her room and attending activities.<BR/>Observation of Resident #44's wheelchair on 08/28/24 at 10:30AM revealed a [Name of Wheelchair Brand] wheelchair next to Resident #44's bed. Wheelchair was observed with a broken left arm pad with padding exposed. Wheelchair was observed to be dusty and when Resident #44 transferred from the bed into her wheelchair, the wheelchair size narrowed causing difficulty for Resident #44 to maneuver the wheels. <BR/>Interview with ADON A on 08/28/24 at 12:03PM revealed that Resident #44 did utilize the wheelchair on a daily basis. ADON A revealed that Resident #44 did report to him a few months back that her wheelchair was broken, and he reported the issue to the Maintenance Assistant. ADON A revealed that he was unaware that the complaint related to Resident #44's wheelchair should be constituted as a grievance and instead reported it to the maintenance department. ADON A revealed that he was unaware that Resident #44's complaint about her current wheelchair was still not resolved. ADON A revealed that the Social Worker is the facility grievance official and oversees the facility grievance procedures. ADON A revealed that if a resident had a grievance, he would fill out the facility grievance form, begin the investigation and alert the Social Worker and Administrator of the grievance. ADON A did not reveal a risk to residents for unresolved grievances. <BR/>Interview with Maintenance Assistant on 08/28/24 at 12:37PM revealed that he did work on Resident #44's wheelchair a few months back per a work order he received for her wheelchair. The Maintenance Assistant revealed that the wheelchairs wheels were too loose at that time, and he tightened them. The Maintenance Assistant revealed that he was unaware, and it was not reported to him that Resident #44's wheelchair was broken still and needed servicing, or a new wheelchair was needed. The Maintenance Assistant revealed that he did not review grievances, but if a resident files a grievance related to needed maintenance, then it should have been transcribed into a work order. <BR/>Interview with DON on 08/30/24 at 11:25AM revealed that the facility procedures on grievances was that the DON will receive all grievances from the resident or the staff member who received the grievance from the resident. The DON revealed that he would then either investigate the grievance or alert the appropriate department head to investigate. The DON revealed that the social worker is the facility grievance official, and she is responsible for ensuring that grievances are resolved in a timely manner. The DON revealed that residents are educated on the facility's grievance policy and procedures in resident council, on admission and through daily facility rounds conducted by all facility department heads. The DON revealed a risk to the resident for an unresolved grievance would be delay of care or concerns. <BR/>Interview with Social Worker on 08/30/24 at 1:53PM revealed that she is the facility grievance official. The Social Worker revealed that the procedure for grievances is, if a resident at the facility had a grievance they could go to the front office or the social work office to get a grievance form to fill out and turn into any staff member. The Social Worker revealed that residents can also file grievances verbally to any staff member. Once the grievance was filed it will then be reported to the Administrator and allocated to the appropriate department head. The grievance should be resolved within 72 hours. The Social Worker revealed that residents are educated on facility grievance policies and procedures during care plans. The Social Worker revealed that Resident #44 filed a grievance with ADON A or that an official grievance was filed for Resident #44 related to her wheelchair. The Social Worker revealed that she was unaware that Resident #44 had a broken wheelchair or that her current wheelchair did not meet her needs. The Social Worker did not reveal a risk to residents for unresolved grievances. <BR/>Interview with Administrator on 08/30/24 at 4:39PM revealed that the facility procedures on grievances was that residents can go to any facility department head to file a grievance. The Administrator revealed that then the grievance, after it is filed, will then be transcribed to the grievance log and assigned to the appropriate department head for resolution. The Administrator revealed that the facility social worker is the grievance official and oversees the grievance procedures. The Administrator revealed that she was unaware that Resident #44's grievance related to her wheelchair was not resolved or not transcribed to the grievance log. The Administrator did not reveal a risk to residents for unresolved grievances. <BR/>The facility did not provide a policy related to grievances. A policy was requested to the Administrator on 08/29/24 at 5:44PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the MDS (Minimum Data Set) assessment accurately reflected the resident's status for 1 (Resident #55) of 5 resident's reviewed for MDS assessment accuracy. <BR/>The facility failed to ensure Resident #55's Quarterly MDS assessment with an ARD (assessment reference date) of 05/14/2024, reflected his current diagnosis of Major Depressive Disorder (clinical depression).<BR/>This failure could place residents at risk of not receiving care and services to meet their needs.<BR/>Findings Included:<BR/>Record Review of Resident #55's Quarterly MDS with an ARD (Assessment Reference Date) of 05/14/2024 revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #55's active diagnoses included: Aphasia (brain disorder that affects the ability to speak or understand language), Hemiplegia following cerebral infarction (weakness on one side of the body following a stroke) and muscle weakness. Record Review of the MDS Section I, Active Diagnoses revealed a sub-section titled, Psychiatric/Mood Disorder. The sub-section revealed an option titled, Depression (other than bipolar), this option was not checked, indicating no active diagnoses of depression. Resident #55 had a BIMS score of 1 indicating a severe cognitive impairment. <BR/>Record Review of the document titled, New Patient Referral Form, dated 02/14/2024 revealed Resident #55 was referred to [Psych provider] for psychology and psychiatry services on 02/14/2024 for: Depression/Sadness, withdrawal, tearfulness, agitation, irritability, confusion, high risk behavior and resistance to ADL/Medications. <BR/>Record Review of the document titled, Psychiatric Subsequent Assessment, dated 04/24/2024, revealed Resident #55's primary treating diagnoses was, F33.9- Major Depressive Disorder, recurrent, unspecified. Reason for referral [for psychiatric services] indicated depression, withdrawal, isolation, tearfulness, agitation, irritability, confusion, and resistance to ADL/Medications. Current Psychotropic Medications revealed the following:<BR/>Medication- Trazodone (medication used to treat depression)<BR/>Start Date- 02/07/2024<BR/>Quantity- 1<BR/>Dosage/Frequency- 100mg Tablet/BID <BR/>Treating- F33.9 (Major Depressive Disorder)<BR/>No stop date indicated.<BR/>Record Review of the facility document for Resident #55 titled, Order Summary Report, dated 08/28/2024, revealed the following: <BR/>Active Orders As of 08/28/24 for [Resident #55]<BR/>Order Summary- Trazadone HCI Tablet 50MG (Trazodone HCI)<BR/>Give 1 tablet by mouth two times a day for antidepressant<BR/>Communication method- Phone<BR/>Order Status- Active<BR/>Interview with Resident #55 on 08/27/24 at 11:15AM revealed Resident #55 was tearful and began crying during several times of the interview. Resident #55 expressed feelings of depression, sadness and frustration with his current nursing facility placement and his inability to communicate effectively his needs with staff due to his communication deficits. Resident #55 revealed he had been seeing a psychiatrist but could not reveal if he had been diagnosed with Major Depressive Disorder. <BR/>Interview with LVN I on 08/30/24 at 10:11AM revealed that she had been the nurse for Resident #55. LVN I revealed that she had witnessed crying episodes with Resident #55. LVN I revealed that she was unaware if Resident #55 was currently being treated for Major Depressive Disorder. LVN I revealed that she did have access to Resident #55's MDS and care plan but was unaware of his current and active diagnoses. LVN I revealed that Resident #55 was currently taking medications that treat depression. <BR/>Interview with MDS Nurse G on 08/30/24 at 11:05AM revealed that she was unaware that Resident #55's MDS assessment did not reflect his current diagnosis of Major Depressive Disorder. MDS Nurse G revealed that she was the only person in the facility responsible for MDS assessments and their accuracy up until a few weeks ago. MDS Nurse G revealed that MDS Nurse Q recently started a few weeks ago and now is currently assisting with all assessments. MDS Nurse G revealed that she reviews all clinical documentation including psychiatry visit notes to ensure accuracy of the MDS assessment to ensure it reflects the resident's current clinical condition. MDS Nurse G revealed a risk to the resident for inaccurate MDS assessments would be the potential for missed care and care needs. <BR/>Interview with MDS Nurse Q on 08/30/24 at 11:15AM revealed that revealed that she was unaware that Resident #55's MDS assessment did not reflect his current diagnosis of Major Depressive Disorder. MDS Nurse Q revealed that she had recently been hired at the facility and is responsibility for MDS assessments along with MDS Nurse G. MDS Nurse Q revealed she ensures MDS assessment accuracy by reviewing all clinical documentation along with staff and resident interviews. MDS Nurse Q revealed a risk to the resident for inaccurate MDS assessments would be the potential for missed care and care needs.<BR/>Interview with DON on 08/30/24 at 2:50PM revealed that it was the responsibility of the MDS Nurses to ensure accuracy of all MDS assessments. The DON revealed that he was unaware that Resident #55's Quarterly MDS assessment did not reveal his active diagnosis of Major Depressive Disorder. The DON revealed that he has not seen Resident #55 tearful but was aware he was being treated for Major Depressive Disorder by the facility's psychiatrist. The DON revealed that a risk to the resident for inaccurate MDS assessments would be the missed care areas and interventions. <BR/>Interview with Administrator on 08/30/24 at 5:00PM revealed that the MDS nurses are responsible for ensuring all MDS assessments are accurate and reflect the resident's diagnoses and care. The Administrator revealed that she was aware Resident #55 was currently on psychiatric services but was not aware he was currently being treated for Major Depressive Disorder. The Administrator revealed that a risk to the resident for inaccurate MDS assessments would be the potential for missed care. <BR/>Record Review of the facility's policy titled, Electronic Transmission of the MDS, no date reflected, revealed that, The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data.<BR/>Record Review of the facility's document titled, Job Description-MDS, no date reflected, revealed that, [The] Job Description [is to] conduct and coordinate the development and completion of the resident assessment (MDS) in accordance with current rules, regulations, and guidelines that govern the resident assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to submit an accurate PL1 (PASARR Level 1) screening when residents admitted with a diagnosis of Mental Illness, Intellectual Disability or Developmental Disability for 1 (Resident #55) out of 5 residents reviewed for PASARR screenings.<BR/>The facility failed to submit a new PL1 screening when Resident #55 was diagnosed with Major Depressive Disorder after admission to the facility.<BR/>These failures could affect residents by not receiving a Level II PASARR Evaluation to access for needed services. <BR/>Findings Included:<BR/>Record Review of Resident #55's Quarterly MDS with an ARD of 05/14/2024 revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #55's active diagnoses included: Aphasia (brain disorder that affects the ability to speak or understand language), Hemiplegia following cerebral infarction (weakness on one side of the body following a stroke) and muscle weakness. Resident #55 had a BIMS score of 1 indicating a severe cognitive impairment.<BR/>Record Review of the document titled, Psychiatric Subsequent Assessment, dated 04/24/2024, revealed Resident #55's primary treating diagnoses was, F33.9- Major Depressive Disorder, recurrent, unspecified. Reason for referral [for psychiatric services] indicated depression, withdrawal, isolation, tearfulness, agitation, irritability, confusion, and resistance to ADL/Medications<BR/>Record Review of the document titled, PASRR Level 1 Screening dated 02/07/2024 revealed that Resident #55's PL1 screening indicated that Resident #55 did not have evidence of mental illness, intellectual disability or developmental disability. <BR/>Interview with Resident #55 08/27/24 at 11:30AM revealed that he had not received PASARR services. Resident #55 revealed that nobody at the facility had discussed PASARR services with him. Resident #55 revealed that he would like to be screened for potential PASARR services if he did qualify. <BR/>Interview with MDS Nurse G 08/30/24 at 11:10AM revealed that she along with MDS Nurse Q were responsible for ensuring PASARR Level 1's were accurate and received on admission. MDS Nurse G revealed that she was unaware a new PASARR Level 1 was not submitted for Resident #55 after he was diagnoses with Major Depressive Disorder. MDS Nurse G revealed that if a resident is diagnosed with a new diagnosis of mental illness, developmental disability or intellectual disability a new PASARR Level 1 should be submitted. MDS Nurse G revealed that a risk for incorrect PASARR Level 1 evaluations would be missed care. <BR/>Interview with the DON on 08/30/24 at 3:22PM revealed that MDS A and MDS Nurse Q were responsible for ensuring that the PASARR Level 1's were accurate and received on admission. The DON revealed that he was unaware that Resident #55 did not have a new PASARR Level 1 submitted after being diagnosed with Major Depressive Disorder. The DON revealed the facility procedure for PASARR's was that the facility would ensure the PASARR Level 1 is submitted to the LTC Online Portal on admission and if that PASARR Level 1 indicated yes for, mental illness, developmental disability or intellectual disability then that would trigger a PASARR Level II or evaluation to be completed. The DON revealed a risk for incorrect PASARR Level 1 evaluations would be missed care for the residents. <BR/>Interview with Administrator on 08/30/24 at 5:10PM revealed that she was unaware that Resident #55 did not have a new PASARR Level 1 submitted after he was diagnosed with Major Depressive Disorder during his stay. The Administrator revealed that PASARR provided services for residents such as, therapy, case management and rehabilitation services. The Administrator revealed that it was the responsibility of MDS Nurse G and MDS Nurse Q to ensure accuracy of all PASARR assessments. The Administrator revealed a risk for incorrect PASARR Level 1 evaluations would be the opportunity for missed care needed for the residents. <BR/>The facility did not provide a policy related to PASARR services or PASARR assessments. A policy was requested to the Administrator on 08/29/24 at 5:44PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Residents #1) of three residents reviewed for comprehensive care plans.<BR/>Resident #1's care plan failed to address interventions to prevent complications related to her PICC line. <BR/>This failure placed residents at risk of not receiving individualized care and services to meet their needs and interventions to prevent complications related to each individuals identified concerns. <BR/>Findings included:<BR/>Record review of Resident #1's admission MDS assessment, dated 08/05/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's brief interview for mental status was cognitively intact by staff assessment. The resident had IV medications. Her diagnoses included acute and subacute endocarditis (inflammation of heart value), diabetes mellitus and depression. <BR/>Record review of Resident #1's August 2023 Physician's Orders reflected, Flush PICC line with 2 lumen with 10cc NS before and after meds and every shift for patency, with a start date of 08/02/23. Monitor PICC line site for s/s of infection, with a start date of 08/03/23. Change PICC line dressing using biopatch per facility protocol every Thursday .<BR/>Record review of Resident #1's MAR for August 2023 reflected, Flush PICC line with 2 lumen with 10cc NS before and after meds and every shift for patency, with a start date of 08/02/23. Monitor PICC line site for s/s of infection, with a start date of 08/03/23. Change PICC line dressing using biopatch per facility protocol every Thursday, with a start date of 08/10/23.<BR/>Record review of Resident #1's Care Plan implemented on 08/10/23 revealed it did not address the residents PICC line status or interventions to prevent complications related to the PICC line.<BR/>Observation on 08/17/23 at 12:00 PM revealed Resident #1 had PICC line to her inner right upper arm. <BR/>Interview on 08/17/23 at 12:30 PM with the Administrator revealed the MDS Coordinator was not in the building and was out on personal leave.<BR/>Interview on 08/17/23 at 12:40 PM with the DON revealed any resident with a PICC line should have those areas care planned with interventions to prevent complications. <BR/>Interview on 08/17/23 at 1:18 PM with the Administrator revealed the MDS Coordinator was responsible for creating the comprehensive care plan. He stated the care plan had to include all the resident's identified problems and interventions to prevent complications. He stated they had been without a MDS Coordinator she was out on personal leave. <BR/>The facility's policy, Comprehensive Assessments and the Care Delivery Process, undated, reflected, Comprehensive assessments will be conducted to assist in developing person-centered care plans. Policy Interpretation and Implementation: Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information collection (assessment) phase is to obtain, organize, and subsequently analyze information about a patient. Assessment and information collection includes (WHAT, WHERE, and WHEN?). The objective of the information collection (assessment) phase is to obtain, organize, and subsequently analyze information about a patient.<BR/>Record Review of Facility Policy, Care Plans, Comprehensive Person-Centered, dated 12/2016, revealed, The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment .e. Include the residents stated goals upon admission and desired outcomes; f. Include the residents stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; i. Build on the residents strength .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain good foot health for one (Resident #75) of five residents reviewed for foot care. <BR/>The facility failed to ensure Resident #75 received foot care. <BR/>This failure could place residents at risk of diminished quality of life by not receiving care and services to meet their needs. <BR/>Findings included:<BR/>Record review of Resident #75's Quarterly MDS, dated [DATE], revealed an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included anemia, hypertension, renal failure, neurogenic bladder, Non-Alzheimer's Dementia, malnutrition, anxiety, depression, and insomnia. Her BIMS score was 10 out of 15, which revealed she was moderately impaired. She required extensive assistance with one-person physical assistance regarding personal hygiene. She required total dependence with one-person physical assistance regarding bathing.<BR/>Review of Resident #75's care plan, undated, revealed she required assistance with ADLs and required one-person assist from staff. Her goal was to remain clean, comfortable, well groomed, and maintain optimal mobility on a daily basis. Her intervention was needed encouragement from staff to participate with ADLs as able and staff to assist with/provide ADLs as needed. She was at risk of complications, injury, infection, and ineffective protection related to resisting care. Her goal was to cooperate with care. Her intervention was to encourage as much participation/interaction by the resident as possible during care activities. If possible, negotiate a time for ADLs so that the resident participates in the decision-making process.<BR/>Review of Resident #75's skin assessments dated March 2023 revealed there were no issues regarding her feet. There were no skin assessments for April 2023. <BR/>Review of the facility's podiatry referral list, dated 03/06/23, revealed Resident #75 was not included.<BR/>Interview and observation with Resident #75 on 04/23/23 at 11:46 revealed the skin on the bottom of her feet were red and peeling. There were pieces of dried skin on her linens near her feet. She stated her feet hurt and she did not remember the last time she was seen by a podiatrist. She stated she was unaware the bottom of her feet was red and her skin was peeling. She stated she informed her nurse she was in pain. LVN A came into Resident #75's room and administered Tylenol. <BR/>Interview with LVN A on 04/23/23 at 11:56 AM revealed she had not seen Resident #75's feet prior to surveyor's interview. She stated she did not know her feet were hurting, red, and peeling. She stated the social worker was responsible for residents to receive footcare. She stated Resident #75's feet should not be red or peeling. She stated Resident #75's feet appeared to be dry and only needed lotion on her. She stated the CNAs were responsible for ensuring lotion was applied to her feet. She did not inform the surveyor of any potential risks regarding Resident #75's lack of footcare.<BR/>Observation and Interview with Resident #75 on 04/24/23 at 12:16 PM revealed there was no changes to her feet. The bottom of her feet was red and peeling. There were still pieces of dried skin on her linens near her feet. She stated she had not received footcare.<BR/>Interview with DON on 04/24/23 at 03:31 PM revealed he had not recently viewed Resident #75's feet. He stated he did not remember the last time he saw her feet. The surveyor asked the DON questions regarding Resident #75's feet. He stated he did not know how her feet ended up in their current state. He stated staff should have been applying lotion to her feet. He stated the social worker was responsible for podiatry referrals but was currently on vacation. He stated her feet issue should have been documented on her skin assessments. He stated she was at risk of skin breakdown due to not receiving podiatry care. He stated the nurse should have taken care of Resident #75's feet. He stated the nurse should have assessed the resident's skin, applied lotion, and consulted podiatry. <BR/>Observation and Interview with Resident #75 on 04/25/23 beginning at 3:45 PM revealed her feet had been treated. She stated she received footcare from a staff member. She stated she also had lotion applied to her feet. She stated she felt better and was experiencing less pain in her feet. Her feet appeared to have less dry skin than 04/23/23.<BR/>Interview with CNA B on 04/25/23 at 9:17 AM revealed she had not seen Resident #75's feet prior to 04/25/23. She stated her feet were always covered. She stated she never applied lotion to Resident #75's feet. She stated her feet appeared to have been moisturized by lotion on 04/25/23. She stated she was responsible for applying lotion to residents' feet after showers, dressing, and as needed. She stated she reported residents' dry skin to the nurses and asked if lotions could be applied to the dry area. She stated Resident #75 was at risk of skin breakdown and pressure sores if footcare was not received.<BR/>Interview with Administrator on 04/25/23 at 04:38 PM revealed the facility was contracted with a podiatry provider who offered in house services to residents. She stated the podiatry provider came to the facility in March 2023 and would return in May 2023. She stated the social worker completed podiatry referrals. She stated the social worker was currently on vacation. She stated Resident #75 was non-complaint with ADLs. She stated the social worker spoke with the resident about different service provider options at the facility and she refused services. She stated she did not know if the social worker had documented refusals of all services. She stated she ensured the social worker was making referrals. She stated she discussed podiatry referrals during the morning meeting close to the podiatry provider visit time. She stated the importance of footcare was to ensure residents received nail care and care to their feet to prevent infection. <BR/>Review of facility policy, Foot Care, undated, reflected: Residents will receive appropriate care and treatment in order to maintain mobility and foot health.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for contaminated sharps disposal bins, attached to one (300 Hall MA Medication Cart) of one 300 Hall MA Medication Cart and one (300 Hall Nurse Medication Cart) of one 300 Hall Nurse Medication Cart reviewed for hazards. <BR/>MA B failed to ensure contaminated sharps in the sharps bin attached to the 300 Hall MA Medication Cart, were below the full line. <BR/>MA B failed to ensure medications found on the sharps bin insert lid on the 300 Hall MA Medication Cart, were disposed of properly. <BR/>RN C failed to ensure contaminated sharps in the sharps bin attached to the 300 Hall Nurse Medication Cart, were below the full line. <BR/>These failures placed residents at risk of being exposed to contaminated sharps, possible bloodborne pathogens, and access to unprescribed medications. <BR/>Findings included:<BR/>An observation on 01/30/2024 at 10:07 AM, revealed the plastic insert contained inside the sharps bin attached to MA B's 300 Hall MA Medication Cart was past the full line. Sharps (needles, blades [such as scalpels] and other medical instruments that are necessary for carrying out healthcare work and could cause an injury by cutting or pricking the skin) in the insert blocked the insert's lid from closing completely. Eight pills were observed, stuck between the plastic insert and the insert's lid which contributed to the lid from closing properly. <BR/>In an interview on 01/30/2024 at 10:08 AM, MA B stated she was not aware the sharps in the bin were past the full line because she did not use it. She said the lid on the sharps bin insert should be free to close to ensure staff and resident safety. She said she did not see the medications on the lid of the sharps insert but could see they were preventing the lid from closing completely. She said all staff were responsible to ensure the sharps bin inserts were not filled past the full line however only the nurses had keys to the sharps bins attached to the carts. She said medications should not be disposed of in the sharps bin. She said the full bin and medications posed a hazard for residents and staff. <BR/>In an interview on 01/30/2024 at 10:20 AM, ADON A said the sharps bins should never be filled past the fill line to prevent possible injury to staff or residents. When asked about the medications stuck on the lid of the sharps bin insert, he said medications should not be disposed of in the sharps bin and did not know why the medications were on the sharps bin lid. He stated the medications appeared to be blocking the lid from closing properly. He stated the nurses had keys to the bins and were responsible to ensure the bins were not filled past the full line. He said the medications could be accessible to residents and posed a potential hazard as residents. He said he would find the keys to MA B's cart and change the sharps bin and remove the medications from the lid. <BR/>An observation on 01/30/2024 at 10:30 AM, revealed the plastic insert in the sharps bin, attached to RN C's 300 Hall Nurse Medication Cart to be past the full line. She said it should not be past the full line because the lid would not close properly which posed a potential hazard. She said the nurses had keys to the sharps bins and should ensure the inserts were not filled past the full line. <BR/>In an interview on 01/30/2024 at 1:50 PM, the Administrator said the sharps bin inserts should never be filled past the full line because it posed a potential risk of harm to staff and residents. She said they could be stuck by a needle if the lid did not close properly. She said she expected nursing staff to ensure this was done and nursing management to monitor it. She said medications should not be disposed of in the sharps bins and should not be on the lid of the bins where residents could have access to them. She said many of the residents in the facility tend to wander and could have consumed the medications. <BR/>In an interview on 01/30/2024 at 3:31 PM, the DON said the sharps bins should never be filled past the full line. He said the lid does not close properly when sharps are above the full line which could cause a risk of staff or residents getting stuck with a needle. He said a staff member was recently stuck in this manner and in servicing was conducted. He said medications should be disposed of properly and not placed in the sharps bin. He said he changed out MA B's sharps insert and disposed of the pills that were on the lid. He said he did not feel the medications were accessible because they were in a groove at the back of the insert lid. He said none-the-less the medications should not be there and since the insert lid could not close properly, there was a potential hazard to residents if they were able to get the medications. He said staff are trained on how to dispose of medication properly. <BR/>Record review of the facility's undated policy titled, Safety and Supervision of Residents, reflected, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation - Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. 3. When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. 5. The QAPI Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assist in obtaining routine and emergency dental care for 1 out of 5 residents (Resident #55) reviewed for dental services. <BR/>The facility failed to complete and submit a dental referral for Resident #55 <BR/>This failure could place Resident's at risk for oral complications, dental pain and diminished quality of life. <BR/>Findings Included:<BR/>Record Review of Resident #55's Quarterly MDS with an ARD (Assessment Reference Date) of 05/14/2024 revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #55's active diagnoses included: Aphasia (brain disorder that affects the ability to speak or understand language), Hemiplegia following cerebral infarction (weakness on one side of the body following a stroke) and muscle weakness. Resident #55 had a BIMS score of 1 indicating a severe cognitive impairment. Review of the assessment revealed that Resident #55 had no dental issues identified and he required setup or clean-up assistance for oral hygiene. <BR/>Record Review of the document titled, Care Plan Sheet, dated 05/23/24 revealed Resident #55's quarterly care plan meeting was held on 05/23/24. Document revealed Resident #55 was not present and Resident #55's family member was called, but did not indicate if they were present. Document did not reveal if dental services were reviewed or offered or if a dental referral was initiated or completed. <BR/>Record Review of Resident #55's comprehensive care plan, no date reflected, did not reveal Resident #55's oral/dental status or any interventions related to Resident #55's current dental/oral health needs. <BR/>Interview with Resident #55 on 08/27/24 at 11:15AM revealed that he was aware that the facility offered dental services. Resident #55 revealed that he was able to brush his own teeth, the best he could. Resident #55 revealed that he would like to see the dentist, but he did not know who to ask at the facility about dental services. <BR/>Observation of Resident #55's teeth on 08/27/24 at 11:21AM revealed his teeth were cracked, missing teeth noted, and a strong odor arose from Resident #55's mouth. <BR/>Interview with RP #2 on 08/27/24 at 12:42PM revealed that she was aware that the facility provided routine dental services. RP #2 revealed that she requested a dental referral be completed for Resident #55, but could not remember the exact date. RP #2 revealed that Resident #55 did complain of dental pain to her, RP#2 stated that Resident #55's dental pain was not reported to the facility nursing staff as she was under the impression the dental referral had been completed. <BR/>Interview with LVN F on 08/27/24 at 3:55PM revealed that she had been the nurse assigned to Resident #55 during the 6AM-6PM shift and that had been her normal assignment. LVN F revealed that Resident #55 did not complain of dental or oral pain to her. LVN F revealed Resident #55 could independently manage his oral hygiene needs. LVN F revealed if a resident reported to her of any oral or dental pain or if a resident or family member requested dental services she would alert the attending physician for that resident and the facility social worker. <BR/>Interview with Social Worker on 08/30/24 at 1:59PM revealed that she was responsible for ancillary service coordination at the facility which did include, dental services. The Social Worker revealed that she was not aware Resident #55 was complaining of dental or oral pain or that RP #2 requested dental services. The Social Worker revealed that if a dental referral was made to her or if she was alerted that a resident did need services of any kind, that referral would be completed typically within the week. The Social Worker did not reveal a risk to residents if they did not receive dental services when requested or needed. <BR/>Interview with DON on 08/30/24 at 2:40PM revealed that the facility Social Worker was responsible for ensuring all Resident's are assessed for ancillary services, including dental services. The DON revealed that he was not aware Resident #55 was complaining of oral or mouth pain or that RP #2 requested dental services for Resident #55. The DON revealed that it was his expectation for all Resident's to be assessed for ancillary services, including dental services, quarterly, annually and on admission. The DON revealed if the oral or dental pain was emergent, then the Resident's attending physician would be contacted. The DON revealed a risk to Resident's who do not receive routine dental services when requested or needed would be an increased risk to oral complications and infection. <BR/>Interview with Administrator on 08/30/24 at 4:05PM revealed that dental services along with other ancillary services are reviewed on admission, quarterly and annually with all resident's and their representatives. The Administrator revealed that the facility does have routine dental and emergency dental services available for the facility residents. The Administrator revealed that the Social Worker is responsible for screening Resident's for needed services. The Administrator revealed she was not aware Resident #55 was complaining of mouth and oral pain and that RP #2 requested dental services for Resident #55. The Administrator revealed she would get with the Social Worker to initiate a dental referral immediately for Resident #55. The Administrator revealed a risk to residents who do not receive routine dental services when requested or needed would be an increased risk to oral and health complications. <BR/>Record Review of facility's policy titled, Dental Services, dated December 2016 revealed that, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care .social services representatives

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of the resident needs for 2 (Resident #6, and Resident #83) of 5 residents reviewed for resident rights. <BR/>The facility failed to ensure Resident #6 and Resident #83's call light was placed within reach. <BR/>These failures could place residents at risk of injuries and unmet needs. <BR/>Findings included:<BR/>Review of Resident #6 Quarterly MDS assessment dated [DATE] revealed resident was admitted on [DATE] with readmission on [DATE], diagnoses of cerebral infarction (stroke), dementia (loss of cognition cognitive communication deficit), unsteadiness on feet, difficulty in walking, generalized muscle weakness, and a BIMS score of 7 (severely impaired cognition). <BR/>Review of Resident #6 Care Plan dated initiated 04/04/2023 and revised 05/03/2024 reflected resident had a history of falls and had a fall with injury to his forehead on 04/04/2024 due to an unsteady gait with the intervention to remind resident to call for help before he got up. Review of Care Plan dated initiated 08/22/2018 and revised on 04/11/2023 reflected Resident #6 had an ADL self-care performance deficit and limited mobility due to a stroke with the intervention of Encourage resident to use bell to call for assistance. <BR/>Observation on 06/04/2024 at 11:02 AM of Resident #6 revealed resident was laying in a low bed watching television with his call light hanging off the right side of his bed rail. <BR/>Interview on 06/04/2024 at 11:03 AM with Resident #6 revealed he was alert and slightly confused, he did not know where his call light was and did not know how to find it and stated he could not reach it. <BR/>Interview on 06/04/2024 at 11:15 AM with CNA O revealed she had worked at the facility for a year and was familiar with Resident #6. CNA O stated that Resident #6 was at risk for falls and stated that his call light was out of his reach which put the resident at risk of having a fall by not being able to call for assistance first. CNA O stated call lights are important to be kept within reach of residents because if a resident fell they would not be able to call for assistance. CNA O placed call light next to resident on the bed. <BR/>Interview on 06/05/2024 at 3:51 PM with ADON A revealed Resident #6 was at facility for long term care and had dementia, a history of falls and was on fall precautions which included keeping his bed at a low level, ensure the resident was positioned correctly, and had call light within reach. ADON A stated that she would be concerned if Resident #6's call light was not within reach because even though he was forgetful it was important he had the ability to use the call light. ADON A stated the risk to a resident to not have a call light within reach was that a resident would not be able to call when they need help and could fall. <BR/>Review of Resident #83 Quarterly MDS assessment dated [DATE] revealed resident was admitted on [DATE] and had the diagnoses of osteoarthritis (disease of the joints), pain in unspecified hip, muscle weakness, unsteadiness on feet, and a BIMS of 6 (severely impaired cognition). <BR/>Review of Resident #83's Care Plan dated initiated 01/10/2024 and revised on 01/31/2024 reflected resident was at risk for falls due to a history of falls and had an unsteady gait with the intervention of keep call light within reach. Review of Care Plan dated initiated 05/07/2024 reflected Resident #83 was on hospice services and was at risk of decline in mental and physical conditions with an intervention of call light in reach and answer promptly. <BR/>Observation on 06/04/2024 at 10:50 AM revealed Resident #83 was awake lying in bed, wearing pajamas, with a stuffed animal under his arm and his call light was out of reach, looped and hung on the wall behind the resident's bed.<BR/>Interview on 06/04/2024 at 10:51 AM with Resident #83 revealed he was not sure where his call light was located. <BR/>Interview on 06/04/2024 at 10:59 AM with CNA D revealed he had worked at the facility for 13 years and stated that the call light should be placed within reach next to Resident #83 and was not sure why it was on the wall. CNA D placed call light next to resident on bed. CNA D stated that Resident #83 was at risk of falls and should always have his call light within reach to be able to call for assistance to get out of bed or to be able to call for help if he did fall. CNA D stated that he was not sure who assisted the resident last because hospice services had also been to visit with resident and that any staff member who previously assisted Resident #83 was responsible to ensure the call light was within reach. CNA D stated the risk to a resident by not having a call light within reach is risk of injury, falling, or not having their needs met. <BR/>Interview on 06/05/2024 at 3:53 PM with ADON A revealed Resident #83 had dementia, a history of falls, was ambulatory and liked to walk around in his room by himself. ADON A stated that Resident #83 should always have his call light within reach. ADON A stated the risk to a resident who did not have a call light within reach would be they would not be able to get assistance or could fall and not be able to receive assistance. ADON A stated any staff member who assisted residents was responsible for ensuring call lights were placed within their reach and it was important to ensure residents had their needs met and prevent possible injury.<BR/>Interview on 06/06/2024 at 10:30 AM with DON revealed he had worked at the facility for about 2 months and was familiar with Resident #6 and Resident #83. DON stated that Resident #6 ambulates himself with a wheelchair and had difficultly expressing himself verbally. DON stated Resident #6 was at a high risk of falls because his gait was unsteady and that his call light should always be within his reach so he could ask for assistance. DON stated that Resident #83 was alert but confused and currently was on hospice services and should always have call light within reach so resident could call for assistance if needed. DON stated any staff member including CNAs or RNs are supposed to ensure the call lights were within reach when they round and provide care to residents. DON stated that having a call light within reach of residents was important for safety reasons, so residents are able to call for assistance and have their needs met. <BR/>Interview on 06/06/2024 at 12:56 PM with Administrator revealed she was familiar with Resident #6 and Resident #83 and stated they were both at high risk of falls and should always have their call light within reach. Administrator stated it was important that all residents had their call lights within reach because it was their policy and a safety precaution and ensured residents received assistance that they needed. <BR/>Facility policy on resident call lights was requested on 06/05/2024 and facility provided safety policy titled Safety and Supervision of Residents. Review of safety policy reflected: Systems Approach to Safety . facility-oriented and resident-oriented approaches to safety are used to gather to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for two of five (Resident #1 and Resident #2) residents reviewed for quality of care.<BR/>1. The facility failed to assess and provide treatment for Residents #1's left foot heel, left inner foot by her big toe, and right inner foot by the bony area of her big toe. <BR/>2. The facility failed to implement wound care for Resident #2's left 2nd toe, left 5th toe, and left great toe .<BR/>This failure could place residents at risk for increased pain and infection. <BR/>Findings included :<BR/>1. Review of Resident #1's Quarterly MDS assessment, dated 03/20/23, revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. She had clear speech, was sometimes understood by others, and sometimes understood others. Her BIMS score was 99, which reflected she was unable to complete the interview. Her diagnoses included: hypertension, urinary tract infection, hyperlipidemia, cerebrovascular accident, malnutrition, respiratory failure, and dysphagia. Her Skin Conditions section revealed she was at risk of developing pressure ulcer/injuries, had one stage 4 pressure ulcer, and had two unstageable-deep tissue injuries. Her skin and ulcer /injury treatments were pressure ulcer/injury care and application of dressings to feet.<BR/>Review of Resident #1's physician orders, dated 02/06/23 , reflected, Left foot DTI cleanse with normal saline pat dry apply Betadine with foam dressing daily.<BR/>Review of Resident #1's physician orders, dated 04/11/23, reflected, Clean right foot with normal saline pat dry apply Betadine with foam dressing. Left Heel cleanse with normal saline pat dry apply Betadine with foam dressing daily.<BR/>Review of Resident #1's MAR, dated May 2023, reflected, Clean right foot with normal saline pat dry apply Betadine with foam dressing. One time a day at 9:00 AM for DTI with a start date of 04/12/23. Left foot DTI; cleanse with normal saline pat dry apply Betadine with foam dressing daily. One time a day at 9:00 AM for wound care with a start date of 02/07/23. Left heel; cleanse with normal saline pat dry apply Betadine with foam dressing daily. One time a day at 9:00 AM for wound care with a start date of 04/12/23. The MAR revealed Resident #1 had received wound care from 05/01/23 to 05/09/23 as ordered. <BR/>Review of Resident #1's care plan, undated, reflected, actual impairment to skin integrity of left foot stage DTI, left heel DTI due to fragile skin and debility. Will have no complications from wound and will heal through the next review date. <BR/>Review of facility weekly wound care log, dated 05/01/23, reflected Resident #1 admitted to the facility with wounds to her left heel (measurement 2.4cm x 2.0cm x 0.1cm), left foot (measurements 1.0cm x 0.7cm x 0.1cm), and right foot (measurement 0.5cm x 0.5cm x 0.1cm). The etiology/cause of Resident #1's left heel was pressure-unstageable (tissue type was 100% slough), left foot was a DTI, and right foot was as DTI. Her left heel treatment was Medi honey Calgigraf Ag with foam dressing. Her left and right foot treatments was Betadine with foam dressing. <BR/>An observation of Resident #1 on 05/09/23 at 7:30 AM revealed Left foot heel area with dressing dated 05/06/2023, the wound bed with yellow exudates. The left inner foot by the big toe wound with dark bed covered with foam dressing dated: 05/06/2023. The right inner foot by the bony area of the big toe skin redness not open covered with foam dressing dated: 05/06/2023. <BR/>An interview with LVN A and LVN B on 05/09/23 at 2:13 PM revealed both LVNs were assigned to Resident #1. They stated Resident #1 had wounds located on her sacrum, left foot, and right foot. They stated Resident #1 was supposed to receive wound care every day as ordered to promote healing and to prevent infection. They stated they were aware Resident #1's right and left foot wound care bandages were dated 05/06/23. They stated the bandages indicated Resident #1 had not received wound care since 05/06/23. They stated Resident #1 was at risk of infection. They stated the DON was notified regarding Resident #1's wound care. They stated Resident #1 was assessed and received wound care on 05/09/23. They stated Resident #1's assessment revealed there were no new issues regarding her wounds. They stated they received in-servicing regarding wound care on 05/09/23. <BR/>An interview with the DON on 05/09/23 at 5:28 PM revealed Resident #1 had wounds on her sacrum and feet. He stated he was not aware Resident #1's wound care dressings on her feet were dated 05/06/23. He stated the bandages indicated Resident #1 had not received wound care since that date. He stated Resident #1 received wound care after he was made aware of the incident on 05/09/23. He stated the importance of Resident #1 to receive wound care as ordered was to promote healing. He stated the potential risk to Resident #1 would be a delayed healing time. He stated Resident #1 was to receive wound care daily as ordered. He stated the nurses were responsible for ensuring Resident #1's wound care treatments were completed as ordered. <BR/>2. Review of Resident #2's annual MDS assessment, dated 04/23/23, revealed he was an [AGE] year-old male and admitted to the facility on [DATE]. His diagnoses were hypertension, neurogenic bladder, cerebrovascular accident, and respiratory failure. He had no speech and was rarely/never understood and sometimes understood others. His Skin Conditions section revealed he was at risk of developing pressure ulcer/injuries, had one stage 3 pressure ulcer, and had three venous and arterial ulcers present. His skin and ulcer /injury treatments were pressure ulcer/injury care and application of dressings to feet.<BR/>Review of Resident #2's physician orders, dated 04/25/23, reflected Left 2nd toe, arterial, clean with normal saline skin prep with foam dressing one time a day. Left 5th toe arterial, clean with normal saline skin prep with foam dressing one time a day. Left great toe, cleanse with normal saline pat dry, skin prep with foam dressing daily one time a day for wound care.<BR/>Review of Resident #2's MAR, dated May 2023, reflected, Left 2nd toe arterial, clean with normal saline skin prep with foam dressing one time a day at 9:00 AM with a start day of 04/26/23. Left 5th toe arterial, clean with normal saline skin prep with foam dressing one time a day at 9:00 AM with a start day of 04/26/23. Left great toe arterial, clean with normal saline skin prep with foam dressing one time a day for wound care at 9:00 AM with a start day of 04/26/23. Treatment date 05/09/23 was marked completed by LVN C.<BR/>Review of facility weekly wound care log, dated 05/01/23, reflected Resident #2 had wounds on his left great toe (measurement 1.5cm x 2.0cm x utd), left 2nd toe (measurement 0.5cm x 0.5 cm x utd), and left 5th toe (measurement 1.5cm x 0.2cm x utd). Their etiology/cause were arterial. Their needed treatment was Betadine with foam dressing. The date acquired for his left great toe was 04/20/23, left 2nd toe was 04/23/23, and left 5th toe was 04/23/23. The wounds were acquired while at the facility.<BR/>Observation of Resident #2 on 05/09/23 at 7:25 AM to 3:45 PM revealed his left great toe, 2nd toe, and left fifth toe were not covered by foam dressing and open to air. <BR/>In an interview with LVN C on 05/09/23 at 3:58 PM revealed Resident #2 had wounds on his left foot toes. She stated Resident #2 was supposed to received wound care on his left foot toes daily. She stated he was supposed to receive Betadine and foam dressing on his left foot toes. She stated she completed Resident #2's treatment record for 05/09/23 without completing the treatment. She stated she was unable to locate foam dressing on the treatment cart and decided not to complete his wound care. She stated best practice regarding Resident #2's treatment record was to sign off on treatment after he received wound care. She stated Resident #2 was at risk of infection due to not receiving wound care. She stated she was in-serviced regarding wound care in April 2023.<BR/>In an interview with DON on 05/09/23 at 5:28PM revealed he was recently made aware Resident #2 had not received daily wound care on 05/09/23. He stated he would have to investigate why Resident #2's treatment record was completed by LVN C if the treatment was not completed. He stated his expectation was for LVN C to complete Resident #2's treatment record after the treatment was completed. He stated the risk to Resident #2 not receiving wound care would depend on the nature of his wound and whether the wound was open or closed.<BR/>Review of facility policy, Wound care, undated, reflected: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #24) reviewed for gastrostomy tube management.<BR/>The facility failed to ensure Resident #24's head of bed was elevated at a minimum of 30-degree angle during medication administration and bolus feeding (a way to deliver food directly to the stomach) via gastrostomy tube (G-tube) (A tube directly inserted through the skin to the stomach to deliver nutrition). <BR/>The facility failed to check the Resident #24's residual before administering medications <BR/>This failure could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health.<BR/>Findings include:<BR/>Record review of Resident #24's face sheet dated 4/25/23 revealed a 49- year-old-male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included urinary tract infection, pneumonia, anemia, hypertension, type 2 diabetes, and moderate protein calorie malfunction. <BR/>Record review of Resident #24's Comprehensive MDS dated [DATE] revealed the resident's BIMS score was unable to be scored. Cognitive skills for daily decision making identified Resident #24 as severely impaired. Nutritional Status section identified use of a feeding tube. <BR/>Record review of Resident #24's Care Plan dated 9/20/21 revealed: Focus: Resident #24 had a peg tube and received nutrition and/or hydration via tube, remained as risk for aspiration. Goal: Resident #24 will display no signs and symptoms of volume depletion, weight loss or aspiration. Interventions: Keep head of bed elevated 30-45 degrees during and at least 1 hour after feeding. Further indicated to check for placement of tube and residual amount prior to flushing, feeding, or administering medications. <BR/>Record review of Resident #24's April 2023 medication administration record dated 4/25/23, revealed (Enteral) elevate head of bed 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped every shift. <BR/>Observation on 4/23/23 at 09:58 AM revealed Resident #24 resting in bed and his head of bed was flat and the legs were elevated. Further observation revealed RN D administering medications and bolus feeding while Resident #24's head of bed was flat in bed. After medication administration and bolus feeding the RN D left the residents in the flat position and proceeded to clean the resident's items.<BR/>In an interview on 04/23/23 at 10:18 AM with RN D he stated Resident #24's head of bed was to be elevated during medication administration and bolus feeding to prevent the resident from aspirating. RN D stated the bed was non-functional when he checked early but when he tried to elevate the residents head of bed, the bed was able to elevate without any issues. RN D further stated he was supposed to check for residual before medication administration or bolus feeding. RN D stated residual was to be complete to make sure the resident was not overfed and if the resident was retaining feeding, if so, the resident's primary care provider was to be notified. RN D stated without checking residual could cause other side effects if the resident had too much in the stomach like vomiting, discomfort and even aspiration. <BR/>In an interview on 04/24/23 at 03:04 PM with the DON he stated the staff was to make sure residual was checked and the head of the bed was elevated during medication administration and bolus feeding to prevent resident aspiration. <BR/>Review of the facility policy undated and titled Administering Medications Through an Enteral Tube reflected, after administering medications 18. Have the resident maintain the semi-Fowler's position for at least 30 minutes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all residents had a means to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 2 (Residents #3 and #4) of 9 residents reviewed for resident call systems.<BR/>Residents #3 and #4 were moved to the same room on a covid unit for quarantine after testing positive for the virus. The room did not contain a call system for use at the bedside. <BR/>This failure could place residents at risk of not being able to notify staff when care was needed.<BR/>Findings included:<BR/>Resident #3<BR/>Record review of Resident #3's admission Record dated 12/28/23 revealed he was a [AGE] year-old ma major depressive disorder, le admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), pain in unspecified joints, acute pancreatitis, primary hypertension (high blood pressure), paroxysmal atrial fibrillation (irregular heartbeat), and age-related osteoporosis. <BR/>Record review of Resident #3's MDS assessment dated [DATE] revealed he had a BIMS score of 13, indicating he was cognitively intact, and was receiving hospice services. The MDS revealed he used partial/moderate assistance while moving from a sitting to a standing position and for bed to chair transfers. <BR/>Record review of Resident #3's current Care Plan dated 5/18/23 and revised 6/29/23:<BR/>Focus: Risk for falls related to weakness due to COPD and unsteady gait.<BR/>Goal: Will have decreased risk for serious injury or hospitalization as a result of falling through the next assessment review period.<BR/>Intervention: .Keep call light within reach <BR/>Record review of Resident #3's Progress Notes dated 12/25/23: Resident having generalized weakness and complain of chills, rapid covid test completed-nasal swab positive. Resident was moved to covid unit for isolation. DON, MD and hospice notified. No new orders received at this time. Signed by LVN P.<BR/>Resident #4<BR/>Record review of Resident #4's admission Record dated 12/28/23 revealed he was a [AGE] year-old male admitted to the facility 3/6/21 and re-admitted to the facility on [DATE] with diagnoses including urinary tract infection; essential; hypertension (high blood pressure); moderate protein-calorie malnutrition; schizoaffective disorder, bipolar type; and anxiety disorder. <BR/>Record review of Resident #4's MDS assessment dated [DATE] revealed he had a diagnosis of cerebral palsy, was unable to speak, was rarely understood, rarely understood others, and had severely impaired cognition. The record revealed he was dependent on staff for all activities of daily living.<BR/>Record review of Resident #4's current Care Plan dated 3/7/21 and revised 4/6/23 which reflected: <BR/>Focus: Risk for falls related to impaired cognition.<BR/>Goal: Will have decreased risk for serious injury or hospitalization as a result of falling through the next assessment review period.<BR/>Interventions: .Keep call light within reach <BR/>Record review of Resident #4's Progress Notes revealed the following entry dated 12/26/23: Resident tested positive for Covid 19, guardians not reachable, MD made aware. Signed by LVN G. <BR/>During an interview on 12/28/23 at 8:45 AM, the Administrator stated there were ten residents currently in the facility who tested positive for covid. She stated, when a resident tested positive, they were moved to another unit for isolation until they were cleared of symptoms and tested negative.<BR/>During an observation and interview on 12/28/23 at 10:23 AM revealed Resident #3 was in a room on the covid unit. He was lying in bed, watching a video on his phone. Resident #3 stated he understood the reason for the temporary move due to covid. He mentioned he had no television or call light and was mostly annoyed about the lack of television. Resident #3 stated the staff made rounds and he waited for them to come by to address any complaints or needs he had at that time. Resident #4 was observed in the same room on the far side of the room. A curtain separated the two residents so that his bed was obscured from view from the doorway. He was lying in bed under a blanket. He was awake and looked at this surveyor while spoken to but made no verbal response. The room revealed no call light system was found other than one located in the bathroom. There were no units or devices installed on the wall in which a call light cord could be places as was observed in the other rooms. No bells or other devices were observed on the resident's night stands or bedside tables. Resident #3 stated he had not been provided a means for calling since moving to the room 2 or 3 days ago and was anxious to move back to his original room. He denied complaints and stated he knew to wait for staff to come by before getting up.<BR/>During an interview and observation on 12/28/23 at 10:40 AM, LVN N stated call lights should always be in reach and location of the call light buttons should be checked whenever they were in the rooms. She stated call lights were important so that residents could let you know when they had needs. She stated they rounded frequently because it was a short hall. LVN N stated she was unaware there were no call lights in Resident #3's and #4's room. She stated it was her first day on the unit and she was still conducting her rounds. She was then observed donning PPE and entering Resident #3's room. <BR/>In an interview on 12/28/23 at 10:45 AM, CNA O stated call lights should be in reach for residents at all times and were important because they was how residents [NAME] you know if they needed something. He stated he was not aware there were no call lights available in Resident #3's and #4's room CNA O stated Resident #3 could do a lot for himself and Resident #4 could not use a call light and was nonverbal. CNA O stated he rounded a lot. During the conversation, LVN N returned and stated she had spoken with the maintenance department and they were still in the process of getting rooms ready on the unit. She stated residents were testing positive for covid and needed to be moved quickly.<BR/>During an observation and interview on 12/28/23 at 10:50 AM, the Maintenance Tech was observed entering the unit. He stated he did not know there were no call lights in Resident #3 and #4's room and had just been made aware of the issue. During the interview, LVN N approached and stated they were getting another room ready and planned to move Resident's #3 and #4 as soon as possible.<BR/>During an interview on 12/28/23 at 11:20 AM, ADON H stated he had moved Resident #4 to his room on the covid unit after he tested positive on 12/26/23. He stated Resident #3 was already in the room at that time. ADON H stated did not notice the lack of call lights when he moved Resident #4 to his room. He stated they had several residents test positive for covid that day and they were trying to get them moved as quickly as possible. He said he could not recall whether he checked for call lights when he moved him. He stated call lights were important so that residents could receive assistance when needed. He stated the risk of not having a call light available included delayed care during an emergency.<BR/>In an interview with the Administrator on 12/28/23 at 11:38 AM, she stated the room where Residents #3 and #4 were residing was only used as a temporary hold and they had not planned to leave the residents there. She stated the plan was to move them as soon as other rooms were cleaned and available. The Administrator stated the staff tried to move the residents as quickly as possible when they tested positive for covid in order to contain the spread. She stated the staff rounded constantly and there was always someone in the hall. She stated the risk of not having a call light was residents may have been unable to communicate their needs right away. <BR/>An observation and interview on 12/28/23 at 1:35 PM revealed Residents #3 and #4 had been moved to a different room within the covid unit. Both residents had call lights within reach. Resident #3 was watching TV and stated he was glad to have been moved. Resident #4 was lying in bed with his eyes closed and appeared to be sleeping.<BR/>During an interview with the Maintenance Director on 12/28/23 at 1:42 PM, he stated he just learned the room where Residents #3 and #4 were staying did not have any call lights installed. He stated the room must have been an office at some point. He stated he had not previously received any request to add call lights to the room and he had been unaware there were residents in the room who needed them. <BR/>On 12/28/23 at 2:55 PM, an attempt to reach LVN P via telephone was unsuccessful. A voicemail message was left.<BR/>In an interview on 12/29/23 at 10:01 AM, LVN G stated she did not move Resident #4 to the covid unit and was not certain who did.<BR/>During an interview with the Administrator on 12/28/23 at 4:40 PM, she stated she could not locate a policy specific to call light availability in the rooms and provided their policy otitled Homelike Environment.<BR/>Record review of the facility's policy and procedure titled Homelike Environment, undated and identified as current by the Administrator, reflected:<BR/>Policy Statement<BR/>Residents are provided with a homelike environment and encouraged to use their personal belongings to the extent possible.<BR/>Policy Interpretation and Implementation<BR/>1. Staff provides person-centered care that emphasizes the residents, independence and personal needs and preferences.<BR/>2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .e. answering the call lights timely

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Residents #1) of three residents reviewed for comprehensive care plans.<BR/>Resident #1's care plan failed to address interventions to prevent complications related to her PICC line. <BR/>This failure placed residents at risk of not receiving individualized care and services to meet their needs and interventions to prevent complications related to each individuals identified concerns. <BR/>Findings included:<BR/>Record review of Resident #1's admission MDS assessment, dated 08/05/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's brief interview for mental status was cognitively intact by staff assessment. The resident had IV medications. Her diagnoses included acute and subacute endocarditis (inflammation of heart value), diabetes mellitus and depression. <BR/>Record review of Resident #1's August 2023 Physician's Orders reflected, Flush PICC line with 2 lumen with 10cc NS before and after meds and every shift for patency, with a start date of 08/02/23. Monitor PICC line site for s/s of infection, with a start date of 08/03/23. Change PICC line dressing using biopatch per facility protocol every Thursday .<BR/>Record review of Resident #1's MAR for August 2023 reflected, Flush PICC line with 2 lumen with 10cc NS before and after meds and every shift for patency, with a start date of 08/02/23. Monitor PICC line site for s/s of infection, with a start date of 08/03/23. Change PICC line dressing using biopatch per facility protocol every Thursday, with a start date of 08/10/23.<BR/>Record review of Resident #1's Care Plan implemented on 08/10/23 revealed it did not address the residents PICC line status or interventions to prevent complications related to the PICC line.<BR/>Observation on 08/17/23 at 12:00 PM revealed Resident #1 had PICC line to her inner right upper arm. <BR/>Interview on 08/17/23 at 12:30 PM with the Administrator revealed the MDS Coordinator was not in the building and was out on personal leave.<BR/>Interview on 08/17/23 at 12:40 PM with the DON revealed any resident with a PICC line should have those areas care planned with interventions to prevent complications. <BR/>Interview on 08/17/23 at 1:18 PM with the Administrator revealed the MDS Coordinator was responsible for creating the comprehensive care plan. He stated the care plan had to include all the resident's identified problems and interventions to prevent complications. He stated they had been without a MDS Coordinator she was out on personal leave. <BR/>The facility's policy, Comprehensive Assessments and the Care Delivery Process, undated, reflected, Comprehensive assessments will be conducted to assist in developing person-centered care plans. Policy Interpretation and Implementation: Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information collection (assessment) phase is to obtain, organize, and subsequently analyze information about a patient. Assessment and information collection includes (WHAT, WHERE, and WHEN?). The objective of the information collection (assessment) phase is to obtain, organize, and subsequently analyze information about a patient.<BR/>Record Review of Facility Policy, Care Plans, Comprehensive Person-Centered, dated 12/2016, revealed, The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment .e. Include the residents stated goals upon admission and desired outcomes; f. Include the residents stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; i. Build on the residents strength .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for two of five (Resident #1 and Resident #2) residents reviewed for quality of care.<BR/>1. The facility failed to assess and provide treatment for Residents #1's left foot heel, left inner foot by her big toe, and right inner foot by the bony area of her big toe. <BR/>2. The facility failed to implement wound care for Resident #2's left 2nd toe, left 5th toe, and left great toe .<BR/>This failure could place residents at risk for increased pain and infection. <BR/>Findings included :<BR/>1. Review of Resident #1's Quarterly MDS assessment, dated 03/20/23, revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. She had clear speech, was sometimes understood by others, and sometimes understood others. Her BIMS score was 99, which reflected she was unable to complete the interview. Her diagnoses included: hypertension, urinary tract infection, hyperlipidemia, cerebrovascular accident, malnutrition, respiratory failure, and dysphagia. Her Skin Conditions section revealed she was at risk of developing pressure ulcer/injuries, had one stage 4 pressure ulcer, and had two unstageable-deep tissue injuries. Her skin and ulcer /injury treatments were pressure ulcer/injury care and application of dressings to feet.<BR/>Review of Resident #1's physician orders, dated 02/06/23 , reflected, Left foot DTI cleanse with normal saline pat dry apply Betadine with foam dressing daily.<BR/>Review of Resident #1's physician orders, dated 04/11/23, reflected, Clean right foot with normal saline pat dry apply Betadine with foam dressing. Left Heel cleanse with normal saline pat dry apply Betadine with foam dressing daily.<BR/>Review of Resident #1's MAR, dated May 2023, reflected, Clean right foot with normal saline pat dry apply Betadine with foam dressing. One time a day at 9:00 AM for DTI with a start date of 04/12/23. Left foot DTI; cleanse with normal saline pat dry apply Betadine with foam dressing daily. One time a day at 9:00 AM for wound care with a start date of 02/07/23. Left heel; cleanse with normal saline pat dry apply Betadine with foam dressing daily. One time a day at 9:00 AM for wound care with a start date of 04/12/23. The MAR revealed Resident #1 had received wound care from 05/01/23 to 05/09/23 as ordered. <BR/>Review of Resident #1's care plan, undated, reflected, actual impairment to skin integrity of left foot stage DTI, left heel DTI due to fragile skin and debility. Will have no complications from wound and will heal through the next review date. <BR/>Review of facility weekly wound care log, dated 05/01/23, reflected Resident #1 admitted to the facility with wounds to her left heel (measurement 2.4cm x 2.0cm x 0.1cm), left foot (measurements 1.0cm x 0.7cm x 0.1cm), and right foot (measurement 0.5cm x 0.5cm x 0.1cm). The etiology/cause of Resident #1's left heel was pressure-unstageable (tissue type was 100% slough), left foot was a DTI, and right foot was as DTI. Her left heel treatment was Medi honey Calgigraf Ag with foam dressing. Her left and right foot treatments was Betadine with foam dressing. <BR/>An observation of Resident #1 on 05/09/23 at 7:30 AM revealed Left foot heel area with dressing dated 05/06/2023, the wound bed with yellow exudates. The left inner foot by the big toe wound with dark bed covered with foam dressing dated: 05/06/2023. The right inner foot by the bony area of the big toe skin redness not open covered with foam dressing dated: 05/06/2023. <BR/>An interview with LVN A and LVN B on 05/09/23 at 2:13 PM revealed both LVNs were assigned to Resident #1. They stated Resident #1 had wounds located on her sacrum, left foot, and right foot. They stated Resident #1 was supposed to receive wound care every day as ordered to promote healing and to prevent infection. They stated they were aware Resident #1's right and left foot wound care bandages were dated 05/06/23. They stated the bandages indicated Resident #1 had not received wound care since 05/06/23. They stated Resident #1 was at risk of infection. They stated the DON was notified regarding Resident #1's wound care. They stated Resident #1 was assessed and received wound care on 05/09/23. They stated Resident #1's assessment revealed there were no new issues regarding her wounds. They stated they received in-servicing regarding wound care on 05/09/23. <BR/>An interview with the DON on 05/09/23 at 5:28 PM revealed Resident #1 had wounds on her sacrum and feet. He stated he was not aware Resident #1's wound care dressings on her feet were dated 05/06/23. He stated the bandages indicated Resident #1 had not received wound care since that date. He stated Resident #1 received wound care after he was made aware of the incident on 05/09/23. He stated the importance of Resident #1 to receive wound care as ordered was to promote healing. He stated the potential risk to Resident #1 would be a delayed healing time. He stated Resident #1 was to receive wound care daily as ordered. He stated the nurses were responsible for ensuring Resident #1's wound care treatments were completed as ordered. <BR/>2. Review of Resident #2's annual MDS assessment, dated 04/23/23, revealed he was an [AGE] year-old male and admitted to the facility on [DATE]. His diagnoses were hypertension, neurogenic bladder, cerebrovascular accident, and respiratory failure. He had no speech and was rarely/never understood and sometimes understood others. His Skin Conditions section revealed he was at risk of developing pressure ulcer/injuries, had one stage 3 pressure ulcer, and had three venous and arterial ulcers present. His skin and ulcer /injury treatments were pressure ulcer/injury care and application of dressings to feet.<BR/>Review of Resident #2's physician orders, dated 04/25/23, reflected Left 2nd toe, arterial, clean with normal saline skin prep with foam dressing one time a day. Left 5th toe arterial, clean with normal saline skin prep with foam dressing one time a day. Left great toe, cleanse with normal saline pat dry, skin prep with foam dressing daily one time a day for wound care.<BR/>Review of Resident #2's MAR, dated May 2023, reflected, Left 2nd toe arterial, clean with normal saline skin prep with foam dressing one time a day at 9:00 AM with a start day of 04/26/23. Left 5th toe arterial, clean with normal saline skin prep with foam dressing one time a day at 9:00 AM with a start day of 04/26/23. Left great toe arterial, clean with normal saline skin prep with foam dressing one time a day for wound care at 9:00 AM with a start day of 04/26/23. Treatment date 05/09/23 was marked completed by LVN C.<BR/>Review of facility weekly wound care log, dated 05/01/23, reflected Resident #2 had wounds on his left great toe (measurement 1.5cm x 2.0cm x utd), left 2nd toe (measurement 0.5cm x 0.5 cm x utd), and left 5th toe (measurement 1.5cm x 0.2cm x utd). Their etiology/cause were arterial. Their needed treatment was Betadine with foam dressing. The date acquired for his left great toe was 04/20/23, left 2nd toe was 04/23/23, and left 5th toe was 04/23/23. The wounds were acquired while at the facility.<BR/>Observation of Resident #2 on 05/09/23 at 7:25 AM to 3:45 PM revealed his left great toe, 2nd toe, and left fifth toe were not covered by foam dressing and open to air. <BR/>In an interview with LVN C on 05/09/23 at 3:58 PM revealed Resident #2 had wounds on his left foot toes. She stated Resident #2 was supposed to received wound care on his left foot toes daily. She stated he was supposed to receive Betadine and foam dressing on his left foot toes. She stated she completed Resident #2's treatment record for 05/09/23 without completing the treatment. She stated she was unable to locate foam dressing on the treatment cart and decided not to complete his wound care. She stated best practice regarding Resident #2's treatment record was to sign off on treatment after he received wound care. She stated Resident #2 was at risk of infection due to not receiving wound care. She stated she was in-serviced regarding wound care in April 2023.<BR/>In an interview with DON on 05/09/23 at 5:28PM revealed he was recently made aware Resident #2 had not received daily wound care on 05/09/23. He stated he would have to investigate why Resident #2's treatment record was completed by LVN C if the treatment was not completed. He stated his expectation was for LVN C to complete Resident #2's treatment record after the treatment was completed. He stated the risk to Resident #2 not receiving wound care would depend on the nature of his wound and whether the wound was open or closed.<BR/>Review of facility policy, Wound care, undated, reflected: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #57) of three residents reviewed for environment.<BR/>The facility failed to ensure Resident #57 bedside commode was clean and sanitary. <BR/>This failure could place residents at risk for a diminished quality of life due to the lack of a clean and sanitary homelike environment. <BR/>Findings included: <BR/>Review of Resident #57's face sheet, dated 04/25/23, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included cerebral infarction (stroke), abnormal posture, and end stage renal disease.<BR/>Review of Resident #57's care plan did not address his use of a bedside commode.<BR/>Review of Resident #57's quarterly MDS, dated [DATE], reflected he had a BIMS score of 15. Further review revealed Resident #57 was considered extensive assistance for self-performance related to toilet use and required one person physical assist for support related to toilet use. <BR/>Observation and interview on 04/23/23 beginning at 11:30 AM with Resident #57 revealed he was lying in bed and a bedside commode next to the bed. Resident #57 said that the bedside commode was his and he used it often. On the bedside commode bars was a dried green and brown substance. Resident #57 said that he had a hard time seeing things very clearly and was not aware that there was a dried green and brown substance on the bars where his legs would be while using the commode. Resident #57 said when he used the bedside commode, he alerted staff so that they could come to empty and clean it. Resident #57 said he could not clean the bedside commode himself and needed staff to do it for him, although he was unsure of when the last time staff had cleaned it for him.<BR/>In an interview on 04/23/23 at 1:45 PM with CNA V revealed Resident #57 used a bedside commode and she was responsible for cleaning and emptying it for him. CNA V said Resident #57 usually called staff to his room to help him with his bedside commode when he had used it. CNA V said she was not aware that Resident #57 had a dried green and brown substance on the bottom bar of his bedside commode where his thighs would rest to stabilize him. CNA V said Resident #57 said each time he used the bedside commode it should be cleaned and sanitized by the CNA working with him on that shift. CNA V said she had not been made aware Resident #57 had used his bedside commode during her shift yet so the previous shift must have not cleaned it after he used it. CNA V said the purpose of making sure a resident's bedside commode was cleaned after each use was to keep it and the resident using it cleaned and to prevent odors from occurring. <BR/>In an interview on 04/23/23 at 1:52 PM with LVN Y revealed the CNA assigned to Resident #57 was responsible for cleaning the resident's bedside commode after each use. LVN Y said Resident #57 usually told staff when he used the bedside commode and they would come in to clean it and empty it for him. LVN Y said she was not aware the bedside commode had not been cleaned and had a dried green and brown substance on the bottom bar where his thighs would be while using it. LVN Y said the purpose of keeping the bedside commode cleaned was to prevent a UTI , prevent an infection, or keep odors out of the room.<BR/>In an interview on 04/25/23 at 8:56 AM with the DON revealed Resident #57 used a bedside commode and nursing staff, more specifically the CNA and nurses, were responsible for cleaning it before and after each use. The DON said staff had access to the supplies to be able to clean it for Resident #57. The DON said the purpose of keeping the bedside commode clean was because the resident might not want to use it if it was not clean first. <BR/>Review of the facility's undated policy titled Cleaning and Disinfection of Resident Care Items and Equipment reflected: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include bedpans . (2) Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location) . d. Reusable items are cleaned and disinfected or sterilized between residents . (1) Single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards (e.g., bedpans, urinals).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain good foot health for one (Resident #75) of five residents reviewed for foot care. <BR/>The facility failed to ensure Resident #75 received foot care. <BR/>This failure could place residents at risk of diminished quality of life by not receiving care and services to meet their needs. <BR/>Findings included:<BR/>Record review of Resident #75's Quarterly MDS, dated [DATE], revealed an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included anemia, hypertension, renal failure, neurogenic bladder, Non-Alzheimer's Dementia, malnutrition, anxiety, depression, and insomnia. Her BIMS score was 10 out of 15, which revealed she was moderately impaired. She required extensive assistance with one-person physical assistance regarding personal hygiene. She required total dependence with one-person physical assistance regarding bathing.<BR/>Review of Resident #75's care plan, undated, revealed she required assistance with ADLs and required one-person assist from staff. Her goal was to remain clean, comfortable, well groomed, and maintain optimal mobility on a daily basis. Her intervention was needed encouragement from staff to participate with ADLs as able and staff to assist with/provide ADLs as needed. She was at risk of complications, injury, infection, and ineffective protection related to resisting care. Her goal was to cooperate with care. Her intervention was to encourage as much participation/interaction by the resident as possible during care activities. If possible, negotiate a time for ADLs so that the resident participates in the decision-making process.<BR/>Review of Resident #75's skin assessments dated March 2023 revealed there were no issues regarding her feet. There were no skin assessments for April 2023. <BR/>Review of the facility's podiatry referral list, dated 03/06/23, revealed Resident #75 was not included.<BR/>Interview and observation with Resident #75 on 04/23/23 at 11:46 revealed the skin on the bottom of her feet were red and peeling. There were pieces of dried skin on her linens near her feet. She stated her feet hurt and she did not remember the last time she was seen by a podiatrist. She stated she was unaware the bottom of her feet was red and her skin was peeling. She stated she informed her nurse she was in pain. LVN A came into Resident #75's room and administered Tylenol. <BR/>Interview with LVN A on 04/23/23 at 11:56 AM revealed she had not seen Resident #75's feet prior to surveyor's interview. She stated she did not know her feet were hurting, red, and peeling. She stated the social worker was responsible for residents to receive footcare. She stated Resident #75's feet should not be red or peeling. She stated Resident #75's feet appeared to be dry and only needed lotion on her. She stated the CNAs were responsible for ensuring lotion was applied to her feet. She did not inform the surveyor of any potential risks regarding Resident #75's lack of footcare.<BR/>Observation and Interview with Resident #75 on 04/24/23 at 12:16 PM revealed there was no changes to her feet. The bottom of her feet was red and peeling. There were still pieces of dried skin on her linens near her feet. She stated she had not received footcare.<BR/>Interview with DON on 04/24/23 at 03:31 PM revealed he had not recently viewed Resident #75's feet. He stated he did not remember the last time he saw her feet. The surveyor asked the DON questions regarding Resident #75's feet. He stated he did not know how her feet ended up in their current state. He stated staff should have been applying lotion to her feet. He stated the social worker was responsible for podiatry referrals but was currently on vacation. He stated her feet issue should have been documented on her skin assessments. He stated she was at risk of skin breakdown due to not receiving podiatry care. He stated the nurse should have taken care of Resident #75's feet. He stated the nurse should have assessed the resident's skin, applied lotion, and consulted podiatry. <BR/>Observation and Interview with Resident #75 on 04/25/23 beginning at 3:45 PM revealed her feet had been treated. She stated she received footcare from a staff member. She stated she also had lotion applied to her feet. She stated she felt better and was experiencing less pain in her feet. Her feet appeared to have less dry skin than 04/23/23.<BR/>Interview with CNA B on 04/25/23 at 9:17 AM revealed she had not seen Resident #75's feet prior to 04/25/23. She stated her feet were always covered. She stated she never applied lotion to Resident #75's feet. She stated her feet appeared to have been moisturized by lotion on 04/25/23. She stated she was responsible for applying lotion to residents' feet after showers, dressing, and as needed. She stated she reported residents' dry skin to the nurses and asked if lotions could be applied to the dry area. She stated Resident #75 was at risk of skin breakdown and pressure sores if footcare was not received.<BR/>Interview with Administrator on 04/25/23 at 04:38 PM revealed the facility was contracted with a podiatry provider who offered in house services to residents. She stated the podiatry provider came to the facility in March 2023 and would return in May 2023. She stated the social worker completed podiatry referrals. She stated the social worker was currently on vacation. She stated Resident #75 was non-complaint with ADLs. She stated the social worker spoke with the resident about different service provider options at the facility and she refused services. She stated she did not know if the social worker had documented refusals of all services. She stated she ensured the social worker was making referrals. She stated she discussed podiatry referrals during the morning meeting close to the podiatry provider visit time. She stated the importance of footcare was to ensure residents received nail care and care to their feet to prevent infection. <BR/>Review of facility policy, Foot Care, undated, reflected: Residents will receive appropriate care and treatment in order to maintain mobility and foot health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #24) reviewed for gastrostomy tube management.<BR/>The facility failed to ensure Resident #24's head of bed was elevated at a minimum of 30-degree angle during medication administration and bolus feeding (a way to deliver food directly to the stomach) via gastrostomy tube (G-tube) (A tube directly inserted through the skin to the stomach to deliver nutrition). <BR/>The facility failed to check the Resident #24's residual before administering medications <BR/>This failure could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health.<BR/>Findings include:<BR/>Record review of Resident #24's face sheet dated 4/25/23 revealed a 49- year-old-male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included urinary tract infection, pneumonia, anemia, hypertension, type 2 diabetes, and moderate protein calorie malfunction. <BR/>Record review of Resident #24's Comprehensive MDS dated [DATE] revealed the resident's BIMS score was unable to be scored. Cognitive skills for daily decision making identified Resident #24 as severely impaired. Nutritional Status section identified use of a feeding tube. <BR/>Record review of Resident #24's Care Plan dated 9/20/21 revealed: Focus: Resident #24 had a peg tube and received nutrition and/or hydration via tube, remained as risk for aspiration. Goal: Resident #24 will display no signs and symptoms of volume depletion, weight loss or aspiration. Interventions: Keep head of bed elevated 30-45 degrees during and at least 1 hour after feeding. Further indicated to check for placement of tube and residual amount prior to flushing, feeding, or administering medications. <BR/>Record review of Resident #24's April 2023 medication administration record dated 4/25/23, revealed (Enteral) elevate head of bed 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped every shift. <BR/>Observation on 4/23/23 at 09:58 AM revealed Resident #24 resting in bed and his head of bed was flat and the legs were elevated. Further observation revealed RN D administering medications and bolus feeding while Resident #24's head of bed was flat in bed. After medication administration and bolus feeding the RN D left the residents in the flat position and proceeded to clean the resident's items.<BR/>In an interview on 04/23/23 at 10:18 AM with RN D he stated Resident #24's head of bed was to be elevated during medication administration and bolus feeding to prevent the resident from aspirating. RN D stated the bed was non-functional when he checked early but when he tried to elevate the residents head of bed, the bed was able to elevate without any issues. RN D further stated he was supposed to check for residual before medication administration or bolus feeding. RN D stated residual was to be complete to make sure the resident was not overfed and if the resident was retaining feeding, if so, the resident's primary care provider was to be notified. RN D stated without checking residual could cause other side effects if the resident had too much in the stomach like vomiting, discomfort and even aspiration. <BR/>In an interview on 04/24/23 at 03:04 PM with the DON he stated the staff was to make sure residual was checked and the head of the bed was elevated during medication administration and bolus feeding to prevent resident aspiration. <BR/>Review of the facility policy undated and titled Administering Medications Through an Enteral Tube reflected, after administering medications 18. Have the resident maintain the semi-Fowler's position for at least 30 minutes.

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (300 Hall MA Medication Cart) of six of six medication carts reviewed for medication storage. <BR/>MA B failed to ensure medications found on the sharps bin insert lid on the 300 Hall MA Medication Cart, were disposed of properly. <BR/>This failure placed residents at risk for unauthorized access to the medication cart and a harmful medication can be consumed placing residents at risk for administration of harmful medication. <BR/>Findings included:<BR/>An observation on 01/30/2024 at 10:07 AM revealed, MA B's 300 Hall MA Medication Cart, had eight pills stuck between the plastic insert of the sharps (needles, blades [such as scalpels] and other medical instruments that are necessary for carrying out healthcare work and could cause an injury by cutting or pricking the skin) container and the lid, which prevented the lid from closing properly. Residents were observed self-ambulating through the hall in thier wheelchairs. <BR/>In an interview on 01/30/2024 at 10:08 AM, MA B stated she did not see the medications on the lid of the sharps insert but could see they were preventing the lid from closing completely. She denied that she disposed of the medication but could not say who may have. She said all staff were responsible to ensure medications were secured and disposed of properly. She said medications should not be disposed of in the sharps bin. She said the medications posed a hazard for residents as they could have access to medications not prescribed to them. <BR/>In an interview on 01/30/2024 at 10:20 AM, ADON A said the medications stuck on the lid of the sharps bin insert should not be disposed of in the sharps bin and did not know why the medications were on the sharps bin lid. He stated the medications appeared to be blocking the lid from closing properly. He said the medications could be accessible to residents and posed a potential hazard as residents. He said he would find the keys to MA B's cart and remove the medications from the lid. <BR/>In an interview on 01/30/2024 at 1:50 PM, the Administrator said medications should not be disposed of in the sharps bins and should not be on the lid of the bins where residents could have access to them. She said many of the residents in the facility tend to wander and could have consumed the medications. She said she expected the nursing management to monito this and ensure staff were trained on facility policy. <BR/>In an interview on 01/30/2024 at 3:31 PM, the DON said medications should be disposed of properly and not placed in the sharps bin. He said he changed out MA B's sharps insert and disposed of the pills that were on the lid. He said he was not able to identify what the pills were. He said he did not feel the medications were accessible because they were in a groove at the back of the insert lid, however, the medications should not be there and since the insert lid could not close properly, there was a potential risk to residents consuming the medications if they were able to get the medications. He said staff are trained on how to dispose of medication properly but did not recall when the last training was. <BR/>Record review of the facility's undated policy, titled, Storage of Medications, reflected, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper. or incorrect labels are returned to the pharmacy for proper labeling before storing. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 6. Hazardous drugs shall be clearly marked as such and shall I be stored separately from other medications. 7. Compartments containing drugs and biologicals are locked when not in use. 8. Unlocked medication carts are not left unattended

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for contaminated sharps disposal bins, attached to one (300 Hall MA Medication Cart) of one 300 Hall MA Medication Cart and one (300 Hall Nurse Medication Cart) of one 300 Hall Nurse Medication Cart reviewed for hazards. <BR/>MA B failed to ensure contaminated sharps in the sharps bin attached to the 300 Hall MA Medication Cart, were below the full line. <BR/>MA B failed to ensure medications found on the sharps bin insert lid on the 300 Hall MA Medication Cart, were disposed of properly. <BR/>RN C failed to ensure contaminated sharps in the sharps bin attached to the 300 Hall Nurse Medication Cart, were below the full line. <BR/>These failures placed residents at risk of being exposed to contaminated sharps, possible bloodborne pathogens, and access to unprescribed medications. <BR/>Findings included:<BR/>An observation on 01/30/2024 at 10:07 AM, revealed the plastic insert contained inside the sharps bin attached to MA B's 300 Hall MA Medication Cart was past the full line. Sharps (needles, blades [such as scalpels] and other medical instruments that are necessary for carrying out healthcare work and could cause an injury by cutting or pricking the skin) in the insert blocked the insert's lid from closing completely. Eight pills were observed, stuck between the plastic insert and the insert's lid which contributed to the lid from closing properly. <BR/>In an interview on 01/30/2024 at 10:08 AM, MA B stated she was not aware the sharps in the bin were past the full line because she did not use it. She said the lid on the sharps bin insert should be free to close to ensure staff and resident safety. She said she did not see the medications on the lid of the sharps insert but could see they were preventing the lid from closing completely. She said all staff were responsible to ensure the sharps bin inserts were not filled past the full line however only the nurses had keys to the sharps bins attached to the carts. She said medications should not be disposed of in the sharps bin. She said the full bin and medications posed a hazard for residents and staff. <BR/>In an interview on 01/30/2024 at 10:20 AM, ADON A said the sharps bins should never be filled past the fill line to prevent possible injury to staff or residents. When asked about the medications stuck on the lid of the sharps bin insert, he said medications should not be disposed of in the sharps bin and did not know why the medications were on the sharps bin lid. He stated the medications appeared to be blocking the lid from closing properly. He stated the nurses had keys to the bins and were responsible to ensure the bins were not filled past the full line. He said the medications could be accessible to residents and posed a potential hazard as residents. He said he would find the keys to MA B's cart and change the sharps bin and remove the medications from the lid. <BR/>An observation on 01/30/2024 at 10:30 AM, revealed the plastic insert in the sharps bin, attached to RN C's 300 Hall Nurse Medication Cart to be past the full line. She said it should not be past the full line because the lid would not close properly which posed a potential hazard. She said the nurses had keys to the sharps bins and should ensure the inserts were not filled past the full line. <BR/>In an interview on 01/30/2024 at 1:50 PM, the Administrator said the sharps bin inserts should never be filled past the full line because it posed a potential risk of harm to staff and residents. She said they could be stuck by a needle if the lid did not close properly. She said she expected nursing staff to ensure this was done and nursing management to monitor it. She said medications should not be disposed of in the sharps bins and should not be on the lid of the bins where residents could have access to them. She said many of the residents in the facility tend to wander and could have consumed the medications. <BR/>In an interview on 01/30/2024 at 3:31 PM, the DON said the sharps bins should never be filled past the full line. He said the lid does not close properly when sharps are above the full line which could cause a risk of staff or residents getting stuck with a needle. He said a staff member was recently stuck in this manner and in servicing was conducted. He said medications should be disposed of properly and not placed in the sharps bin. He said he changed out MA B's sharps insert and disposed of the pills that were on the lid. He said he did not feel the medications were accessible because they were in a groove at the back of the insert lid. He said none-the-less the medications should not be there and since the insert lid could not close properly, there was a potential hazard to residents if they were able to get the medications. He said staff are trained on how to dispose of medication properly. <BR/>Record review of the facility's undated policy titled, Safety and Supervision of Residents, reflected, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation - Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. 3. When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. 5. The QAPI Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary.

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (300 Hall MA Medication Cart) of six of six medication carts reviewed for medication storage. <BR/>MA B failed to ensure medications found on the sharps bin insert lid on the 300 Hall MA Medication Cart, were disposed of properly. <BR/>This failure placed residents at risk for unauthorized access to the medication cart and a harmful medication can be consumed placing residents at risk for administration of harmful medication. <BR/>Findings included:<BR/>An observation on 01/30/2024 at 10:07 AM revealed, MA B's 300 Hall MA Medication Cart, had eight pills stuck between the plastic insert of the sharps (needles, blades [such as scalpels] and other medical instruments that are necessary for carrying out healthcare work and could cause an injury by cutting or pricking the skin) container and the lid, which prevented the lid from closing properly. Residents were observed self-ambulating through the hall in thier wheelchairs. <BR/>In an interview on 01/30/2024 at 10:08 AM, MA B stated she did not see the medications on the lid of the sharps insert but could see they were preventing the lid from closing completely. She denied that she disposed of the medication but could not say who may have. She said all staff were responsible to ensure medications were secured and disposed of properly. She said medications should not be disposed of in the sharps bin. She said the medications posed a hazard for residents as they could have access to medications not prescribed to them. <BR/>In an interview on 01/30/2024 at 10:20 AM, ADON A said the medications stuck on the lid of the sharps bin insert should not be disposed of in the sharps bin and did not know why the medications were on the sharps bin lid. He stated the medications appeared to be blocking the lid from closing properly. He said the medications could be accessible to residents and posed a potential hazard as residents. He said he would find the keys to MA B's cart and remove the medications from the lid. <BR/>In an interview on 01/30/2024 at 1:50 PM, the Administrator said medications should not be disposed of in the sharps bins and should not be on the lid of the bins where residents could have access to them. She said many of the residents in the facility tend to wander and could have consumed the medications. She said she expected the nursing management to monito this and ensure staff were trained on facility policy. <BR/>In an interview on 01/30/2024 at 3:31 PM, the DON said medications should be disposed of properly and not placed in the sharps bin. He said he changed out MA B's sharps insert and disposed of the pills that were on the lid. He said he was not able to identify what the pills were. He said he did not feel the medications were accessible because they were in a groove at the back of the insert lid, however, the medications should not be there and since the insert lid could not close properly, there was a potential risk to residents consuming the medications if they were able to get the medications. He said staff are trained on how to dispose of medication properly but did not recall when the last training was. <BR/>Record review of the facility's undated policy, titled, Storage of Medications, reflected, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper. or incorrect labels are returned to the pharmacy for proper labeling before storing. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 6. Hazardous drugs shall be clearly marked as such and shall I be stored separately from other medications. 7. Compartments containing drugs and biologicals are locked when not in use. 8. Unlocked medication carts are not left unattended

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for contaminated sharps disposal bins, attached to one (300 Hall MA Medication Cart) of one 300 Hall MA Medication Cart and one (300 Hall Nurse Medication Cart) of one 300 Hall Nurse Medication Cart reviewed for hazards. <BR/>MA B failed to ensure contaminated sharps in the sharps bin attached to the 300 Hall MA Medication Cart, were below the full line. <BR/>MA B failed to ensure medications found on the sharps bin insert lid on the 300 Hall MA Medication Cart, were disposed of properly. <BR/>RN C failed to ensure contaminated sharps in the sharps bin attached to the 300 Hall Nurse Medication Cart, were below the full line. <BR/>These failures placed residents at risk of being exposed to contaminated sharps, possible bloodborne pathogens, and access to unprescribed medications. <BR/>Findings included:<BR/>An observation on 01/30/2024 at 10:07 AM, revealed the plastic insert contained inside the sharps bin attached to MA B's 300 Hall MA Medication Cart was past the full line. Sharps (needles, blades [such as scalpels] and other medical instruments that are necessary for carrying out healthcare work and could cause an injury by cutting or pricking the skin) in the insert blocked the insert's lid from closing completely. Eight pills were observed, stuck between the plastic insert and the insert's lid which contributed to the lid from closing properly. <BR/>In an interview on 01/30/2024 at 10:08 AM, MA B stated she was not aware the sharps in the bin were past the full line because she did not use it. She said the lid on the sharps bin insert should be free to close to ensure staff and resident safety. She said she did not see the medications on the lid of the sharps insert but could see they were preventing the lid from closing completely. She said all staff were responsible to ensure the sharps bin inserts were not filled past the full line however only the nurses had keys to the sharps bins attached to the carts. She said medications should not be disposed of in the sharps bin. She said the full bin and medications posed a hazard for residents and staff. <BR/>In an interview on 01/30/2024 at 10:20 AM, ADON A said the sharps bins should never be filled past the fill line to prevent possible injury to staff or residents. When asked about the medications stuck on the lid of the sharps bin insert, he said medications should not be disposed of in the sharps bin and did not know why the medications were on the sharps bin lid. He stated the medications appeared to be blocking the lid from closing properly. He stated the nurses had keys to the bins and were responsible to ensure the bins were not filled past the full line. He said the medications could be accessible to residents and posed a potential hazard as residents. He said he would find the keys to MA B's cart and change the sharps bin and remove the medications from the lid. <BR/>An observation on 01/30/2024 at 10:30 AM, revealed the plastic insert in the sharps bin, attached to RN C's 300 Hall Nurse Medication Cart to be past the full line. She said it should not be past the full line because the lid would not close properly which posed a potential hazard. She said the nurses had keys to the sharps bins and should ensure the inserts were not filled past the full line. <BR/>In an interview on 01/30/2024 at 1:50 PM, the Administrator said the sharps bin inserts should never be filled past the full line because it posed a potential risk of harm to staff and residents. She said they could be stuck by a needle if the lid did not close properly. She said she expected nursing staff to ensure this was done and nursing management to monitor it. She said medications should not be disposed of in the sharps bins and should not be on the lid of the bins where residents could have access to them. She said many of the residents in the facility tend to wander and could have consumed the medications. <BR/>In an interview on 01/30/2024 at 3:31 PM, the DON said the sharps bins should never be filled past the full line. He said the lid does not close properly when sharps are above the full line which could cause a risk of staff or residents getting stuck with a needle. He said a staff member was recently stuck in this manner and in servicing was conducted. He said medications should be disposed of properly and not placed in the sharps bin. He said he changed out MA B's sharps insert and disposed of the pills that were on the lid. He said he did not feel the medications were accessible because they were in a groove at the back of the insert lid. He said none-the-less the medications should not be there and since the insert lid could not close properly, there was a potential hazard to residents if they were able to get the medications. He said staff are trained on how to dispose of medication properly. <BR/>Record review of the facility's undated policy titled, Safety and Supervision of Residents, reflected, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation - Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. 3. When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. 5. The QAPI Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary.

Based on interviews and record review, the facility failed to ensure sufficient nursing staff with appropriate competencies and skills set to provide nursing and related services for one (Hospitality Aide A) of three employees reviewed for staff qualifications.<BR/>1. The facility failed to ensure Hospitality Aide A had a current nurse aide certification while employed at the facility while actively providing care for residents on 02/12/25: 6:00 AM - 2:00 PM shift, 02/10/25: 6:00 AM - 2:00 PM shift, 02/08/25: 6:00 AM - 2:00 PM shift, 02/07/25: 6:00 AM - 2:00 PM shift. <BR/>This failure could result in residents being provided care by staff who do not have the training and competency needed for providing care. <BR/>Findings include:<BR/>Record review of Hospitality Aide A's personnel file revealed her date of hire was not listed. She did not have a CNA license. <BR/>Record review of the facility's schedule revealed Hospitality Aide A was listed as a CNA and counted as a CNA in the numbers for the schedule on dates:<BR/>02/12/25: 6:00 AM - 2:00 PM shift<BR/>02/10/25: 6:00 AM - 2:00 PM shift<BR/>02/08/25: 6:00 AM - 2:00 PM shift<BR/>02/07/25: 6:00 AM - 2:00 PM shift<BR/>An interview on 02/12/25 at 2:00 PM with Hospitality Aide A revealed she was working on Hall 300. She said her job duties included making beds and taking out the trash. She said she helped CNAs provide care to residents. She also said that when the facility was short of staff, she would feed residents, perform incontinence care, and work as the second staff for two person transfers. Hospitality Aide A said she had finished school to be a CNA but had not taken her CNA test. <BR/>An interview on 02/12/25 at 2:35 PM with ADON revealed she assisted with staffing. She said Hospitality Aide A did not have a CNA license. The ADON said Hospitality Aide A was not supposed to work by herself. The ADON said Hospitality Aide A was not supposed to be counted in the schedule numbers and was supposed to work as an extra staff as a Hospitality Aide. The ADON said 7 CNAs were required for the 6:00 AM - 2:00 PM shift and 6 CNAs were required for the 2:00 PM - 10:00 PM shift. The ADON said when she made the schedule she included Hospitality Aide A in the numbers, but she was supposed to work with another CNA. <BR/>An interview with the DON on 02/12/25 at 3:45 PM revealed he was aware that Hospitality Aide A did not have a CNA license. The DON said Hospitality Aide A was not allowed to provide care independently. The DON said there was no risk to the resident for Hospitality Aide A to work, because he would never allow her to work independently. The DON said he did not know Hospitality Aide A was counted as a CNA in the schedule numbers even though he reviewed the schedule every day. He said he never saw Hospitality Aide A work without another CNA. <BR/>The Administrator was asked to provide a facility policy for competent nursing staff on 02/12/25 at 4:23 PM. The Administrator failed to provide the policy prior to exit on 02/12/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for one (Resident #75) of three residents observed for indwelling urinary catheters.<BR/>The facility failed to ensure Resident #75's catheter bag was changed as ordered by the physician.<BR/>These failures could place residents with urinary catheters at risk for urethral tears, dislodging of the catheter, and urinary tract infections.<BR/>Findings included:<BR/>Record review of Resident #75's Quarterly MDS, dated [DATE], revealed an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included anemia, hypertension, renal failure, neurogenic bladder, Non-Alzheimer's Dementia, malnutrition, anxiety, depression, and insomnia. Her BIMS score was 10 out of 15, which revealed she was moderately impaired. Her appliances used was an indwelling catheter and she was always incontinent. <BR/>Review of Resident #75's care plan, undated, reflected her focus was at risk for infection related to foley catheter. Her goal was to remain free from signs/symptoms of infection due to catheter. Her intervention was staff to provide catheter care every shift as ordered/indicated.<BR/>Review of Resident #75's physician orders, dated 08/15/22, reflected, Change foley drainage bag every two weeks every night shift every 14 days for infection control.<BR/>Observation and interview with Resident #75 on 04/23/23 beginning at 11:36 AM revealed her catheter bag was clipped to her bed and dated 03/14/23. There appeared to be sediment in her catheter tubing and discoloration of her catheter bag. Resident #75 stated she did not remember the last time she had her catheter bag changed. She stated she did not know how frequently her catheter bag was supposed to be changed. She stated she was not experiencing any discomfort from her catheter.<BR/>Interview with LVN A on 04/24/23 at 11:52 AM revealed she changed Resident #75's catheter bag and tubing on 04/24/23. She stated the catheter bag was dated 03/14/23. She stated Resident #75's catheter tubing and bag had sediment build up. She stated there was a physician order to change the catheter bag every two weeks during the night shift. She stated she did not know why 03/14/23 was written on the catheter bag. She stated the purpose of changing Resident #75's catheter bag every two weeks was to prevent infection.<BR/>Interview with DON on 04/24/23 at 03:20 PM revealed Resident #75's had a catheter. He stated the catheter bag was to be changed every two weeks. He stated the catheter bag was to be changed every two weeks due to sediments, bag becoming crusted, and infection control. He stated the purpose of dating the catheter bag was to inform the next nurse when the bag was last changed. He stated he was not aware Resident #75's catheter bag was dated 03/14/23. He Resident #75 was at risk of an infection. He stated the nurses were responsible for changing residents' catheter bags. He stated the managers and himself were responsible for ensuring nurses were changing catheter bags. <BR/>Review of facility policy, Catheter Care, Urinary, undated, reflected: The purpose of this procedure is to prevent catheter-associated urinary tract infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 2 (Resident # 15 and #20) of 3 residents reviewed for pharmacy services.<BR/>MA B failed to administer medications timely as ordered by physician to Resident # 20<BR/>LVN D failed to administer medications timely as ordered by physician to Resident # 15<BR/>The deficient practice could place residents at risk of not receiving the therapeutic effects from their medications as intended by the prescribing physician order.<BR/>The findings included:<BR/>Record review of Resident #15's face sheet dated 01/30/24 revealed an [AGE] years old female, admitted to the facility on [DATE] with diagnoses that included hypertension (blood pressure that is higher than normal), hypothyroidism (happens when the thyroid gland doesn't make enough thyroid hormone) and malignant neoplasm of unspecified site of right female breast (breast cancer) <BR/>Record review of Resident #15's physician order summary dated 01/30/24 reflected metoprolol succinate ER oral tablet extended release 24-hour 25 mg (metoprolol succinate) give 50 mg via g-tube two times a day for hypertension. <BR/>Record review of Resident #15's medication administration record dated 01/30/24 reflected Metoprolol ER 50 mg 1 tablet scheduled at 9 am. <BR/>Observation on 01/30/24 at 11:25 a.m., revealed LVN D administered Resident #15the following medications: Ferrous sulfate 5 cc, Magnesium 400 mg 1 tablet, Potassium chloride 15 cc, Vitamin B-12 1000 mcg 1 tablet and Metoprolol ER 50 mg 1 tablet <BR/>Record review of Resident #20's face sheet dated 01/30/24 revealed a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses that included insomnia, constipation, gastro-esophageal reflux disease without esophagitis, angina pectoris, vitamin d deficiency, major depressive disorder, Parkinson's disease, and type 1 diabetes mellitus.<BR/>Record review of resident's #20's physician orders summary dated 01/30/24 reflected, Keppra tablet 500 mg (levetiracetam) give 1 tablet by mouth two times a day for seizures, methocarbamol oral tablet 750 mg (methocarbamol) give 1 tablet by mouth three times a day for muscle spasms and pain, Norco oral tablet 7.5-325 mg (hydrocodone-acetaminophen) give 1 tablet by mouth two times a day for pain, Topamax oral tablet 25 mg (topiramate) give 1 tablet by mouth two times a day for migraines, trospium chloride tablet 20 mg give 1 tablet by mouth two times a day for incontinence/frequency/urgency, <BR/>Record review of Resident #20's medication administration record dated 01/30/24 reflected Hydrocodone 7.5 - 325 mg 1 tablet was scheduled at 9 am and 9 pm, methocarbamol 750 mg 1 tablet scheduled at 9am, 2 pm and 9 am, Topiramate 25 mg 1 tablet scheduled at 9 am and 9 pm, levetiracetam 500 mg 1 tablet scheduled at 9 am and 9 pm, trospium chloride 20 mg 1 tablet scheduled at 9 am and 9 pm. <BR/>Observation on 01/30/24 at 11:54 a.m., revealed MA B administered the following medications to Resident #20, Hydrocodone 7.5 - 325 mg 1 tablet, methocarbamol 750 mg 1 tablet, Topiramate 25 mg 1 tablet, levetiracetam 500 mg 1 tablet, trospium chloride 20 mg 1 tablet, <BR/>Interview on 01/30/24 at 11:58 a.m., MA B revealed she still had about three more resident to administer medications that were scheduled to be administered in the morning. MA B stated she was late to administer medications because she was assigned more resident because another medication aide called off. MA B stated she was supposed to administer the medications per orders and within the one-hour window which was one hour before and one hour after the scheduled time. MA B stated medications were supposed to be administered timely because other medications that were scheduled more than once a day could be administered too close to each to other which could have a negative effect on the resident. <BR/>Interview with LVN D on 01/30/24 at 1:40 p.m., revealed she was a charge nurse and she mainly worked on the night shift, and she had been requested to assist on the 6-2 shift. She acknowledged administering medication to Resident # 15 late. LVN D stated the resident's assignment had changed after one of the staff members called off. LVN D stated the resident's medications was to be administered timely within the one-hour window to prevent any negative effects if the medications were scheduled more than one time per day which could be administered to close to each other. <BR/>Interview with the DON on 01/30/24 at 3:50 p.m., he stated the charge nurse and medication aide were to administer medication per the orders and per the scheduled time. The DON stated the staff were late because one of the medication aide had called off leaving one medication aide to administer the medications. The DON stated the medications were not supposed to be administered late because some of the medications that were scheduled more than once a day could be administered too close to each other which could lead to a negative effect and at times not being effective if they were pain medications. The DON stated the staff had been in-serviced on medication administration. <BR/>Record review of the facility policy undated titled Administering oral medications, Purpose. The purpose of this procidure is to provide guidelines for the safe administartions of oral medications. The policy did fcnot indicate the times the mediactions were to be administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #53, Resident #74) of 8 residents reviewed for ADLs. <BR/>The facility failed to ensure:<BR/>1- <BR/>Resident #53 had her fingernails cleaned and trimmed.<BR/>2- <BR/>Resident #74 had his fingernails cleaned and trimmed.<BR/>This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. <BR/>Findings include:<BR/>1-Record review of Resident #53's Quarterly MDS assessment dated [DATE] reflected Resident #53 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Hemiplegia (paralysis that affects only one side of the body) affecting right side, and dementia. Resident #53's cognition was severely impaired. Resident #53 was always incontinent of bowel and bladder and required assistance with personal hygiene.<BR/>Review of Resident #53's Comprehensive Care Plan, revised 06/08/23, reflected the following: Focus: [Resident #53] required assistance from staff with ADL. Goal: [Resident #53] will remain clean, comfortable, well groomed, and will maintain optimal mobility on daily basis. Interventions: Staff will encourage resident to participate with ADLs as able. Staff to assist with / provide ADLs as needed.<BR/>An observation and interview on 06/04/24 at 11:33 AM revealed Resident #53's right hand contracted with fingernails were approximately 0.5 inches long. Fingernails on the left hand were long, dirty, and chipped. In an interview with Resident #53 stated she would like the fingernails to be trimmed and cleaned.<BR/>2.A record review of Resident #74's Quarterly MDS assessment dated [DATE] reflected Resident #74 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia, age related physical debility, and lack of coordination. Resident #74 had a BIMS of 11 which indicated Resident #74's cognition was moderately impaired. She required extensive assistance of two-person physical assistance with personal hygiene.<BR/>A record review of Resident #74's Comprehensive Care Plan, revised 03/27/23, reflected the following: Focus: [Resident #74] required assistance from staff with ADL. Goal: [Resident #74] will remain clean, comfortable, well groomed, and will maintain optimal mobility on daily basis. Interventions: Staff will encourage resident to participate with ADLs as able. Staff to assist with / provide ADLs as needed. <BR/>An observation and interview on 06/04/24 at 11:33 AM revealed Resident #74 was laying in her bed. The nails on both hands were approximately 0.3 centimeter in length extending from the tip of her fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #74 was unable to answer questions.<BR/>In an interview with CNA M on 06/04/24 at 11:40 AM, she stated both CNAs and LVNs were responsible for nail care. She stated if a resident has diabetes, only nurses were allowed to provide nailcare. She stated the risk for not performing nailcare was increased risk of infection. She stated both Resident #53 and #74 were not diabetics and she offered to clean and trim their fingernails after the interview. <BR/>In an interview with the DON on 06/06/24 at 8:40 AM revealed his expectation was that nail care should be provided every Sunday or as needed, especially during shower time. He stated that CNAs were responsible for doing nail care unless the resident had a diagnosis of diabetes. He also stated that as the DON, either himself or his designee were responsible to do routine rounds for monitoring. The DON stated residents having long and dirty fingernails could be an infection control issue and skin breakdown. <BR/>Record Review of the facility policy titled Activities of Daily Living, Supporting not dated 1, 2023 reflected, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident who needs respiratory care is provided such care, consistent with professional standards of practice, the resident's care plan, and the resident's goal and preferences for one (Resident #26) of two residents reviewed for tracheostomy care.<BR/>The facility failed to dispose of Resident #26's suction catheter after use. <BR/>These failures placed the residents at risk of respiratory infections. <BR/>Findings included:<BR/>Record review of Resident #26's Quarterly MDS, dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included hypertension, diabetes mellitus, hyperlipidemia, aphasia, seizure disorder, anxiety disorder, and respiratory failure. Her BIMS score was 0 out of 15, which revealed she was severely impaired. She required total dependence with one-to-two-person physical assistance regarding ADLs. She received oxygen therapy, suctioning, and tracheostomy care. <BR/>Review of Resident #26's care plan, undated, revealed she had a tracheostomy due to impaired breathing mechanics. Her goal was to have no signs or symptoms of infection. Her interventions were use of universal precautions as appropriate and suction as necessary. <BR/>Observation and Interview with Resident #26 on 04/23/23 beginning at 12:25 PM revealed the suction catheter had brownish colored particles on the outside of the tube and was left uncovered in her room. The resident was unable to communicate. <BR/>Observation and Interview with LVN Y on 04/23/23 beginning at 1:02 PM revealed there was dried thick mucus left on the suction catheter. She stated the suction catheter was used to suction secretions out of Resident #26's trach. She stated the suction catheter was supposed to be thrown in the trash after single use to prevent infection. She stated she did not know why the suction catheter was not thrown away. She removed discarded the suction catheter in the trash. <BR/>Interview with DON on 04/25/23 at 12:21 PM revealed Resident #26 had a trach and required suctioning. He stated there was a suction machine and supplies in her room. He stated the suction catheter was used with the suction machine to remove her secretions as needed. He stated he was informed during staff training to use the suction catheters once and discard them in the trash. He stated the suction catheters were not to be left uncovered with dried mucus. He stated the technique was supposed to create a sterile environment for Resident #26. He stated the suction catheter being left uncovered with dried mucus was an infection control issue. He stated Resident #26 could be at risk of an infection due to staff breaking the sterile environment. <BR/>Review of facility policy, Tracheostomy Care, undated, reflected: The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation.<BR/>The facility failed to ensure food was properly stored in the facility's kitchen.<BR/>This failure could place residents at risk for food-borne illness. <BR/>Findings included: <BR/>Observation of the facility's refrigerator on 04/23/23 at 9:21 AM revealed: <BR/>- 1 roll of meat thawing directly on the 2nd shelf rack from the top and above a box of potatoes; <BR/>- 1 carton of milk dated best by 04/20/23;<BR/>- 1 orange with white fuzzy spots; and<BR/>- 4 green bell peppers with white spots.<BR/>Observation of the facility's freeze on 04/23/23 at 9:27 AM revealed:<BR/>- plastic wrap and strips of tape left on shelf rack and floor; <BR/>- pieces of corn, green beans, and sherbet cup on the floor; <BR/>- red spill on a shelf rack; <BR/>- 1 box of beef patties open and exposed to air;<BR/>- 1 box of white ranch dinner roll dough open and exposed to air; <BR/>- 1 box of chocolate chip cookie dough open and exposed to air; <BR/>- 1 bag of carrots open and exposed to air; <BR/>- 1 box of peas open and exposed to air; <BR/>- 1 box of simply sweet corn open and exposed to air; <BR/>- 1 box of homestyle cinnamon roll dough open and exposed to air; and<BR/>- 1 box of frozen cookie dough. <BR/>Observation of an open area in the facility's kitchen on 04/23/23 at 9:35 AM revealed: <BR/>- 1 box of instant food thickener open and exposed to air; and<BR/>- 2 loafs of bread dated best buy 04/22/23;<BR/>Observation of the seasoning rack in the facility's kitchen on 04/23/23 at 9:46 AM revealed: <BR/>- 1 open bottle of melted butter; and<BR/>- 1 open container of ground black pepper. <BR/>In an interview with the Dietary Manager on 04/23/23 at 4:26 PM, revealed the cooks were responsible for food storage. She stated meat should not have been thawing on a shelf above a box of potatoes. She stated the meat should have been thawing in a pan on the bottom shelf in the refrigerator. She stated the molded and expired food should have been discarded. She stated items should not be exposed to air and should be sealed or closed. She stated she followed behind the cooks to ensure food was stored properly. She stated she was responsible for ensuring the freezer was cleaned. She stated there was a weekly cleaning log for the cooks and dietary aides. She stated she checks the cleaning log every Monday. She stated improper food storage could cause residents to be exposed to food borne illnesses and cause food to become freezer burnt.<BR/>Review of facility policy, Food Receiving and Storage, undated, reflected: Foods shall be received and stored in a manner that complies with safe food handling practices.<BR/>Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation.<BR/>The facility failed to ensure food was properly stored in the facility's kitchen.<BR/>This failure could place residents at risk for food-borne illness. <BR/>Findings included: <BR/>Observation of the facility's refrigerator on 04/23/23 at 9:21 AM revealed: <BR/>- 1 roll of meat thawing directly on the 2nd shelf rack from the top and above a box of potatoes; <BR/>- 1 carton of milk dated best by 04/20/23;<BR/>- 1 orange with white fuzzy spots; and<BR/>- 4 green bell peppers with white spots.<BR/>Observation of the facility's freeze on 04/23/23 at 9:27 AM revealed:<BR/>- plastic wrap and strips of tape left on shelf rack and floor; <BR/>- pieces of corn, green beans, and sherbet cup on the floor; <BR/>- red spill on a shelf rack; <BR/>- 1 box of beef patties open and exposed to air;<BR/>- 1 box of white ranch dinner roll dough open and exposed to air; <BR/>- 1 box of chocolate chip cookie dough open and exposed to air; <BR/>- 1 bag of carrots open and exposed to air; <BR/>- 1 box of peas open and exposed to air; <BR/>- 1 box of simply sweet corn open and exposed to air; <BR/>- 1 box of homestyle cinnamon roll dough open and exposed to air; and<BR/>- 1 box of frozen cookie dough. <BR/>Observation of an open area in the facility's kitchen on 04/23/23 at 9:35 AM revealed: <BR/>- 1 box of instant food thickener open and exposed to air; and<BR/>- 2 loafs of bread dated best buy 04/22/23;<BR/>Observation of the seasoning rack in the facility's kitchen on 04/23/23 at 9:46 AM revealed: <BR/>- 1 open bottle of melted butter; and<BR/>- 1 open container of ground black pepper. <BR/>In an interview with the Dietary Manager on 04/23/23 at 4:26 PM, revealed the cooks were responsible for food storage. She stated meat should not have been thawing on a shelf above a box of potatoes. She stated the meat should have been thawing in a pan on the bottom shelf in the refrigerator. She stated the molded and expired food should have been discarded. She stated items should not be exposed to air and should be sealed or closed. She stated she followed behind the cooks to ensure food was stored properly. She stated she was responsible for ensuring the freezer was cleaned. She stated there was a weekly cleaning log for the cooks and dietary aides. She stated she checks the cleaning log every Monday. She stated improper food storage could cause residents to be exposed to food borne illnesses and cause food to become freezer burnt.<BR/>Review of facility policy, Food Receiving and Storage, undated, reflected: Foods shall be received and stored in a manner that complies with safe food handling practices.<BR/>Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 2 (Resident # 15 and #20) of 3 residents reviewed for pharmacy services.<BR/>MA B failed to administer medications timely as ordered by physician to Resident # 20<BR/>LVN D failed to administer medications timely as ordered by physician to Resident # 15<BR/>The deficient practice could place residents at risk of not receiving the therapeutic effects from their medications as intended by the prescribing physician order.<BR/>The findings included:<BR/>Record review of Resident #15's face sheet dated 01/30/24 revealed an [AGE] years old female, admitted to the facility on [DATE] with diagnoses that included hypertension (blood pressure that is higher than normal), hypothyroidism (happens when the thyroid gland doesn't make enough thyroid hormone) and malignant neoplasm of unspecified site of right female breast (breast cancer) <BR/>Record review of Resident #15's physician order summary dated 01/30/24 reflected metoprolol succinate ER oral tablet extended release 24-hour 25 mg (metoprolol succinate) give 50 mg via g-tube two times a day for hypertension. <BR/>Record review of Resident #15's medication administration record dated 01/30/24 reflected Metoprolol ER 50 mg 1 tablet scheduled at 9 am. <BR/>Observation on 01/30/24 at 11:25 a.m., revealed LVN D administered Resident #15the following medications: Ferrous sulfate 5 cc, Magnesium 400 mg 1 tablet, Potassium chloride 15 cc, Vitamin B-12 1000 mcg 1 tablet and Metoprolol ER 50 mg 1 tablet <BR/>Record review of Resident #20's face sheet dated 01/30/24 revealed a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses that included insomnia, constipation, gastro-esophageal reflux disease without esophagitis, angina pectoris, vitamin d deficiency, major depressive disorder, Parkinson's disease, and type 1 diabetes mellitus.<BR/>Record review of resident's #20's physician orders summary dated 01/30/24 reflected, Keppra tablet 500 mg (levetiracetam) give 1 tablet by mouth two times a day for seizures, methocarbamol oral tablet 750 mg (methocarbamol) give 1 tablet by mouth three times a day for muscle spasms and pain, Norco oral tablet 7.5-325 mg (hydrocodone-acetaminophen) give 1 tablet by mouth two times a day for pain, Topamax oral tablet 25 mg (topiramate) give 1 tablet by mouth two times a day for migraines, trospium chloride tablet 20 mg give 1 tablet by mouth two times a day for incontinence/frequency/urgency, <BR/>Record review of Resident #20's medication administration record dated 01/30/24 reflected Hydrocodone 7.5 - 325 mg 1 tablet was scheduled at 9 am and 9 pm, methocarbamol 750 mg 1 tablet scheduled at 9am, 2 pm and 9 am, Topiramate 25 mg 1 tablet scheduled at 9 am and 9 pm, levetiracetam 500 mg 1 tablet scheduled at 9 am and 9 pm, trospium chloride 20 mg 1 tablet scheduled at 9 am and 9 pm. <BR/>Observation on 01/30/24 at 11:54 a.m., revealed MA B administered the following medications to Resident #20, Hydrocodone 7.5 - 325 mg 1 tablet, methocarbamol 750 mg 1 tablet, Topiramate 25 mg 1 tablet, levetiracetam 500 mg 1 tablet, trospium chloride 20 mg 1 tablet, <BR/>Interview on 01/30/24 at 11:58 a.m., MA B revealed she still had about three more resident to administer medications that were scheduled to be administered in the morning. MA B stated she was late to administer medications because she was assigned more resident because another medication aide called off. MA B stated she was supposed to administer the medications per orders and within the one-hour window which was one hour before and one hour after the scheduled time. MA B stated medications were supposed to be administered timely because other medications that were scheduled more than once a day could be administered too close to each to other which could have a negative effect on the resident. <BR/>Interview with LVN D on 01/30/24 at 1:40 p.m., revealed she was a charge nurse and she mainly worked on the night shift, and she had been requested to assist on the 6-2 shift. She acknowledged administering medication to Resident # 15 late. LVN D stated the resident's assignment had changed after one of the staff members called off. LVN D stated the resident's medications was to be administered timely within the one-hour window to prevent any negative effects if the medications were scheduled more than one time per day which could be administered to close to each other. <BR/>Interview with the DON on 01/30/24 at 3:50 p.m., he stated the charge nurse and medication aide were to administer medication per the orders and per the scheduled time. The DON stated the staff were late because one of the medication aide had called off leaving one medication aide to administer the medications. The DON stated the medications were not supposed to be administered late because some of the medications that were scheduled more than once a day could be administered too close to each other which could lead to a negative effect and at times not being effective if they were pain medications. The DON stated the staff had been in-serviced on medication administration. <BR/>Record review of the facility policy undated titled Administering oral medications, Purpose. The purpose of this procidure is to provide guidelines for the safe administartions of oral medications. The policy did fcnot indicate the times the mediactions were to be administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 2 (Resident # 15 and #20) of 3 residents reviewed for pharmacy services.<BR/>MA B failed to administer medications timely as ordered by physician to Resident # 20<BR/>LVN D failed to administer medications timely as ordered by physician to Resident # 15<BR/>The deficient practice could place residents at risk of not receiving the therapeutic effects from their medications as intended by the prescribing physician order.<BR/>The findings included:<BR/>Record review of Resident #15's face sheet dated 01/30/24 revealed an [AGE] years old female, admitted to the facility on [DATE] with diagnoses that included hypertension (blood pressure that is higher than normal), hypothyroidism (happens when the thyroid gland doesn't make enough thyroid hormone) and malignant neoplasm of unspecified site of right female breast (breast cancer) <BR/>Record review of Resident #15's physician order summary dated 01/30/24 reflected metoprolol succinate ER oral tablet extended release 24-hour 25 mg (metoprolol succinate) give 50 mg via g-tube two times a day for hypertension. <BR/>Record review of Resident #15's medication administration record dated 01/30/24 reflected Metoprolol ER 50 mg 1 tablet scheduled at 9 am. <BR/>Observation on 01/30/24 at 11:25 a.m., revealed LVN D administered Resident #15the following medications: Ferrous sulfate 5 cc, Magnesium 400 mg 1 tablet, Potassium chloride 15 cc, Vitamin B-12 1000 mcg 1 tablet and Metoprolol ER 50 mg 1 tablet <BR/>Record review of Resident #20's face sheet dated 01/30/24 revealed a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses that included insomnia, constipation, gastro-esophageal reflux disease without esophagitis, angina pectoris, vitamin d deficiency, major depressive disorder, Parkinson's disease, and type 1 diabetes mellitus.<BR/>Record review of resident's #20's physician orders summary dated 01/30/24 reflected, Keppra tablet 500 mg (levetiracetam) give 1 tablet by mouth two times a day for seizures, methocarbamol oral tablet 750 mg (methocarbamol) give 1 tablet by mouth three times a day for muscle spasms and pain, Norco oral tablet 7.5-325 mg (hydrocodone-acetaminophen) give 1 tablet by mouth two times a day for pain, Topamax oral tablet 25 mg (topiramate) give 1 tablet by mouth two times a day for migraines, trospium chloride tablet 20 mg give 1 tablet by mouth two times a day for incontinence/frequency/urgency, <BR/>Record review of Resident #20's medication administration record dated 01/30/24 reflected Hydrocodone 7.5 - 325 mg 1 tablet was scheduled at 9 am and 9 pm, methocarbamol 750 mg 1 tablet scheduled at 9am, 2 pm and 9 am, Topiramate 25 mg 1 tablet scheduled at 9 am and 9 pm, levetiracetam 500 mg 1 tablet scheduled at 9 am and 9 pm, trospium chloride 20 mg 1 tablet scheduled at 9 am and 9 pm. <BR/>Observation on 01/30/24 at 11:54 a.m., revealed MA B administered the following medications to Resident #20, Hydrocodone 7.5 - 325 mg 1 tablet, methocarbamol 750 mg 1 tablet, Topiramate 25 mg 1 tablet, levetiracetam 500 mg 1 tablet, trospium chloride 20 mg 1 tablet, <BR/>Interview on 01/30/24 at 11:58 a.m., MA B revealed she still had about three more resident to administer medications that were scheduled to be administered in the morning. MA B stated she was late to administer medications because she was assigned more resident because another medication aide called off. MA B stated she was supposed to administer the medications per orders and within the one-hour window which was one hour before and one hour after the scheduled time. MA B stated medications were supposed to be administered timely because other medications that were scheduled more than once a day could be administered too close to each to other which could have a negative effect on the resident. <BR/>Interview with LVN D on 01/30/24 at 1:40 p.m., revealed she was a charge nurse and she mainly worked on the night shift, and she had been requested to assist on the 6-2 shift. She acknowledged administering medication to Resident # 15 late. LVN D stated the resident's assignment had changed after one of the staff members called off. LVN D stated the resident's medications was to be administered timely within the one-hour window to prevent any negative effects if the medications were scheduled more than one time per day which could be administered to close to each other. <BR/>Interview with the DON on 01/30/24 at 3:50 p.m., he stated the charge nurse and medication aide were to administer medication per the orders and per the scheduled time. The DON stated the staff were late because one of the medication aide had called off leaving one medication aide to administer the medications. The DON stated the medications were not supposed to be administered late because some of the medications that were scheduled more than once a day could be administered too close to each other which could lead to a negative effect and at times not being effective if they were pain medications. The DON stated the staff had been in-serviced on medication administration. <BR/>Record review of the facility policy undated titled Administering oral medications, Purpose. The purpose of this procidure is to provide guidelines for the safe administartions of oral medications. The policy did fcnot indicate the times the mediactions were to be administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #53, Resident #74) of 8 residents reviewed for ADLs. <BR/>The facility failed to ensure:<BR/>1- <BR/>Resident #53 had her fingernails cleaned and trimmed.<BR/>2- <BR/>Resident #74 had his fingernails cleaned and trimmed.<BR/>This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. <BR/>Findings include:<BR/>1-Record review of Resident #53's Quarterly MDS assessment dated [DATE] reflected Resident #53 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Hemiplegia (paralysis that affects only one side of the body) affecting right side, and dementia. Resident #53's cognition was severely impaired. Resident #53 was always incontinent of bowel and bladder and required assistance with personal hygiene.<BR/>Review of Resident #53's Comprehensive Care Plan, revised 06/08/23, reflected the following: Focus: [Resident #53] required assistance from staff with ADL. Goal: [Resident #53] will remain clean, comfortable, well groomed, and will maintain optimal mobility on daily basis. Interventions: Staff will encourage resident to participate with ADLs as able. Staff to assist with / provide ADLs as needed.<BR/>An observation and interview on 06/04/24 at 11:33 AM revealed Resident #53's right hand contracted with fingernails were approximately 0.5 inches long. Fingernails on the left hand were long, dirty, and chipped. In an interview with Resident #53 stated she would like the fingernails to be trimmed and cleaned.<BR/>2.A record review of Resident #74's Quarterly MDS assessment dated [DATE] reflected Resident #74 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia, age related physical debility, and lack of coordination. Resident #74 had a BIMS of 11 which indicated Resident #74's cognition was moderately impaired. She required extensive assistance of two-person physical assistance with personal hygiene.<BR/>A record review of Resident #74's Comprehensive Care Plan, revised 03/27/23, reflected the following: Focus: [Resident #74] required assistance from staff with ADL. Goal: [Resident #74] will remain clean, comfortable, well groomed, and will maintain optimal mobility on daily basis. Interventions: Staff will encourage resident to participate with ADLs as able. Staff to assist with / provide ADLs as needed. <BR/>An observation and interview on 06/04/24 at 11:33 AM revealed Resident #74 was laying in her bed. The nails on both hands were approximately 0.3 centimeter in length extending from the tip of her fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #74 was unable to answer questions.<BR/>In an interview with CNA M on 06/04/24 at 11:40 AM, she stated both CNAs and LVNs were responsible for nail care. She stated if a resident has diabetes, only nurses were allowed to provide nailcare. She stated the risk for not performing nailcare was increased risk of infection. She stated both Resident #53 and #74 were not diabetics and she offered to clean and trim their fingernails after the interview. <BR/>In an interview with the DON on 06/06/24 at 8:40 AM revealed his expectation was that nail care should be provided every Sunday or as needed, especially during shower time. He stated that CNAs were responsible for doing nail care unless the resident had a diagnosis of diabetes. He also stated that as the DON, either himself or his designee were responsible to do routine rounds for monitoring. The DON stated residents having long and dirty fingernails could be an infection control issue and skin breakdown. <BR/>Record Review of the facility policy titled Activities of Daily Living, Supporting not dated 1, 2023 reflected, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for two (Residents #50 and #23) of four residents reviewed for infection control.<BR/>MA X failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #50 and #23. <BR/>This failure could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included:<BR/>Observation on 04/23/23 at 9:25 AM of MA X using a wrist blood pressure monitor for Resident #50. At 9:27 AM MA X took the same wrist blood pressure monitor to Resident #23. MA X did not sanitize or clean the wrist blood pressure monitor between the two residents.<BR/>In an interview on 04/23/23 at 9:32 AM with MA X revealed she did use the wrist blood pressure monitor on Resident #50 and Resident #23 without cleaning or sanitizing it in between the residents. MA X said she knew she should have done that to not spread germs but forgot to. MA X said she did have access to sanitizing wipes on her medication cart. <BR/>In an interview on 04/25/23 at 8:56 AM with the DON revealed staff using medical equipment between residents should always sanitize or clean it in between uses. The DON said staff had access to supplies used to clean or sanitize medical equipment and the purpose of doing so was for infection control.<BR/>Review of the facility's undated policy titled Cleaning and Disinfection of Resident Care Items and Equipment reflected: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include bedpans, blood pressure cuffs . (2) Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location) . 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for two (Resident #4 and Resident #111) of six residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #4 and Resident #111 within 48 hours of their admissions. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services.Findings included: Review of Resident #4's Face Sheet, dated 07/23/25, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE], with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident #4's Baseline Care Plan, dated 05/13/25, reflected the ADON signed the document as completed on 05/13/25. Review of Resident #111's Face Sheet, dated 07/22/25, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including history of falling (past instances of falling). Review of Resident #111's Baseline Care Plan, dated 07/19/25, reflected the ADON signed the document as completed on 07/19/25. During an interview with ADON B on 07/22/25 at 12:44PM, she stated she completed the Baseline Care Plans for Resident #4 and Resident #111. She stated although the IDT Meetings were held within 48 hours of admission for both residents, the Baseline Care Plans were not completed within that required timeframe. She confirmed that Resident #4's Baseline Care Plan was completed on 05/13/25, and that Resident 111's Baseline Care Plan was completed on 7/19/25. ADON B stated there were times in which Baseline Care Plans were not completed within the required 48-hour timeframe following admission. She stated there was not a specific reason for this delay. ADON B stated the risk of Baseline Care Plans not being completed within the required timeframe included direct care staff members not having basic information about their newly admitted residents. Review of the facility's Care Plans - Baseline policy, dated 12/2016, reflected, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission.

Based on observation, interview, and record review, the facility failed to ensure that the daily nurse staffing was posted as required. <BR/>The facility failed to post the daily staffing information posting from 04/20/23 to 04/23/23.<BR/>This failure could place the residents, families, and visitors at risk of not having access to information regarding the daily nurse staffing data and facility census.<BR/>Findings included:<BR/>Observation on 04/23/23 at 9:07 AM revealed the daily nurse staffing posting was dated 04/20/23.<BR/>Observation on 04/23/23 at 9:30 AM revealed the daily nurse staffing posting was dated 04/20/23.<BR/>In an interview on 04/25/23 at 12:00 PM with the Administrator revealed the nursing department was responsible for ensuring the daily nurse staffing was updated daily.<BR/>In an interview on 04/25/23 at 12:25 PM with the DON revealed he was responsible for ensuring the daily nurse staffing was updated daily but he was not in the building over the weekend. The DON said he normally assigned a nurse to update the posting over the weekends since he was not in the building. The DON said he was not sure why the nurse did not update the daily nurse posting since 04/20/23. The DON said the purpose of the posting was to let people know how many residents and staff were in the building or on that shift. <BR/>Review of the facility's undated policy titled Posting Direct Care Daily Staffing Numbers reflected: 1. At the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for two (Residents #50 and #23) of four residents reviewed for infection control.<BR/>MA X failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #50 and #23. <BR/>This failure could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included:<BR/>Observation on 04/23/23 at 9:25 AM of MA X using a wrist blood pressure monitor for Resident #50. At 9:27 AM MA X took the same wrist blood pressure monitor to Resident #23. MA X did not sanitize or clean the wrist blood pressure monitor between the two residents.<BR/>In an interview on 04/23/23 at 9:32 AM with MA X revealed she did use the wrist blood pressure monitor on Resident #50 and Resident #23 without cleaning or sanitizing it in between the residents. MA X said she knew she should have done that to not spread germs but forgot to. MA X said she did have access to sanitizing wipes on her medication cart. <BR/>In an interview on 04/25/23 at 8:56 AM with the DON revealed staff using medical equipment between residents should always sanitize or clean it in between uses. The DON said staff had access to supplies used to clean or sanitize medical equipment and the purpose of doing so was for infection control.<BR/>Review of the facility's undated policy titled Cleaning and Disinfection of Resident Care Items and Equipment reflected: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include bedpans, blood pressure cuffs . (2) Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location) . 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for one (Resident #75) of three residents observed for indwelling urinary catheters.<BR/>The facility failed to ensure Resident #75's catheter bag was changed as ordered by the physician.<BR/>These failures could place residents with urinary catheters at risk for urethral tears, dislodging of the catheter, and urinary tract infections.<BR/>Findings included:<BR/>Record review of Resident #75's Quarterly MDS, dated [DATE], revealed an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included anemia, hypertension, renal failure, neurogenic bladder, Non-Alzheimer's Dementia, malnutrition, anxiety, depression, and insomnia. Her BIMS score was 10 out of 15, which revealed she was moderately impaired. Her appliances used was an indwelling catheter and she was always incontinent. <BR/>Review of Resident #75's care plan, undated, reflected her focus was at risk for infection related to foley catheter. Her goal was to remain free from signs/symptoms of infection due to catheter. Her intervention was staff to provide catheter care every shift as ordered/indicated.<BR/>Review of Resident #75's physician orders, dated 08/15/22, reflected, Change foley drainage bag every two weeks every night shift every 14 days for infection control.<BR/>Observation and interview with Resident #75 on 04/23/23 beginning at 11:36 AM revealed her catheter bag was clipped to her bed and dated 03/14/23. There appeared to be sediment in her catheter tubing and discoloration of her catheter bag. Resident #75 stated she did not remember the last time she had her catheter bag changed. She stated she did not know how frequently her catheter bag was supposed to be changed. She stated she was not experiencing any discomfort from her catheter.<BR/>Interview with LVN A on 04/24/23 at 11:52 AM revealed she changed Resident #75's catheter bag and tubing on 04/24/23. She stated the catheter bag was dated 03/14/23. She stated Resident #75's catheter tubing and bag had sediment build up. She stated there was a physician order to change the catheter bag every two weeks during the night shift. She stated she did not know why 03/14/23 was written on the catheter bag. She stated the purpose of changing Resident #75's catheter bag every two weeks was to prevent infection.<BR/>Interview with DON on 04/24/23 at 03:20 PM revealed Resident #75's had a catheter. He stated the catheter bag was to be changed every two weeks. He stated the catheter bag was to be changed every two weeks due to sediments, bag becoming crusted, and infection control. He stated the purpose of dating the catheter bag was to inform the next nurse when the bag was last changed. He stated he was not aware Resident #75's catheter bag was dated 03/14/23. He Resident #75 was at risk of an infection. He stated the nurses were responsible for changing residents' catheter bags. He stated the managers and himself were responsible for ensuring nurses were changing catheter bags. <BR/>Review of facility policy, Catheter Care, Urinary, undated, reflected: The purpose of this procedure is to prevent catheter-associated urinary tract infections.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for two (Residents #50 and #23) of four residents reviewed for infection control.<BR/>MA X failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #50 and #23. <BR/>This failure could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included:<BR/>Observation on 04/23/23 at 9:25 AM of MA X using a wrist blood pressure monitor for Resident #50. At 9:27 AM MA X took the same wrist blood pressure monitor to Resident #23. MA X did not sanitize or clean the wrist blood pressure monitor between the two residents.<BR/>In an interview on 04/23/23 at 9:32 AM with MA X revealed she did use the wrist blood pressure monitor on Resident #50 and Resident #23 without cleaning or sanitizing it in between the residents. MA X said she knew she should have done that to not spread germs but forgot to. MA X said she did have access to sanitizing wipes on her medication cart. <BR/>In an interview on 04/25/23 at 8:56 AM with the DON revealed staff using medical equipment between residents should always sanitize or clean it in between uses. The DON said staff had access to supplies used to clean or sanitize medical equipment and the purpose of doing so was for infection control.<BR/>Review of the facility's undated policy titled Cleaning and Disinfection of Resident Care Items and Equipment reflected: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include bedpans, blood pressure cuffs . (2) Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location) . 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed conduct a Comprehensive Assessment within 14 calendar days after admission for 1 of 5 residents (Resident #111) reviewed for Comprehensive Assessments and timing. The facility failed to ensure a Comprehensive MDS Assessment for Resident #111 was completed within 14 days after her admission to the facility. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.Findings included: Review of Resident #111's Face Sheet, dated 07/22/25, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including history of falling (past instances of falling). Review of Resident #111's electronic medical record on 07/22/25 reflected no evidence that an MDS Assessment had been completed. During an interview with the [NAME] President of Reimbursement on 07/22/25 at 12:09PM, he stated the facility did not currently have a full-time MDS Coordinator. He said the facility had a couple of remote MDS Coordinators who were assisting the facility until the vacant position could be filled. The [NAME] President of Reimbursement confirmed Resident #111's Comprehensive (Admission) MDS Assessment had not been completed within the required timeframe. He stated the risk of MDS Assessments not being completed within the required timeframe included the potential for residents not receiving necessary services. Review of the facility's Electronic Transmission of the MDS policy, undated, reflected, .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data.