Franklin Heights Nursing & Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 resident (Residents #83) of 8 reviewed for medication administration. <BR/>MA S administered Resident #83 medication prior to taking blood pressure. <BR/>This deficient practice could cause a decline in health of residents who receive medication that are not according to physician orders. <BR/>Findings included: <BR/>Review of Resident #83's face sheet dated 03/28/23 revealed a [AGE] year-old female with an admission date of 11/21/22. <BR/>Review of Resident #83's History and Physical dated 02/27/23 revealed she was diagnosed with hypertension (high blood pressure). <BR/>Review of physician orders dated 3/28/2023 revealed an order for Lisinopril Tablet 10 MG Give 1 tablet by mouth one time a day for hypertension hold if SBP &lt;110mm/Hg, pulse &lt;60. <BR/>Observations during medication pass on 03/28/23 at 8:40 AM, MA S was observed preparing medication and taking it to Resident #83 room. After MA S handed the medication to Resident #83 and Resident #83 took the medications. After the Resident #83 swallowed the medication MA S proceeded to take Resident #83 blood pressure which resulted in 181/85, and her heart rate was 93. <BR/>Interview with MA S on 03/28/23 at 08:45 AM revealed Resident #83 blood pressure had been running high lately. The doctor was aware and had been modifying her medications to address this issue. MA S stated, I am trained to notify the floor nurse of any blood pressure that is too high or low and if they refuse.<BR/>In an interview with LVN T on 03/18/23 at 9:00 AM, he stated Resident #83 usually had blood pressure readings that were high. LVN T stated, they are trained to take blood pressure prior to medication administration since it has parameters to hold if the parameter is out of range. LVN T stated Resident #83 blood pressure baseline is elevated and doctor is aware. <BR/>Interview with the DON on 3/28/23 at 03:00 PM revealed that nursing staff administering medication should be taking blood pressure prior since it can cause resident to become hypotensive (have blood pressure that is too low). The staff gets yearly training and as needed. <BR/>Policy not obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 resident (Residents #83) of 8 reviewed for medication administration. <BR/>MA S administered Resident #83 medication prior to taking blood pressure. <BR/>This deficient practice could cause a decline in health of residents who receive medication that are not according to physician orders. <BR/>Findings included: <BR/>Review of Resident #83's face sheet dated 03/28/23 revealed a [AGE] year-old female with an admission date of 11/21/22. <BR/>Review of Resident #83's History and Physical dated 02/27/23 revealed she was diagnosed with hypertension (high blood pressure). <BR/>Review of physician orders dated 3/28/2023 revealed an order for Lisinopril Tablet 10 MG Give 1 tablet by mouth one time a day for hypertension hold if SBP &lt;110mm/Hg, pulse &lt;60. <BR/>Observations during medication pass on 03/28/23 at 8:40 AM, MA S was observed preparing medication and taking it to Resident #83 room. After MA S handed the medication to Resident #83 and Resident #83 took the medications. After the Resident #83 swallowed the medication MA S proceeded to take Resident #83 blood pressure which resulted in 181/85, and her heart rate was 93. <BR/>Interview with MA S on 03/28/23 at 08:45 AM revealed Resident #83 blood pressure had been running high lately. The doctor was aware and had been modifying her medications to address this issue. MA S stated, I am trained to notify the floor nurse of any blood pressure that is too high or low and if they refuse.<BR/>In an interview with LVN T on 03/18/23 at 9:00 AM, he stated Resident #83 usually had blood pressure readings that were high. LVN T stated, they are trained to take blood pressure prior to medication administration since it has parameters to hold if the parameter is out of range. LVN T stated Resident #83 blood pressure baseline is elevated and doctor is aware. <BR/>Interview with the DON on 3/28/23 at 03:00 PM revealed that nursing staff administering medication should be taking blood pressure prior since it can cause resident to become hypotensive (have blood pressure that is too low). The staff gets yearly training and as needed. <BR/>Policy not obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #198) of 2 residents reviewed for Midline/PICC (Peripherally Inserted Central Catheter) care. <BR/>Resident #78 midline (intravenous catheter) dated 05/20/2024, the dressing edges where loose and coming off, dressing had dried blood towards the bottom of the dressing, and was dated 05/20/24. <BR/>This failure placed residents at risk of developing an infection. <BR/>Findings included: <BR/>Record review of Resident #78 ' s face sheet dated 05/28/24, revealed an admission on [DATE] to the facility. <BR/>Record review of Resident #78 ' s facility history and physical dated 06/08/23, revealed, a [AGE] year-old male diagnosed with borderline Diabetes and total knee replacement, and infection of prosthesis (a device such as an artificial leg, that replaces a part of the body). <BR/>Record review of Resident #78 ' s admission MDS dated [DATE], revealed an intact cognition to be able to recall or make daily decision with a BIMS (tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 15. Resident #78 was diagnosed with Diabetes Mellitus, and infection due to internal right knee prosthesis. Resident #78 was marked for antibiotic use and IV medications. <BR/>Record review of Resident #78 ' s order recap dated 05/07/24, revealed, PICC Line Dressing Change every 7 days one time a day every Tuesday, Wednesday &ndash; PICC Line dressing change every 7 days. <BR/>Record review of Resident #78 ' s care plan dated 04/24/24, revealed had a skin soft tissue/cellulitis infection. Administer antibiotic as per medical doctor ' s orders. Perform any dressing changes as ordered. <BR/>Observation and interview on 05/28/24 at 9:07 AM, Resident #78 was in his room lying down on the bed. Resident #78 had an IV with dressing on his left inner arm dated 05/20/24. The dressing edges were loose and coming off. Inside the dressing there was dried blood. Resident #198 stated he was on antibiotics and was getting them through the IV line. <BR/>During an interview on 05/28/24 at 11:39 AM, with Resident #78, he stated the nurses had changed his dressing from his left arm to his right arm. Resident #78 stated he was receiving antibiotics for infection he had. <BR/>During an interview on 05/30/24 at 9:47 AM, with Resident #78, he stated the dressing was changed on 05/29/24. Resident #78 stated the nurse came in and changed his dressing. <BR/>During an interview on 05/30/24 at 9:50 AM, with LVN E, she stated Resident #198 was on antibiotics and was receiving them intravenous due to an infection. LVN E stated the IV line was changed from the left side arm to the right-side arm on 05/20/24. LVN E stated the dressing should have already been changed. LVN E stated it was expected for the nurses to be changing the dressing as ordered by the physician. LVN E stated that not changing the dressing could lead to an infection. <BR/>During an interview on 05/31/24 at 1:13 PM, with the DON, she stated if a physician order stated to change the dressing every Tuesday and Wednesday then it needed to be changed out. The DON stated failure to follow the physician order could be a risk of infection for Resident #78.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an alleged violation of injury of unknown origin immediately to the administrator of the facility and to other officials (including to state survey agency) in accordance with State law and according to their policy for 1 (Resident # 13) of 2 residents reviewed for allegations of injury with unknown origin. <BR/>The facility failed to report Resident #13 ' s injury of unknown origin related to her dislocated jaw to State Office. <BR/>This failure could place all residents at risk for abuse and/or neglect by not immediately reporting allegations of injuries of unknown origin to the proper authorities at the facility. <BR/>Findings Include: <BR/>Resident #13 <BR/>Record review of Resident #13 ' s face sheet dated 01/18/2024 revealed an [AGE] year-old female who was admitted on [DATE]. <BR/>Record review of Resident #13 ' s history and physical dated 06/08/2023 revealed admitting diagnoses of debility (weakness caused by an illness, injury, or aging) post observation and isolation due to exposure to coronavirus complicated by underlying dementia and chronic comorbidities. <BR/>Record review of Resident #13 ' s quarterly MDS dated [DATE] revealed a BIMS score of 04, she was severely cognitive impaired and required extensive assistance with one-person physical assist for eating. <BR/>Record review of Resident #13 ' s care plan last reviewed on 12/12/23 revealed focus area for ADL self-care performance deficit related to limited mobility with interventions for eating that requires staff participation. <BR/>Record review of Resident #13 ' s SBAR dated 12/31/23 revealed noticed patient with poor appetite, she needs frequent monitoring to make her increase her fluid and meal intake. This was noticed on 12/26/23. Patient was diagnosed with URI she has been on antibiotics. MD was notified and new orders were continue monitoring and encouraging fluids. Resident #13 was her own responsible party. <BR/>Record review of Resident 13 ' s transfer form dated 01/01/2024 revealed she was transferred to hospital. The document did not give reason for transfer. <BR/>Record review of Resident #13 ' s progress note written by LVN A dated 01/01/2024 revealed Resident ' s mouth remained opened without ability to shut or speak. Resident is DNR though writer was concerned with change in condition. Resident was sent to local emergency room for evaluation. <BR/>Record review of Resident #13 ' s local hospital discharge summary report dated 01/18/2024 revealed admission information: Resident #13 presenting with decreasing oral intake of fluids and evidence of urinary tract infection with sepsis (the body's extreme response to an infection). However, in addition of the above the patient has been found after being admitted to the hospital that she has a spontaneous dislocation of the jaw which apparently was the cause of her difficulty to have adequate oral intake of fluids and food. <BR/>During an interview om 01/18/2024 at 9:43 am, Hospital Staff stated Resident #13 was transferred to the hospital with concerns of low blood pressure and low oxygen saturation level. Hospital Staff stated the facility did not notify the hospital of Resident #13 inability to close her jaw and was concerned. Hospital Staff stated they identified Resident #13 dislocated jaw shortly after she was admitted for treatment. <BR/>During an interview on 01/18/2024 at 10:12 am, DON stated she had been notified by LVN A that she was sending out Resident #13 to the hospital for further evaluation due to being lethargic, altered mental status and low oxygen saturation level. The DON stated the facility does follow up with local hospital for updates. The DON stated she received referral paperwork on January 10th where she read Resident #10 had a dislocated jaw and was pending surgery for g-tube for feeding. The DON stated she was concerned on the dislocation of the jaw and asked the nurses and CNAs to follow up on any bruising and determine if Resident #12 had a recent fall that may had contributed. The DON stated Resident #13 had a decrease in appetite and was reported to MD, they thought it was a decline due to coronavirus infection. The DON stated the facility continued to monitor and after she talked to staff, she was not able to determine a possible cause for Resident #13 dislocation of jaw. The DON stated she assumed the dislocated jaw occurred while she was at the hospital but did not call the hospital to question the charge nurses. The DON stated it would be considered an injury of unknown origin and was not sure if she had to report to State Office due to the dislocated jaw found at the hospital. <BR/>During an interview on 01/18/2024 at 11:05 am, Regional Compliance Nurse stated she was notified by the DON that Resident #13 had been sent out for further evaluation after a change in condition was later told about her dislocated jaw. Regional Compliance Nurse stated she asked the DON if Resident #13 had sustained a recent fall, if she followed up with staff to check if they noticed bruising or anything out the normal on her face in which she (DON) stated no evidence of recent falls, bruising or abnormalities to face noticed. Regional Compliance Nurse stated it was expected for DON to had followed up with hospital to verify if Resident #13 had been admitted with the dislocated jaw, if she had been and the facility did not identify a source of cause the dislocated jaw would be considered an injury of unknown origin. Regional Compliance Nurse stated the dislocated jaw should had been reported to State Office. <BR/>Record review of the facility Abuse/Neglect policy dated 03/29/18 revealed, The facility will provide and ensure the promotion and protection of resident rights. It was each individuals ' responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. <BR/>Reporting &ndash; Any person having reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, State and or Adult Protective Services. Stated law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. <BR/>Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility Administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 07/10/19. <BR/>If the allegations involve abuse or result in serious bodily injury, the report was to be made within 2 hours of the allegation. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 1 (Resident #3) of 4 residents reviewed for wound care. <BR/>Resident #3 was not given wound care as prescribed to left and right heel to cleanse with normal saline cleanser, pat dry, apply foam heel protector or abdominal pad and wrap with roll gauze dressing every Monday, Wednesday, and Friday for protection as ordered as there was no wound care performed on 03/13/24. <BR/>This failure could affect residents by placing them at risk of deterioration of the wound. <BR/>Findings included: <BR/>Record review of Resident #3's face sheet dated 03/15/24, revealed, admission on [DATE] to the facility. <BR/>Record review of Resident #3's facility history and physical dated 10/26/23, revealed, a [AGE] year-old male diagnosed with Diabetes Mellitus .<BR/>Record review of Resident #3's care plan dated 01/15/24, revealed has a pressure ulcer or potential for pressure ulcer development. Administer medications as ordered. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Notify nurse immediately of any new areas of skin breakdown. Open area, redness, blisters, bruises, discoloration noted during bath or daily care. <BR/>Record review of Resident #3's physician orders dated 02/28/24, revealed, to trauma wound of the right 1st toe. Cleanse with normal saline wound cleanser, apply Medi-Honey (hastens the healing of wounds through its anti-inflammatory effects), then Hydrophera (treatment of wounds burns, ulcers, and yeast) blue foam, cover with abdominal dressing and wrap with roll gauze, secure with Med Fix tape, everyday shift. Wound care to evaluate and treat as warranted for wound of the right great toe. <BR/>Record review of Resident #3's Weekly Skin assessment dated [DATE], revealed, open area to the right great toe, discoloration, black, red, serosanguinous drainage. Scab to the right knee. <BR/>Record review of Resident #3's Weekly Skin assessment dated [DATE], revealed, open are to the right great toe, discoloration of black, red to affected area. Minimal serosanguinous drainage. No foul smell or purulent drainage present. No other signs and symptoms noted. Peri skin was dry. No Erythema or edema present. <BR/>Record review of Resident #3's Weekly Skin assessment dated [DATE], revealed, Physician who was medical director of facility present and was asked to assess the patients wound. At this time order was given to floor nurse to transfer the Resident #3 to emergency room. At this time Physician F also notified.<BR/>Wound care for Resident #3 was not observed due to Resident #3 being in the hospital. <BR/>During an interview on 03/15/24 at 3:27 PM, with LVN C, he stated that the DON and him would be responsible for wound care during the weekdays. LVN C stated Resident #3 had hit his right big toe on the wall during shower time. LVN C stated Resident #3 had bleeding underneath his right big toenail. LVN C stated on 03/13/24, LVN D did not perform wound care as Resident #3 was notify him that it had not been done. LVN C stated Resident #3's dressing still had his initials from 03/12/24. LVN C stated Resident #3 had recorded LVN D, where Resident #3 had asked LVN D if he was going to do wound care and LVN D replied that he was going to go do it later and never did. <BR/>During an interview on 03/15/24 at 4:48 PM, with NP, he stated he was informed of Resident #3 hitting his toe and having a discoloration. NP stated that wound care was ordered. NP stated on 03/13/24, Resident #3 had not had wound care done. NP stated it would have affected Resident #3 if wound care was not preformed. <BR/>During an interview on 03/15/24 at 4:12 PM, with Physician, he stated it was reported to him that Resident #3 had bumped his foot on the wall and had a scab on the injury site. The Physician stated wound care was started last week. The Physician stated the nurses are to provide wound care. The Physician stated Resident #3 was diabetic. The Physician stated there could have been a risk to Resident #3 if physician orders were not followed. The Physician stated the wound could get worse if wound care was not provided.<BR/>During an interview on 03/18/24 at 2:38 PM, with LVN D, he stated the nurses and LVN C needed to be providing wound care as per physician orders. LVN D stated not providing wound care as order could be a risk to the resident of the wound worsening or infection. LVN D stated he was aware on 03/13/24, that LVN C was suspended and did not provide wound care for Resident #3. LVN D stated not doing wound care would be a risk of wounds worsening. <BR/>During an interview on 03/18/24 at 4:17 PM, with the Administrator, she stated anytime LVN C was not in the facility the nurses were expected to do wound care. The Administrator stated the DON, ADON, and nurse to nurse report was how the nurses will know to do their own wound care. The Administrator stated wound care not being done as per physician orders for the residents with wounds would be out compliance. The Administrator stated she was not clinical but said missing a day of wound care she thought would be bad. The Administrator stated Resident #3 had hit his toe in the shower wall and had a cut. The Administrator stated LVN C knew Resident #3 had a diagnoses of Diabetes Mellitus. The Administrator stated it was reported to the physician and wound care orders were given to conduct wound care. <BR/>During an interview on 03/19/24 at 11:20 AM, with the ADON, she stated the facility does have a wound care nurse which was LVN C. The ADON stated the DON and ADON will tell the nurses that LVN C did not go into work and the nurses are expected once notified to doing the wound care. The ADON stated there could be a negative outcome if wound care was not provided which could result in the resident getting worse or sick. The ADON stated it was expected for the nurses to be following physician orders and not following physician orders could cause wounds to get worse. <BR/>During an interview on 03/19/24 at 1:56 PM, with the Regional Nurse, she stated wound care needs to be conducted as per physician orders. Regional Nurse stated not providing wound care as prescribed could result in the missing a change in the wound care. Regional Nurse stated the DON, ADON, and the floor nurses in the weekdays when LVN C was not at work are to be doing the wound care on residents. Regional Nurse stated management would let the nurses know LVN C would not be at work. <BR/>Record review of the facility Skin Integrity Management policy dated 10/05/16, revealed, Wound care should be performed as ordered by the physician.<BR/>Record review of the facility Skin Assessment policy dated 08/15/24, revealed, It was the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to allow of appropriate intervention be initiated in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 (Resident #11) of 3 residents reviewed for urinary catheter care. <BR/>Resident #11's catheter bag did not have a catheter bag cover exposing the catheter bag filled with urine<BR/>This failure could have compromised residents' dignity for those who require urinary catheter care. <BR/>Findings include: <BR/>Record review of Resident #11's face sheet dated 02/14/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #11's facility history and physical dated 11/06/23 revealed a [AGE] year-old male diagnosed with schizophrenia (a serious mental disorder in which people interpret reality abnormally) and bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode)). <BR/>Record review of Resident #11's quarterly MDS dated [DATE] revealed an intact cognition to be able to recall and make daily decisions BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 13. Resident #11 was dependent on nursing staff for toileting. Resident #11 had an indwelling catheter. <BR/>Record review of Resident #11's care plan dated 01/13/24 revealed indwelling catheter - check for kinks and maintain the drainage bag off the floor, ensure tubing is anchored to the resident's leg or linens so that tubing was not pulling on the urethra, monitor and document intake and output as per facility policy, and for signs of discomfort on urination and frequency. <BR/>Observation on 02/15/24 at 9:47 AM revealed Resident #11 was lying down in the bed with an indwelling catheter. The indwelling catheter was hanging from the bed and did not have a cover. <BR/>Observation and interview on 02/15/24 at 9:54 AM with LVN J, she stated Resident #11's indwelling catheter bag needed to have a cover for Resident #11's dignity, his privacy, and infection control. LVN J stated it was everyone's responsibility for ensuring the indwelling catheter bag had a covers. <BR/>During an interview on 02/15/24 at 10:28 AM with the ADON G, she stated indwelling catheters were to be placed on the edge of the bed hanging with a cover for privacy. ADON G stated not having a cover could result in a negative outcome for the resident's dignity. ADON G stated it was the nurses and CNAs responsibility to ensure there was a privacy cover on the indwelling catheter bag. <BR/>During an interview on 02/15/24 at 11:00 AM with the Area Director of operations, stated DON was suspended, so no interview regarding the indwelling catheter was conducted with DON. <BR/>Record review of the facility's Catheter Insertion, Male/Female policy and procedure manual dated 2003 revealed, An indwelling catheter provides continuous bladder drainage in residents with a neurogenic bladder or urinary disfunction.<BR/>Catheter Change/Replacement - Catheters that are encrusted so that urinary outflow was blocked should be changed. <BR/>Record review of the facility's Resident Rights policy manual dated 11/28/16 revealed, Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.<BR/>Respect and Dignity - The resident has a right to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #14) of 16 residents reviewed for call light placement.<BR/>The facility failed to ensure that Residents #14's call light was within her reach.<BR/>This failure placed residents at risk of not being able to call for assistance when needed.<BR/>Findings included: <BR/>Record review of Resident #14's face sheet dated 02/17/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #14's facility history and physical dated 01/06/23 revealed a [AGE] year-old female diagnosed with severe intellectual disability (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills) and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). <BR/>Record review of Resident #14's annual MDS dated [DATE], revealed positive for Intellectual Disability. No score was documented for BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements). Activities of Daily Living noted Resident #14 was dependent on nursing staff for eating, oral/personal hygiene, toileting, showering, and dressing. Resident #14 was diagnosed with Cerebral Palsy, Seizure Disorder (a disorder of the brain), lack of coordination, and severe intellectual disabilities. <BR/>Record review of Resident #14's care plan dated 03/16/23, revealed she has a communication problem due to Intellectual Disability. Ensure/provide a safe environment: Call light within reach.<BR/>Observation and interview on 02/17/24 at 2:42 PM with Admissions Marketing Director K and Admissions Marketing Director L, revealed the call light was clipped on to the call light cord on the wall away from Resident #14 who was lying down on her bed. The Admissions Marketing Director K stated the call light had to be within reach of the resident. Admissions Marketing Director K stated it was so Resident #14 could call for assistance. Admissions Marketing Director L stated the risk of not having the call light within reach could result injury or a fall. Admissions Marketing Director L stated all staff were trained in call light placement with residents. <BR/>During an attempted interview on 02/17/24 at 2:50 PM with Resident #14, when interviewed Resident #14 just looked and smiled at investigator. <BR/>During an interview on 02/17/24 at 3:17 PM with CNA M, she stated call lights had to be within reach of a resident to be able to call facility staff for assistance. CNA M stated not having the call light within could result in the resident not being able to call for help or assistance if they needed. CNA M stated it was everyone's responsibility to ensure resident call lights were within reach. <BR/>During an interview on 02/17/24 at 3:02 PM with CNA O stated everyone was responsible for ensuring call lights were within reach of the residents. CNA O stated there could be a risk if it was not within reach in which the resident would not be able to call for assistance or help. <BR/>During an interview on 02/17/24 at 3:28 PM with NCNA N, he stated residents needed to have call lights within so residents would be able to call nursing staff for anything or in an emergency. NCNA N stated there could be a risk to the resident like falling or like someone was in their room that should not be in there . <BR/>During an interview on 02/17/24 at 3:39 PM with the Administrator, she stated call lights have to be within the reach of the residents for assistance or an in emergency. The Administrator stated there was a risk if there was an emergency. The Administrator stated that all facility staff were trained on call lights. <BR/>During an interview on 02/17/24 at 3:05 PM with the Regional Nurse, she stated the facility had no call light policy.<BR/>Record review of the facility's Resident Rights policy manual dated 11/28/16 revealed, Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.<BR/>Respect and Dignity - The resident has a right to be treated with respect and dignity, including:<BR/>The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to implement written policies that prohibit and prevent abuse for one (Resident #2) of four residents reviewed for abuse<BR/>The facility failed to implement their abuse policy when they failed to report, investigate and protect residents from further potential abuse when Resident #2 made an allegation of sexual abuse <BR/>An IJ Immediate Jeopardy (IJ) was identified on 02/16/24. The IJ template was provided to the facility on [DATE] at 3:01 PM. While the IJ was removed on 02/17/24, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor its plan for effectiveness.<BR/>This failure could place all residents at risk for sexual abuse/exploitation and other abuses by not immediately following the facility policy and procedure manual of recognizing, reporting, investigating, allegations of sexual abuse/exploitation and other abuses. <BR/>Findings Include:<BR/>Record review of the facility Abuse/Neglect policy and procedure manual dated 03/29/18, revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. It was each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.<BR/>Sexual Abuse: Non-consensual sexual contact of any type with a resident.<BR/>Reporting - Any person having reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, state and or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons.<BR/>Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriate of resident properly or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet criteria of Provider Letter 19-17 dated 07/10/19. <BR/>Investigation - Comprehensive investigations will be the responsibility of the administrator and or the Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated.<BR/>Record review of Resident #2's face sheet dated 02/13/24, revealed admission on [DATE] to the facility. <BR/>Record review of Resident #2's most recent facility history and physical in the system dated 12/21/20, revealed a [AGE] year-old female (present age [AGE] year-old) diagnosed with Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), Vascular Dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage, and cachexia (a complicated metabolic syndrome related to underlying illness and characterized by muscle mass loss with or without fat mass loss). <BR/>Record review of Resident #2's quarterly MDS dated [DATE], revealed a moderate impaired cognition BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 11 to be able to make daily decision and recall information. Resident #2 needed partial/moderate (half the help) assistance from nursing staff to help in showering/bathing. Resident #2 was diagnosed with Non-Alzheimer's Dementia, muscle wasting, lack of coordination, and muscle weakness (no muscle strength). <BR/>Record review of Resident #2's care plan dated 12/19/20, revealed for bathing she required two staff for assistances. Care plan dated 12/19/20 revealed impaired cognitive function or impaired thought processes due to Dementia. Engage the resident in simple, structed activities that avoid overly demanding tasks. Monitor/document/report to medical doctor any changes in cognitive function, specially changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding other, level of consciousness, mental status. <BR/>Record review of Resident #2's [NAME] (documentation on the facility system that CNAs use to view resident care) dated 02/17/24, revealed bathing: requires staff x2 for assistance. <BR/>Record review of Resident #2's shower report dated 02/02/24 at 8:16 PM and 02/09/24 at 5:57 PM, revealed CNA H had showered/bathed Resident #2. <BR/>Record review of CNA H's time sheet dated 02/02/24 and 02/09/24, revealed he had been working on Resident #2's shower days on Friday 02/02/24 and 02/09/24. Resident #2 showers on Mondays, Wednesdays and Fridays of every week. <BR/>Record review of Resident #2's Weekly Assessments, Event Note Assessments, all other Assessments dated 02/12/24, revealed, from 02/02/24 to 02/13/24 did not indicate any assessments were conducted for the sexual abuse/exploitation allegation of Resident #2. <BR/>Record review of Resident #2's Progress Notes dated 02/12/24 revealed, from 02/02/24 to 02/13/24, did not indicate any assessments were conducted or any information regarding the sexual abuse/exploitation allegation of Resident #2. <BR/>Record review and observation of text message provided to surveyor between LVN F, LVN E, and DON 02/02/24 at 5:17 PM read as follows: LVN F when you get a chance can you go talk to Resident #2, she told the Business Office Assistant that when CNA H or CNA O bath her they do something to her. <BR/>At 5:25 PM - LVN F stated, Yes I will.<BR/>At 5:28 PM - DON stated, thank you, let me know what she says. <BR/>At 6:08 PM - LVN F stated, Resident #2 says she feels CNA H touches her inappropriately when he's bathing her. <BR/>At 6:13 PM - DON stated, OMG (oh my god). <BR/>LVN F stated, Shouldn't the Social Worker and Administrator have interviewed Resident #2. I feel like that's serious allegations.<BR/>LVN E stated, Resident #2 says that when CNA H's washing her he washes her Parts and she feels him put his fingers inside of her. <BR/>DON - stated she would talk to her on Monday (unknown which Monday). <BR/>LVN F stated, No one came to help out. <BR/>Nothing else follows in the text message in regard to the sexual abuse/exploitation outcry from Resident #2. <BR/>During an interview on 02/12/24 at 4:42 PM, with LVN F, he stated that he had received a text message on 0202/24 from the DON revealing that Resident #2 was stating CNA H was touching her in her private parts during shower/bath time. LVN F stated he and LVN E went to go speak with Resident #2 on 02/02/24 after he received the text message from the DON; in which she told them that CNA H was touching her and would stick his fingers inside of her when he showered her and did not want CNA H to shower her anymore. LVN F stated he thought it was a serious allegation and thought the Administrator and Social Worker would be the ones to go interview Resident #2 regarding her allegation. <BR/>During an interview on 02/12/24 at 5:12 PM with LVN E, she stated the DON had sent LVN F a text message wanting for LVN F to go speak to Resident #2 about her allegation. LVN E stated that she went with LVN F to go talk to Resident #2 in which she stated that CNA H had touched her in her private parts. LVN E stated the DON and Administrator should have been the ones to go and interview Resident #2. LVN E stated Resident #2 claimed that CNA H would penetrate her through the shower chair and would go underneath the bottom of the shower chair. <BR/>During an interview on 02/13/24 at 1:00 PM with Resident #2, she stated she had reported to LVN F that Resident #2 had been touching her down there when CNA H showers her. Resident #2 stated CNA H will put on his music and dance while he showers her. Resident #2 stated she did not have strength and was weak to fight back against CNA H. Resident #2 stated this happened everytime CNA H would shower her. Resident #2 stated she did not want CNA H around her and did not feel safe around him. Resident #2 stated she had not reported at first due to feeling embarrassed. <BR/>During an interview on 02/13/24 at 1:35 PM with the DON, she stated that Resident #2 had made an outcry of sexual abuse/exploitation to the Business Office Assistant on 02/02/24. The DON stated the Business Office Assistant was told by Resident #2 that CNA H had touched Resident #2 in her private area. The DON stated she had instructed LVN F to go and speak with Resident #2 regarding the sexual abuse/exploitation outcry and report back to her what she had said. The DON stated she was still working on the investigation. The DON stated she had not done any assessments on Resident #2. The DON stated LVN E had done a body assessment for Resident #2, but it was not documented. The DON stated if it was not documented it did not happen. The DON stated she could not recall the exact date of Resident #2's sexual abuse/exploitation outcry. The DON stated she had not imputed anything into the computer. The DON stated there was no reason for the delay for not documenting and doing an assessment on Resident #2. The DON stated she would consider an outcry of sexual abuse/exploitation to be very important. The DON stated CNA H was not suspended and was still working at the facility and would not be able to answer why CNA H was not suspended. The DON stated CNA H was still working after the incident and there still existed a risk to the resident(s) of being sexually abuse/exploited. The DON stated it had not been reported to state survey agency and had no reason for the delay to notify state survey agency. The DON stated the Administrator was to report abuse and neglect allegations/incidents. The DON stated she had not reported it to the Administrator and said she had no explanation why she did not report it to her. <BR/>During an interview on 02/13/24 at 2:55 PM with the Administrator, she stated she was unaware of the alleged allegation from Resident #2 of sexual abuse/exploitation. The Administrator stated she was just notified right now of the sexual abuse/exploitation outcry for Resident #2 from LVN F. The Administrator stated she was told by LVN F that Resident #2 had alleged CNA H had touched her inappropriately. The Administrator stated LVN F told the DON about what Resident #2 had alleged. The Administrator stated she was not told by the DON what Resident #2 had alleged. The Administrator stated once an outcry of an allegation has been made, it needed to be reported to the Abuse Coordinator which was her. The Administrator stated she would take measures to talk to the resident and see what had happened as well as suspend the staff to ensure the safety of the Resident #2 until the conclusion of the investigation. The Administrator stated there could be a risk if the outcome was proven correct in that CNA H did do the sexual abuse/exploitation. The Administrator stated she had sent CNA H home immediately as soon as she found out. The Administrator stated she still needed to go speak to Resident #2. The Administrator stated she did not know if a body assessment was conducted for Resident #2. The Administrator stated she did not report it to state survey agency as she was not notified of the sexual abuse/exploitation allegation. The Administrator stated facility staff were trained on abuse, neglect, and exploitation and facility staff did not follow the facility abuse policy protocol for reporting. The Administrator stated it would have been protocol for the nurses to do a body assessment. <BR/>During an interview on 02/13/24 at 4:35 PM with the Social Worker, she stated she was just notified of the alleged allegation made of sexual abuse/exploitation from Resident #2 and was conducting interviews with the facility residents. The Social Worker stated Resident #2 had told her that she had reported CNA H. The Social Worker stated Resident #2 told her that CNA H touches her in her private parts and when he wipes her that he sticks his fingers in her. The Social Worker stated Resident #2 commented that CNA H puts on the music and begins to dance to it while he was showering her. The Social Worker stated Resident #2 had not reported it when it was happening because she felt embarrassed to report it and ashamed to tell her (family member). The Social Worker stated Resident #2 did not feel safe when CNA H was working at the facility. <BR/>During an interview on 02/16/24 at 2:08 PM with the Administrator, she stated that law enforcement was not notified on 02/02/24. The Administrator stated during the investigation a head-to-toe assessment of Resident #2 was done by LVN F and LVN E indicating no harm to Resident #2. The Administrator stated the facility only contacts the police if there was harm. The Administrator stated both LVN F and LVN E did the body assessment but was only verbally communicated but there was not documentation of the incident or assessment. <BR/>During an interview on 02/16/24 at 2:26 PM with LVN F, he stated he was never told to do a body assessment on Resident #2. LVN F stated there was no body assessment done on 02/02/24. LVN F stated he would have to have had a physician order or a directive from his DON to conduct the body assessment which there were none of. LVN F stated he was not trained or certified on assessing residents who claim sexual abuse/exploitation. LVN F stated he did not know what to look for. LVN F stated if he was looking for anything it would be bruises or marks on Resident #2. LVN F stated he recommended for Resident #2 to have been sent out to the hospital to have a rape kit done. LVN F stated on 02/13/24 he was told to go assess Resident #2. <BR/>During an interview on 02/16/24 at 2:39 PM with LVN E, she stated she was never told to do a head-to-toe body assessment on Resident #2 on 02/02/24. LVN E stated she quickly checked Resident #2's thigh and opened up her brief to see if there was any bruises or marks but did not know what to look for as she was not trained or certified to conduct a sexual assessment on a resident. LVN E stated when a resident claims sexual abuse/exploitation that they were sent out to the hospital to go get checked out. LVN E stated on 02/13/24, she was directed to go assess Resident #2. <BR/>During an interview on 02/17/24 at 5:02 PM with the Regional Nurse, she stated the facility nurses were not trained or certified to do sexual assessments but could assess the resident externally to see if there was any bruises or markings. <BR/>Record review of the facility's Documentation policy and procedure manual dated 2003 revealed, Documentation was the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has a legal requirement regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessments, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets weekly, daily, monthly, discharge).<BR/>Goal- The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. <BR/>The facility will ensure that information was comprehensive and timely and properly signed. <BR/>Document completed assessments in a timely manner and per policy. <BR/>Complete documentation in narrative nursing notes as needed in a timely manner.<BR/>Daily documentation x72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability.<BR/>Record review of the facility Event Reporting: Completion Of (Regional Nurse stated this was the facility's accident policy) policy and procedure not dated revealed, Investigation: The investigation should be completed by the DON/Administrator or designee. The investigation report documents a though investigation of the events of the reported Event including person, equipment, and materials that were involved. The investigation report must include what actions were taken to prevent subsequent Events and signatures of the individuals as indicated on the form.<BR/>The facility will complete an Event report on variances that occur with the facility. Variances include falls, skin tears, bruises, abrasions, lacerations, fractures, choking, burns, elopement, or behavior that affects others. <BR/>Record review of the facility Bath, Tub/Shower policy and procedures dated 2003, revealed, The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level.<BR/>The resident will experience improved comfort and cleanliness by bathing.<BR/>Become familiar with type and pattern of bathing, assistance or aids needed, skin condition, presence of dress or casts.<BR/>Remain with the resident if he was weak or assistance was needed in washing. <BR/>The Administrator and DON were informed on 02/16/24 at 3:01 PM, that an Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested.<BR/>02/16/24 at 5:19 PM - Area Director of operations submitted 1st Plan of Removal.<BR/>02/16/24 at 6:27 PM - Facility was notified of the 1st denied Plan of Removal.<BR/>02/16/24 at 7:51 PM - Administrator submitted 2nd Plan of Removal.<BR/>02/17/24 at 11:12 AM - Facility notified of 2nd denied Plan of Removal. <BR/>02/17/24 at 11:50 AM - Administrator was notified of approved Plan of Removal.<BR/>The Plan of Removal revealed the facility took the following actions: <BR/>Interventions:<BR/>One on One in-service on Abuse Reporting with the Administrator, DON, and Social Worker by Area Director of Operation on 2/13/2024 at 4:30 pm <BR/>Staff working with Alleged perpetrators have been interviewed by ADO. The resident is doing ok; no distress was noted, and the resident was able to voice concerns. <BR/>The alleged perpetrator was suspended on 2/13/2024 at 4:30 pm, pending the outcome of the investigation. Investigation completed on 2/14/2024.<BR/>Resident safety surveys were initiated by the social worker on 2/13/2024, and no abuse incidents have been reported. Completion date of 2/13/2024 <BR/>DON was suspended on 2/16/24 at 4:30 pm, pending the outcome of the investigation. <BR/>The following in-services were initiated on 2/13/2024 by Administrator/ADO: Any staff member not present or in-service on 2/13/2024 will not be allowed to assume their duties until in-service.<BR/>o <BR/>All Staff<BR/>Abuse/Neglect<BR/>Abuse/Neglect Reporting<BR/>Who to Report Abuse/Neglect to<BR/>All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report. Completion date 2/17/2024<BR/>o <BR/>The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services.<BR/>New staff will be in service during orientation. <BR/>Any employees who are allegedly involved in any abuse will be suspended pending investigation.<BR/>The medical director was notified of the immediate jeopardy situation on 2/16/2024 at 4:40. <BR/>Monitoring<BR/>The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review.<BR/>The administrator will submit documentation of the investigation with Resident and Staff interviews, as well as weekly follow-up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with the outcome of the investigation.<BR/>The Area Director will monitor abuse allegations reported and check the real-time system, which monitors keywords like abuse x 4 weeks' documentation and PCC for any incidents and accidents.<BR/>The QA committee will review findings of abuse allegations and investigations monthly and make changes to the system as needed.<BR/>On 02/17/24 at 11:55 AM Verification phase began with the facility approved Plan of Removal. <BR/>During an interview on 02/17/24 at 11:57 AM with the Administrator and Area Director of Operations, the Area director of Operations stated on 02/13/24 at 4:30 PM she had already in-serviced the Administrator, DON, and Social Worker regarding Abuse Reporting. The Administrator stated on 02/13/24 at 4:30 PM CNA H was suspended pending the outcome of the investigation for Resident #2. The Area Director of Operations stated on 02/16/24 at 4:30 PM the DON was suspended pending the outcome of the investigation. The Area Director of Operations stated the facility had completed the investigation on 02/14/24, for Resident #2 and was found to be unconfirmed. The Administrator stated on 02/13/24 a Safety Survey of the residents was conducted by the Social Worker and found no abuse incidents had been reported by the residents. The Administrator stated the facility was moving forward with termination of CNA H with unrelated issues to the alleged allegation. The Administrator stated Resident #2 stated she was doing fine, able to voice concerns, and no distress was noted. The Administrator and Area Director of Operations stated on 02/13/24 an in-service was initiated by both Administrator and Area Director of Operations for Abuse/Neglect, Abuse/Neglect Reporting, and Who to report Abuse/Neglect too. The Administrator stated facility staff not present, during the in-service will not be allowed to resume their duties until in-serviced. The Administrator stated on 02/17/24 all in-services provided to facility staff had to be communicate back to the presenter acknowledging they understood what was being in-serviced on. The Administrator stated quizzes were given and examples had to be provided by the in-service-e confirming understanding of the material. The Administrator stated new employees would be in-serviced on during orientation. The Administrator stated all alleged employees involved in an allegation will be suspended pending the outcome of the investigation. <BR/>The Area Director of Operation stated on 02/16/24 at 4:40 PM the Medical Director was notified of the Immediate Jeopardy, commenting that the facility will have to get better. The Area Director of Operation stated the Administrator was to report any and all allegations of abuse and submit all documentation for investigations conducted which would be reviewed by Area Director of Operations and Risk Management. The Area Director of Operations stated the Administrator was also to submit interviews with staff and residents related to investigations four times a week to ensure safety/satisfaction outcomes. The Area Director of Operations stated the facility system will be checked for key words like abuse four times a week for incidents or accidents that might have happened or have been documented. The Administrator stated an off-cycle Quality Assurance meeting was held on 02/16/24 at 5:00 PM, regarding the Immediate Jeopardy and follow ups will be held monthly to see if adjustments are needed to abuse allegations and investigations. <BR/>During an interview on 02/17/24 at 12:42 PM with LVN P, he stated, he had received an in-service on abuse. LVN P stated that any kind abuse had to be reported to the Administrator immediately. LVN P stated during the in-service it was talked about the 5 different types of abuses such as emotional, verbal, physical, sexual, and financial abuse to include injuries of unknown origin. LVN P stated that the in-servicer did test his knowledge on the material by asking him questions and giving him a quiz on it. <BR/>During an interview on 02/17/24 at 12:48 PM with LVN Q, he stated, he received an in-service on abuse and neglect. LVN Q stated as soon as an alleged allegation was made or suspect, it must be reported immediately to the Administrator. LVN Q stated he was asked questions about the in-service he had received and had to answer them. <BR/>During an interview on 02/17/24 at 12:42 PM with LVN I, she stated, she had received several in-services such as abuse. LVN I stated she was told of the different types of abuses and if she saw or suspected abuse happening who to report it to. LVN I stated she had to report abuse to the Administrator who was the Abuse Coordinator. LVN I stated she was questioned on the in-service like it was a test. <BR/>During an interview on 02/17/24 at 1:15 PM with MA R, she stated, she was in-serviced on abuse and neglect. MA R stated any suspected or seen abuse had to be report to the Abuse Coordinator which was the Administrator. MA R stated she was questioned on what was in-serviced.<BR/>During an interview on 02/17/24 at 1:23 PM with ADON G, she stated, she had received an in-service regarding abuse and neglect. ADON G stated they told her what constitutes abuse and neglect and who to report it to. ADON G stated abuse was reported to the Administrator immediately. ADON G stated she was questioned over the in-service(s) of abuse to check her knowledge. <BR/>During an interview on 02/17/24 at 1:31 PM with CNA T, she stated, an in-service of abuse was given to her. CNA T stated it entailed what abuse was and the different types. CNA T stated she was questioned over the material being presented. CNA T stated any kind of abuse had to be reported immediately to the Administrator. <BR/>During an interview on 02/17/24 at 1:43 PM with CNA U, she stated, she was in-serviced on abuse regarding the different types of abuse. CNA U stated staff were to report if someone talks bad or physically hits a resident. bad or physically hits them. CNA U stated it had to be reported to the Administrator. CNA U stated she had received a quiz on the in-service. <BR/>During an interview on 02/17/24 at 1:52 PM with LVN V, she stated, she had received an in-service on abuse and neglect on 02/16/24. LVN V stated to report anything the facility staff felt was abuse and who to report it to. LVN V stated it was to be reported to the Abuse Coordinator which was the Administrator. LVN V stated she was asked questions about what they felt it was reportable and why. <BR/>Record review of the facility Monitoring Tools dated 02/17/24, revealed, the following:<BR/>In-Services - The Administrator will audit all new employee filles to ensure in-services are being completed.<BR/>Ensure Quizzes are being completed - Administrator will gather quiz sheet 3 per day. <BR/>Record review of the facility In-services dated 02/13/24, 02/14/24, 02/16/24 revealed, the following:<BR/>Abuse Reporting/Investigation<BR/>Abuse and Neglect<BR/>After the Plan or Removal and Monitoring: The Administrator was informed the Immediate Jeopardy was removed on 02/17/24 at 3:35 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor it's plan for effectiveness.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an alleged violation of injury of unknown origin immediately to the administrator of the facility and to other officials (including to state survey agency) in accordance with State law and according to their policy for 1 (Resident # 13) of 2 residents reviewed for allegations of injury with unknown origin. <BR/>The facility failed to report Resident #13 ' s injury of unknown origin related to her dislocated jaw to State Office. <BR/>This failure could place all residents at risk for abuse and/or neglect by not immediately reporting allegations of injuries of unknown origin to the proper authorities at the facility. <BR/>Findings Include: <BR/>Resident #13 <BR/>Record review of Resident #13 ' s face sheet dated 01/18/2024 revealed an [AGE] year-old female who was admitted on [DATE]. <BR/>Record review of Resident #13 ' s history and physical dated 06/08/2023 revealed admitting diagnoses of debility (weakness caused by an illness, injury, or aging) post observation and isolation due to exposure to coronavirus complicated by underlying dementia and chronic comorbidities. <BR/>Record review of Resident #13 ' s quarterly MDS dated [DATE] revealed a BIMS score of 04, she was severely cognitive impaired and required extensive assistance with one-person physical assist for eating. <BR/>Record review of Resident #13 ' s care plan last reviewed on 12/12/23 revealed focus area for ADL self-care performance deficit related to limited mobility with interventions for eating that requires staff participation. <BR/>Record review of Resident #13 ' s SBAR dated 12/31/23 revealed noticed patient with poor appetite, she needs frequent monitoring to make her increase her fluid and meal intake. This was noticed on 12/26/23. Patient was diagnosed with URI she has been on antibiotics. MD was notified and new orders were continue monitoring and encouraging fluids. Resident #13 was her own responsible party. <BR/>Record review of Resident 13 ' s transfer form dated 01/01/2024 revealed she was transferred to hospital. The document did not give reason for transfer. <BR/>Record review of Resident #13 ' s progress note written by LVN A dated 01/01/2024 revealed Resident ' s mouth remained opened without ability to shut or speak. Resident is DNR though writer was concerned with change in condition. Resident was sent to local emergency room for evaluation. <BR/>Record review of Resident #13 ' s local hospital discharge summary report dated 01/18/2024 revealed admission information: Resident #13 presenting with decreasing oral intake of fluids and evidence of urinary tract infection with sepsis (the body's extreme response to an infection). However, in addition of the above the patient has been found after being admitted to the hospital that she has a spontaneous dislocation of the jaw which apparently was the cause of her difficulty to have adequate oral intake of fluids and food. <BR/>During an interview om 01/18/2024 at 9:43 am, Hospital Staff stated Resident #13 was transferred to the hospital with concerns of low blood pressure and low oxygen saturation level. Hospital Staff stated the facility did not notify the hospital of Resident #13 inability to close her jaw and was concerned. Hospital Staff stated they identified Resident #13 dislocated jaw shortly after she was admitted for treatment. <BR/>During an interview on 01/18/2024 at 10:12 am, DON stated she had been notified by LVN A that she was sending out Resident #13 to the hospital for further evaluation due to being lethargic, altered mental status and low oxygen saturation level. The DON stated the facility does follow up with local hospital for updates. The DON stated she received referral paperwork on January 10th where she read Resident #10 had a dislocated jaw and was pending surgery for g-tube for feeding. The DON stated she was concerned on the dislocation of the jaw and asked the nurses and CNAs to follow up on any bruising and determine if Resident #12 had a recent fall that may had contributed. The DON stated Resident #13 had a decrease in appetite and was reported to MD, they thought it was a decline due to coronavirus infection. The DON stated the facility continued to monitor and after she talked to staff, she was not able to determine a possible cause for Resident #13 dislocation of jaw. The DON stated she assumed the dislocated jaw occurred while she was at the hospital but did not call the hospital to question the charge nurses. The DON stated it would be considered an injury of unknown origin and was not sure if she had to report to State Office due to the dislocated jaw found at the hospital. <BR/>During an interview on 01/18/2024 at 11:05 am, Regional Compliance Nurse stated she was notified by the DON that Resident #13 had been sent out for further evaluation after a change in condition was later told about her dislocated jaw. Regional Compliance Nurse stated she asked the DON if Resident #13 had sustained a recent fall, if she followed up with staff to check if they noticed bruising or anything out the normal on her face in which she (DON) stated no evidence of recent falls, bruising or abnormalities to face noticed. Regional Compliance Nurse stated it was expected for DON to had followed up with hospital to verify if Resident #13 had been admitted with the dislocated jaw, if she had been and the facility did not identify a source of cause the dislocated jaw would be considered an injury of unknown origin. Regional Compliance Nurse stated the dislocated jaw should had been reported to State Office. <BR/>Record review of the facility Abuse/Neglect policy dated 03/29/18 revealed, The facility will provide and ensure the promotion and protection of resident rights. It was each individuals ' responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. <BR/>Reporting &ndash; Any person having reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, State and or Adult Protective Services. Stated law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. <BR/>Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility Administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 07/10/19. <BR/>If the allegations involve abuse or result in serious bodily injury, the report was to be made within 2 hours of the allegation. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all alleged violations involving abuse, neglect, and exploitation and injuries of unknown origin were thoroughly investigated for 1 (Resident #13 ) of 5 residents reviewed for abuse and neglect. <BR/>The facility did not thoroughly investigate Resident #13 ' s injury of unknown origins. <BR/>This failure could place residents at risk for abuse, neglect, and decreased quality of life. <BR/>Findings include: <BR/>Record review of Resident #13 ' s face sheet dated 01/18/2024 revealed an [AGE] year-old female who was admitted on [DATE]. <BR/>Record review of Resident #13 ' s history and physical dated 06/08/2023 revealed admitting diagnoses of debility post been seen under observation and isolation due to exposure to coronavirus complicated by underlying dementia and chronic comorbidities. <BR/>Record review of Resident #13 ' s quarterly MDS dated [DATE] revealed a BIMS score of 04, she was severely cognitive impaired. Required extensive assistance with one-person physical assist for eating. <BR/>Record review of Resident #13 ' s care plan last reviewed on 12/12/23 revealed focus area for ADL self-care performance deficit related to limited mobility with interventions for eating that requires staff participation. <BR/>Record review of Resident #13 ' s SBAR dated 12/31/23 revealed noticed patient with poor appetite, she needs frequent monitoring to make her increase her fluid and meal intake. This was noticed on 12/26/23. Patient was diagnosed with URI she has been on antibiotics. MD was notified and new orders were continue monitoring and encouraging fluids. Resident #13 was her own responsible party. <BR/>Record review of Resident 13 ' s transfer form dated 01/01/2024 revealed she was transferred to hospital. The form did not specify reason for transfer. <BR/>Record review of Resident #13 ' s progress note written by LVN A dated 01/01/2024 revealed Resident ' s mouth remained opened without ability to shut or speak. Resident is DNR though writer was concerned with change in condition. Resident was sent to local emergency room for evaluation. <BR/>Record review of Resident #13 ' s local hospital discharge summary report dated 01/18/2024 revealed admission information: Resident #13 presenting with decreasing oral intake of fluids and evidence of urinary tract infection with sepsis. However, in addition of the above the patient has been found after being admitted to the hospital that she has a spontaneous dislocation of the jaw which apparently was the cause of her difficulty to have adequate oral intake of fluids and food. <BR/>During an interview om 01/18/2024 at 9:43 am, Hospital Staff stated Resident #13 was transferred to the hospital with concerns of low blood pressure and low oxygen saturation level. Hospital Staff stated the facility did not notify the hospital of Resident #13 inability to close her jaw and was concerned. Hospital Staff stated they identified Resident #13 dislocated jaw shortly after she was admitted for treatment. <BR/>During an interview on 01/18/2024 at 10:12 am, DON stated she had been notified by LVN A that she was sending out Resident #13 to the hospital for further evaluation due to lethargic, altered mental status and low oxygen saturation level. The DON stated the facility does follow up with local hospital for updates. The DON stated she received referral paperwork on January 10th where she read Resident #10 had a dislocated jaw and was pending surgery for g-tube for feeding. The DON stated she was concerned on the dislocation of the jaw and asked the nurses and CNAs to follow up on any bruising and determine if Resident #13 had a recent fall that may had contributed. The DON stated Resident #13 had a decrease in appetite and was reported to MD, they thought it was a decline due to coronavirus infection. The DON stated the facility continued to monitor and after she talked to staff, she was not able to determine a possible cause for Resident #13 dislocation of jaw. The DON stated she assumed the dislocated jaw occurred while she was at the hospital but did not call the hospital to question the charge nurses to gather information on findings. The DON although she was able to rule out abuse and neglect, no in-service was provided to the facility staff. The DON stated she did not document her internal investigation related to Resident #13 dislocated jaw, and did not give reason for not documenting. The DON stated risks included residents still being at risk for abuse and neglect. The DON stated she should had followed up with hospital staff to gather details on incident and should had in-service the staff on abuse and neglect. <BR/>During an interview on 01/18/2024 at 11:05 am, Regional Compliance Nurse stated she was notified by DON that Resident #13 had been sent out for further evaluation after a change in condition was later told about her dislocated jaw. Regional Compliance Nurse stated she asked DON if Resident #13 had sustained a recent fall, if she followed up with staff to check if they noticed bruising or anything out the normal on her face in which she (DON) stated no evidence of recent falls, bruising or abnormalities to face noticed. Regional Compliance Nurse stated it was expected for DON to had followed up with hospital to verify if Resident #13 had been admitted with the dislocated jaw, if she had been and the facility did not identify a source of cause the dislocated jaw would be considered an injury of unknown origin. Regional Compliance Nurse stated it was expected for DON to do an in-service on abuse and neglect or even fall prevention to address the incident in hopes of preventing similar incident to re-occur. <BR/>During an interview on 01/18/2024 at 11:49 am, MD stated he treated Resident #13 at the hospital when she was sent out for further evaluation. MD stated he had treated Resident #13 for several years. MD stated the facility would had not known the cause for Resident #13 dislocated jaw. MD stated when he assessed Resident #13 at the hospital and noticed she could not close her mouth and had difficulty speaking and did not see evidence of forced trauma to location. MD stated the facility could had asked him for update and he would had notified them that Resident #13 dislocated jaw could have been a slow process related her socket in jaw. MD stated while Resident #13 was in the hospital the staff were able to place her jaw back in place but was dropped shortly after. MD stated Resident #13 required surgery to keep jaw in place. <BR/>During an interview on 01/19/2024 at 10:47 am, LVN A stated she was the nurse in charge who sent out Resident #13 to hospital for further evaluation. LVN A stated Resident #13 had already been on close monitoring due to decrease in appetite, she had a urinary infection and had recently recovered from coronavirus as well. LVN A stated the morning Resident #13 was sent out to the hospital, she was in her bed and would not answer any questions. LVN A stated this was unusual for Resident #13 and noticed she was not able to speak and close her mouth completely. LVN A stated she noticed the change around 8 am, and she had started shift at 6 am and did not have her mouth open like that. LVN A stated she decided to send Resident #13 out for further evaluation to be assessed and notified, MD, and family for courtesy since Resident #13 was her own responsible party. <BR/>Record review of the facility Abuse/Neglect policy dated 03/29/18 revealed, The facility will provide and ensure the promotion and protection of resident rights. It was each individuals ' responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. <BR/>Investigation - Comprehensive investigations will be the responsibility of the administrator and or abuse preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. <BR/>The Abuse Preventionist and or Administrator will conduct a thorough investigation of the incident(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure residents were provided supervision and assistive devices to prevent accidents for 2 of 10 (Resident #1 and Resident #12) residents reviewed for accidents. <BR/>The facility failed to provide supervision to prevent the elopement of Resident #1. <BR/>Staff failed to respond to the door alarm when the resident exited the facility. Resident #1 was outside, unsupervised by staff for approximately 1 hours, and suffered lacerations and abrasions. <BR/>This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/19/24. The IJ template was provided to the Administrator. The IJ was removed on 01/20/24, but the facility remained out of compliance at a scope of actual harm and severity level of isolated because the facility failed to have a system in place to ensure residents are monitored when facility door alarms sound off. <BR/>The facility failed to conduct safe transfers for Resident #12, CNA F did a one-person transfer with Hoyer lift. <BR/>These failure could place residents at risk of harm and injuries due to lack of supervision and failure to follow protocols. <BR/>Findings include: <BR/>Resident #1 <BR/>Record review of Resident #1 ' s face sheet dated 01/19/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #1 ' s facility history and physical dated 11/20/23 revealed a [AGE] year-old male diagnosed with anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), mental illness (disorders that affect your mood, thinking and behavior), and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). <BR/>Record review of Resident #1 ' s admission MDS dated [DATE] revealed a moderately cognitive impairment to be able to recall and make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 7. Resident #1 had a behavior of wandering. Activities of daily living revealed Resident #1 to be independent with eating, oral hygiene, toileting, dressing, toilet transfers, sit to stand, lying to sitting on side of bed, and be able to walk 150 feet but only 10 feet on uneven surfaces. Resident #1 was diagnosed with Coronary Artery Disease (caused by plaque buildup in the wall of the arteries that supply blood to the heart), Seizure Disorder (abnormal electrical brain activity), anoxic brain damage, cardiomyopathy, and lack of coordination (Uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), muscle weakness (no muscle strength), and cognitive communication deficit (difficulty with thinking and how someone uses language). <BR/>Record review of Resident #1 ' s care plan dated 12/06/23 [sic] revealed at risk for elopement as evidenced by anoxic brain damage. Assess/record/report to medical doctor risk factors for potential elopement such as - wandering. Repeated request to leave facility, statements such as, I ' m leaving (no date was indicated for this comment), I ' m going home (no date was indicated for this comment), attempts to leave facility, elopement attempts from previous facility. <BR/>Supervise closely and make regular compliance rounds whenever resident was in room. Determine the reason the resident was attempting to elope. Is the resident looking for something or someone? Does it indicate the need for more exercise? Intervene as appropriate. <BR/>Resident #1 was at risk for wandering. Impaired safety awareness. Assess for fall risk. <BR/>Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. <BR/>Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? <BR/>If a resident was exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. <BR/>Resident #1 was on anticoagulant therapy. Avoid activities that could result injury. Take precautious to avoid falls. <BR/>Record review of Resident #1 ' s Elopement Risk assessment dated [DATE] revealed high risk for elopement score of 12. Moderately impaired - decision poor, cues/supervision required. Elopement was signed and locked on 11/30/23 instead of being locked on 11/20/23 when Resident #1 was admitted to facility. <BR/>Record review of Resident #1 ' s Elopement Risk assessment dated [DATE] revealed high risk for elopement score of 11. Moderately impaired - decision poor, cues/supervision required. It was unknown why an elopement assessment was conduct as Resident #1 was no longer returned to the facility. <BR/>Record review of Resident #1 ' s Fall Risk assessment dated [DATE] revealed a moderate score of 8. Resident #1 had intermittent confusion. <BR/>Record review of Resident #1 ' s Order Recap dated 11/20/23 revealed on anticoagulant - monitor for bruising, nosebleeds, for prolonged bleeding from wound. <BR/>Review of weather records for 11/30/23 between 6:15 am to 7:45 am, the temperature was 51-53 degrees Fahrenheit, there was light rain, and wind gusts from 30 to 37 miles per hour. [https://www.wunderground.com/history/daily/us/tx/el-paso/KELP/date/2023-11-30 accessed 2/2/24]. <BR/>Record review of Resident #1 ' s progress notes written by LVN A dated 11/30/23 revealed, at 8:30 am - As per nursing 06:00 am staff CNA (unidentified) noticed resident was not in his room. Checked on dining room and receptionist where resident always stays. Code orange elopement) was activated. Family, DON, Administrator, police department, medical doctor notified. <BR/>10:04 am - As per 6am CNA staff started doing rounds and got into patient room later around 7:00 am. <BR/>Record review of sister facility ' s progress notes dated 11/30/23, where Resident #1 transferred, following the elopement, revealed Resident arrived via car accompanied by family member at 10:00 AM. According to family member he eloped from previous facility and was found wandering streets in the Westside of the city until he was picked up by the police. Police then transported Resident #1 to a family member residential address that he remembered. Family member was then contact and picked up Resident #1 and bought him here. Resident #1 looked disheveled (things other than hair that have a messy or untidy appearance) in appearance. Walking in socks because his shoes were still wet from the rain. Head to toe assessment - laceration and abrasion noted to facial area/upper right brow/forehead. Large dark discoloration to left side of ribs. <BR/>Record review of Resident #1 ' s skin assessment from sister facility dated 11/30/23 revealed Resident #1 with the following: <BR/>a dark painful bruise to left side of ribs 14cm by 9cm. <BR/>Right pinky finger with a skin tear 0.3cm by 0.3cm. <BR/>Right side abrasion above upper brow 6cm by 5.5cm. <BR/>Right cheek abrasion 2cm by 2cm. <BR/>Left palm abrasion 5cm by 4cm. <BR/>Right palm abrasion 7cm by 4cm. <BR/>Left knee abrasion 3.5cm by 3.5cm. <BR/>Right knee abrasion 6cm by 3.5 cm. <BR/>Left top of foot abrasion 4.5cm by 2cm. <BR/>Right elbow abrasion 2cm by 2cm. <BR/>Right side laceration above upper brow 0.5cm by 0.5cm <BR/>Left side laceration near orbital 1cm linear laceration. <BR/>Right side of sacral area laceration, crescent shaped 0.5cm. <BR/>Skin findings - redness to neck and chest <BR/>Record review of the x-ray conducted, by the sister facility, after the resident transferred from this facility, of Resident #1 dated 11/30/23 revealed X-Ray to right rib status post fall, pain, bruising. <BR/>Findings: Multiple radiographs of ribs were obtained. They show no fracture or other focal bony abnormality. There was no evidence for pneumothorax (a collapsed lung), pleural effusion (an unusual amount of fluid around the lung), pleural thickening (develops when scar tissue thickens the delicate lining around the lungs (the pleura) or pulmonary contusion (an injury to the lung parenchyma in the absence of laceration to lung tissue or any vascular structures). The view of the chest shows no abnormality area. <BR/>Record review of the Resident #1 ' s Event Note dated 11/30/23 revealed, As per nursing, 06:00AM - staff CNA noticed resident was not in his room. Checked on dining room and receptionist area where resident likes to stay. Code Orange was activated. Family, DON, Administrator, police department, medical doctor was notified. <BR/>Note What door exited - Unknown <BR/>Note How long missing - Unknown <BR/>Record review of city streets on google maps dated 01/19/24 revealed near the facility was a busy two-way intersection (265.24 ft away) with a speed limit of 35 miles per hour. Further up the street near the facility was another four-way busy intersection (1,222.46 ft away) with a speed limit of 45 miles per hour. <BR/>Record review of facility 3613-A that was submitted to state agency dated 12/07/23 revealed - Timeline - <BR/>&middot; <BR/>5AM resident was seen in his bed asleep <BR/>&middot; <BR/>5:30 AM resident was given his morning medications <BR/>&middot; <BR/>5:40 AM CNA observed resident walking around his room <BR/>&middot; <BR/>6:15 AM LVN heard back door alarm going off, she run to check and did not see anyone. <BR/>&middot; <BR/>6:25 AM Construction workers saw an old man walking around the parking lot, did not mention anything since they did not know he was a resident of the facility. <BR/>&middot; <BR/>6:35 AM Code Orange was initiated. Staff searched the premises and nearby stores and gas stations. <BR/>&middot; <BR/>7:12 AM EPPD notified of a missing person <BR/>&middot; <BR/>7:45 AM EPPD took resident to mothers <BR/>&middot; <BR/>8:45 AM resident arrived at sister facility and rehab <BR/>&middot; <BR/>Transferred to sister facility as per family <BR/>Record review of Detective e-mail dated 01/22/24 revealed Resident #1 was found at 7:50 AM on local retailer 1.29 miles (2.08 km). Resident #1 was alert and the weather was unknown at that time. <BR/>During an observation and interview on 01/19/24 at 10:36 am, Surveyor A and Administrator opened hallway 1 exit door for alarm to ring. LVN K and CNA L responded to door alarm. No administrative staff were observed responding to the door alarm. LVN K stated when exit door alarm rings she was to open the door and check the outside premises to ensure no residents were observed outside. LVN K stated she would then do a head count and ensure all her residents were accounted for and notify DON. <BR/>During an interview on 01/19/2024 at 10:43 am, LVN K stated when exit door alarms ring all staff were expected to respond to the exit door and assist to include housekeeping, CNAs, nurses, and administration staff. LVN K stated the lack of response from staff when door alarm rang was concerning. LVN K stated only her and CNA L responded to the door alarm. LVN K stated she had 5 CNAs on that side of the building. LVN K stated she knew 2 CNAs were busy with changing residents, CNA K responded, was not aware of CNA S whereabouts and CNA R was out on break. <BR/>During an observation and interview on 01/19/24 at 11:13 am, SW office was the closest office to hallway 1. The SW denied hearing a door alarm ring. <BR/>During an interview on 01/19/23 at 11:00 AM with the Administrator, she stated she was notified of Resident #1 missing from ADON E at 6:50 AM, in which the nursing staff could not find him. The Administrator stated she had instructed ADON E to check all the rooms in the facility. The Administrator stated a CNA went in Resident #1 ' s room to get him up for the day and could not find him. The Administrator stated she had informed the ADON E that she would start looking outside when she got to the facility. The Administrator stated Resident #1 did not have a history of elopement in their facility and the past facility he came from. The Administrator stated Resident #1 did not have a wander guard as the facility was a wander guard free facility. The Administrator stated the local police department did not give the facility the police report of Resident #1 and did not know why. The Administrator stated the back door leading to the back patio was going off in the morning around 6 AM. The Administrator stated LVN A responded to the door and turned off the alarm. The Administrator stated LVN A looked outside and saw no one and other staff members responded but once seeing LVN A had responded turned around and went back to their work areas. The Administrator stated the facility staff did not do a perimeter check around the facility. The Administrator stated it was not documented that a head count was conducted to make sure no other residents were missing. The Administrator stated it was expected for facility staff to respond immediately to door alarms and check to see what was going on or if anybody needed assistance. The Administrator stated she in-serviced the facility staff in regard to whenever a door alarm goes off that facility staff have to respond and not go back to what they are doing. The Administrator stated Resident #1 exited through the back door. The Administrator stated the facility implemented other interventions such as shortening the front door lock from 30 seconds to 15 seconds, changing the code on the doors, and conducting audits on residents with elopement. The Administrator stated the facility made every effort to prevent elopement. The Administrator stated as per their facility Elopement Prevention policy the facility did not think about placing all their wandering residents in the same hallway. <BR/>During an observation and interview on 01/19/24 at 11:17 am, Surveyor B opened exit door on hallway 2 (furthest away from receptionist/ dining room area) for alarm to ring. Administrative staff offices were by the receptionist and dining room area. Surveyor A could faintly hear the door alarm ringing. No Administrative staff responded to door alarm. The Receptionist denied hearing a door alarm ringing. <BR/>During an interview on 01/19/24 at 1:33 PM with Sister Facility Administrator, he stated Resident #1 was readmitted to his facility. Sister Facility Administrator stated the family bought Resident #1 to the facility. Sister Facility Administrator stated the facility had photos of Resident #1 having bruises to the right side of face and bruises to hands/knees and ribs. Sister Facility Administrator stated a skin assessment was conducted. Sister Facility Administrator state the local police found Resident #1 and took him to his family member place. Sister Facility Administrator stated Resident #1 was soaking wet due to it raining outside. Sister Facility Administrator stated the facility had x-rays and results were negative for fractures. <BR/>During an interview on 01/19/24 at 2:23 PM with Police Officer, he stated a call was placed by the facility on 11/30/23 at 7:43 AM reporting a missing person. Police Officer stated Resident #1 was found at 7:50 AM. Police Office stated when missing persons are reported the officer responding was to create a report if they had sustained any injuries even if it was weather related. Police Officer stated there was not one made for this case. Police Officer stated could be possible he could be okay. Police Officer stated it did not indicate where the resident was found and he appeared okay. Police Officer stated Resident #1 was taken home. <BR/>During an interview on 01/19/24 at 3:08 PM with LVN A, she stated the day of the incident with Resident #1 the back door alarm was going off. LVN A stated she came in at 6:00 AM and it was going off. LVN A stated the back patio fence doors were not open. LVN A stated she turned off the back door alarm and did not see a Receptionist posted near the front entrance door, which was opposite of the back. LVN A stated she checked that no one was outside. LVN A stated LVN Q looked in the front entrance and did not see anyone. LVN A stated as soon as the missing person was announced the nursing staff all jumped in to help and search. LVN A stated she did not let the other nurses know that they needed to do a head count, but all of her residents were accounted for. LVN A stated the alarm went off and after the alarm went off she did her head count. <BR/>Record review of Family Members photos of Resident #1 dated 01/24/24, taken when Resident #1 was brought to their house, by police, revealed bleeding abrasion(s) to Resident #1 ' s right upper brow and right cheek, scrapes or scratches to both left and right knees, red marks. <BR/>Record review of facility training dated 01/19/24 When exiting be aware of surroundings, wait until door was locked to step away in-service not dated revealed it was given and signed by facility staff. <BR/>Record review of facility training Do not share door code with residents/family members not dated revealed it was given and signed by facility staff. <BR/>Record review of facility training Changing door code every 2 weeks not dated revealed it was given and signed by facility staff. <BR/>Record review of facility Remodel area Window door check for Hall 1, 2, 3, 4, 5, 6 dated September, October, November with no year revealed dates and times. <BR/>Record review of facility Assessment Scoring Report sheet dated 01/01/20-01/01/19/24 revealed 30 facility residents at risk of elopment. <BR/>Record review of the facility Elopement Prevention policy dated 01/2023 revealed, Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for resident who are at risk elopement. <BR/>If a resident was discovered to be missing, a search shall begin immediately. (See policy entitled Elopement Response.) <BR/>Use door locks that are out of reach/sight to prevent wanders from opening doors. <BR/>Use door alarms or monitoring devices to notify staff when residents try to leave the facility. <BR/>Consider putting wandering residents on the same unit with a single exit near the nursing station. <BR/>If applicable, consider the resident for a secured unit. <BR/>Physical Plant: All facility exits that residents have access to will have a device in place to alert staff of elopement attempts. <BR/>Wander guard System <BR/>Keypad exit magnetic locks <BR/>Keyed Alarms <BR/>Secured Unit <BR/>Staff Training: Staff will receive training during their orientation process and then annually regarding - Elopement prevention, Operation of all exit devices, and Actions to take if elopement occurs. <BR/>Record review of the facility Elopement Response policy dated 10/27/10 revealed, Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or was suspected, our elopement response plan will be immediately implemented. <BR/>Should an employee discover the resident was missing from the facility, he/she should: Make a thorough search of the building(s) and premises. <BR/>Make an extensive search of the surrounding area. <BR/>If unable to locate resident in the building, proceed as follows: After 30-minutes, if the resident has not been found, the following calls must be made: <BR/>Report missing resident to the police. <BR/>Post return resident evaluation and care: The facility will evaluate its elopement prevention program and all residents will be reassessed for elopement risk. <BR/>Record review of the facility elopement Drill or Actual Elopement Guide and in-service dated 04/10/23, 06/29/23, and 10/31/23 revealed, Instruction: elopement drills should be conducted monthly on different shifts at random times. The facility Administrator only provided these 3 in-services and failed to produce the other months as indicated to be done monthly. <BR/>Time how long it takes staff to begin looking and realize the resident/mascot cannot be found and initiate the elopement plan. <BR/>Evaluate the actions of the staff and the efficiency of the elopement plan. <BR/>Report the findings to the QAPI committee. <BR/>Record review of the facility Preventive Strategies to Reduce Fall Risk policy dated 10/05/16 revealed, Policy: The goal of fall prevention strategies was to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident ' s mobility. <BR/>Record review of the facility Assessment Scoring Report dated 01/01/20-01/19/24 revealed 30 resiudents with elopement risk. <BR/>Incident Reporting - Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s). <BR/>The Administrator and DON were informed on 01/19/24 at 4:40 PM that Immediate jeopardy (IJ) had been identified and copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. <BR/>The following Plan of Removal submitted by the facility was accepted on 1/20/2024 at 10:16 am. <BR/>The Plan of Removal revealed the facility took the following actions: <BR/>Starting 1/19/24, facility staff were in-serviced by the DON/ADON on the following: <BR/>All active employee during shift where alarm is heard should Immediately respond to alarm and check the surrounding external areas when alarm goes off. <BR/>Charge nurses are responsible to do a head count when the door alarm goes off. The head count will be completed within 15min. If resident is not accounted for, charge nurse will initiate code orange. <BR/>The nurse will complete the head count and document on facility system, 24-hour report, and will report to the administrator. <BR/>If all residents are accounted for charge nurse will page overhead speaker, code orange all clear. <BR/>Installation of stop alarms will be completed by 1/19/24 by 8:00pm and alarms will be on, ON mode, at all times. <BR/>Stop alarms were tested upon installation by Maintenance director to ensure that it is audible throughout the facility including dining room and offices. <BR/>New staff/Agency staff will be educated during orientation. <BR/>All staff not in-service on 1/19/2024 in person or on the phone will be in-serviced before the start of their shift. <BR/>On 1/19/24, the maintenance director of the facility did the following: <BR/>Stop alarms are being installed by 1/19/24 by 8:00pm in all exit doors to ensure the alarm sound is loud enough to reach offices and dining rooms. <BR/>The medical director was notified of this plan on January 19, 2024, and an off-cycle QAPI plan was initiated regarding this event, completion date 1/20/24 9:00 am <BR/>This affected Resident #1 and had the potential to affect 30 other residents with wandering/exit seeking behaviors, <BR/>Residents are identified by the Elopement risk assessment in facility system. <BR/>Monitoring: <BR/>The DON and/or designee will monitor that headcount, outdoor checks, and sign-out sheets are used properly and completed at least five times per week. <BR/>The administrator, DON, and/or designee will do elopement drills weekly to ensure staff are responding immediately to door alarms. <BR/>Maintenance director/designee will be responsible for testing alarms 2 times a week to ensure alarms are working properly. <BR/>Interviews, observations and Record Review to confirm implementation of the Plan of Removal were conducted as follows: <BR/>Observations on 01/20/2024: <BR/>10:16 am, admin opened door to hallway 3. CNA U, 2 staff from down the hallway in hallway 1 respond. CNA W and CNA G, 2 maintenance personnel in the hallway looked over to door. <BR/>10:20 am, admin opened hallway 6 alarm. CNA I, Housekeeping Aide, HR, LVN X, Transportation Aide, LVN Y, and CNA F responded. <BR/>10:25 am, hallway 1 door was pushed alarm went off. LVN M, CNA U, CNA W, CNA Z, Housekeeping Aide, SCNA BB, and Maintenance Assistant all responded immediately within 5 seconds of pushing the exit door. <BR/>10:27 am, hallway 1 door was pushed alarm went off. Could hear in reception SW responded and receptionist was with family but notified Administrator. <BR/>10:38 AM - Maintenance Director turn on the alarm system and the doors in the hallway closed and exit doors opened. Facility staff were seen responding from all over the facility. Charge nurses were seen taken head count of the residents. An all clear was given after the head count was taken. <BR/>Interviews on 01/20/24: <BR/>CNA I, Housekeeping Aide, HR, LVN N, LVN X, Transportation Aide, LVN Y, CAN F confirmed in-services provided regarding code orange, response to exit door alarms, assist with head count, search outside premises/perimeter to ensure no residents were found outside, police notification, stated they could identify elopement risk residents in PCC and/or elopement binders that were located in nurses station and receptionist area. <BR/>During an interview on 01/20/24 beginning at 10:30 AM with CNA I, Housekeeping Aide, HR, LVN N, LVN X, Transportation Aide, LVN Y, CAN F confirmed in-services provided regarding code orange, response to exit door alarms, assist with head count, search outside premises/perimeter to ensure no residents were found outside, police notification, stated they could identify elopement risk residents in PCC and/or elopement binders that were located in nurses station and receptionist area. <BR/>During an interview on 01/20/24 at 11:30 AM with ADON E, she stated she had worked the night shift on 01/19/24 and was in-serviced with the door alarm response. ADON E stated it was procedures to responding to the door alarm soundings. ADON E stated when the door alarms sounds then everyone had to respond to the door that was alarming. ADON E stated facility staff where to also go outside and check the perimeter of the facility to see of there were any residents outside. ADON E stated the nurses were to conduct a head count of all the residents to ensure they were all in the facility. ADON E stated if all residents were accounted for then an all clear could be call, if not then a Code Orange (Indicating Elopement) would have to be initiated. ADON E stated if the resident was not found within 30 minutes, then the local police would have to be notified. <BR/>During an interview on 01/20/24 at 11:58 AM with CNA T, she stated she was in-serviced on when the door alarm goes off the facility staff have to rush to the door that ' s sounding. CNA T stated two or three staff have to go outside and search the surrounding areas of the facility. CNA T stated if the resident was not found then they call a Code Orange (Indicating Elopement) and the Administrator gets notified. CNA T stated a head count was to be done by the nurses. CNA T stated after 30-minutes of looking for the missing resident then the facility staff call the police. CNA T stated if the resident was found then the nurse gets notified and an all clear gets called. <BR/>During an interview on 01/20/24 at 11:58 AM with the DON, she stated when a door alarm goes off the nurses need to conduct a head count of all the residents to ensure they are all accounted for. The DON stated when a door alarm goes off all staff are to respond to the door alarm that was going off. The DON stated staff are to search the perimeter for any residents. The DON stated the managers will be responsible for ensuring the nurses are doing the head count of the residents. The DON stated the nurses will also review the sign in/out sheets to make sure the residents are accounted for and the DON and ADONs will oversee that the nurses are doing the checks. The DON stated Maintenance Director will check the outdoor combination locks. The DON stated there was a check sheet for maintenance checking the outdoor combination locks. The DON stated the Administrator, and the DON will be in charge of conducting the Elopement Drill every week with the assistance of an alert resident or a stuff animal. The DON stated the focus of the elopement drill was to check for staff response and timing. <BR/>During an interview on 01/20/24 at 12:28 PM with the Administrator, she stated the DON will ensure that nurses are doing a head count when a door alarm goes off. The Administrator stated there was a spread sheet that was created to document the headcounts. The Administrator stated the outdoor checks are when the facility staff go outside and check the perimeter of the facility to see if there are any residents. The Administrator stated her, and the DON were responsible for checking the headcount and outdoor checks on the spread sheet to ensure the staff are doing the headcount and outdoor checks. The Administrator stated the elopement drill were to be conducted weekly on different times and days. The Administration stated they were looking to see the response time and how staff work together with deflating task with the elopement drill. The Administrator stated these drills will be record on the Elopement Drill Form. The Administrator stated the Maintenance Director will checking the door alarms to make sure they are working properly (making sure they are ringing) and will be recorded on a sign on/off sheet. The Administrator stated the sheets will be turned in at the end of each week for her to review. <BR/>Record review of facility in-service dated 01/19/24 revealed it was given and signed by facility staff The in-service indicated when a door alarm goes off, charge nurse are responsible to do a head count within 15 minutes if resident not accounted for. Charge nurse will initiate Code Orange <BR/>Record review of facility in-service dated 01/19/24 revealed it was given and signed by facility staff. The in-service indicate the nurse will complete the head count and document on facility system, 24-hours report, and will be reported to the administrator. <BR/>Record review of facility in-service dated 01/19/24 revealed it was given and signed by facility staff. The in-service indicate If all residents are accounted for change nurse with page overhead speaker, code orange all clear <BR/>Record review of facility Call police after 30-mintues of resident missing in-service dated 01/19/24 revealed it was given and signed by facility staff. <BR/>Record review of facility Check and walk the perimeter when a door alarm goes off in-service dated 01/19/24 revealed it was given and signed by facility staff. <BR/>Record review of fac[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure that residents received the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible for 1 (Resident #11) of 5 residents reviewed for indwelling catheters in that:<BR/>Resident #11's indwelling catheter tubing was full and cloudy and evaluated on a wedge not being able to drain downwards properly. <BR/>These failures placed residents at risk of collection tube becoming full and allowing urine to flow back into the bladder that could result in a urinary tract infection.<BR/>Findings include: <BR/>Record review of Resident #11's face sheet dated 02/14/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #11's facility history and physical dated 11/06/23 revealed a [AGE] year-old male diagnosed with schizophrenia (a serious mental disorder in which people interpret reality abnormally) and bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode)). <BR/>Record review of Resident #11's quarterly MDS dated [DATE] revealed an intact cognition to be able to recall and make daily decisions BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 13. Resident #11 was dependent on nursing staff for toileting. Resident #11 had an indwelling catheter. <BR/>Record review of Resident #11's care plan dated 01/13/24 revealed indwelling catheter - check for kinks and maintain the drainage bag off the floor, ensure tubing is anchored to the resident's leg or linens so that tubing was not pulling on the urethra, monitor and document intake and output as per facility policy, and for signs of discomfort on urination and frequency. <BR/>Observation on 02/15/24 at 9:47 AM revealed Resident #11 was lying down in the bed with an indwelling catheter. The indwelling catheter tubing was cloudy. The catheter tubing was all the way full. The indwelling catheter tubing was hanging off a wedge creating a back flow to the resident. <BR/>Observation and interview on 02/15/24 at 9:54 AM with LVN J, she stated Resident #11's indwelling catheter was full and looked cloudy. LVN J stated the way the indwelling catheter tubing was positioned could create blockage and back flow resulting in a risk of urinary tract infection. LVN J stated it was everyone's responsibility for ensuring the indwelling catheter tubing was positioned properly. <BR/>During an interview on 02/15/24 at 10:28 AM with the ADON G, she stated tubing should be straight and not kinked allowing flow downwards to the catheter bag. ADON G stated the indwelling catheter tubing being kinked or elevated could cause back flow resulting in urinary retention and a urinary tract infection. ADON G stated it was the nurses and CNAs responsibility to ensure there the tubing was positioned correctly and not kinked. <BR/>During an interview on 02/15/24 at 11:00 AM with the Area Director of operations, stated DON was suspended, so no interview regarding the indwelling catheter was conducted with DON. <BR/>Record review of the facility's Catheter Insertion, Male/Female policy and procedure manual dated 2003 revealed, An indwelling catheter provides continuous bladder drainage in residents with a neurogenic bladder or urinary disfunction.<BR/>Catheter Change/Replacement - Catheters that are encrusted so that urinary outflow was blocked should be changed. <BR/>Record review of the facility's Resident Rights policy manual dated 11/28/16 revealed, Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.<BR/>Respect and Dignity - The resident has a right to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to promote and facilitate resident self-determination through support of resident choice for 1 of 10 residents (Resident #11) reviewed for respect and dignity. <BR/>The facility staff failed to honor Resident #11 ' s request to turn on her TV, instead of going to sleep. <BR/>This failure could place residents at risk of diminished quality of life. <BR/>Findings included: <BR/>Record review of Resident # 11 ' s face sheet dated 01/18/24 revealed, admission on [DATE] and re-admission on [DATE] to the facility. Resident #11 was a [AGE] year-old female diagnosed with Cerebral Palsy (weakness or problems with using the muscles), muscle weakness (no muscle strength), contracture of muscle to right hand, insomnia (a sleep disorder in which you have trouble falling and/or staying asleep), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), paraplegia (paralysis that affects your legs, but not your arms), and mild intellectual disabilities. <BR/>Record review of Resident # 11 ' s history and physical, MDS, and care plan were not obtained. <BR/>Record review of facility investigation of alleged abuse dated 12/22/23 revealed in a witness statement not dated, Later that night we had an electrical problem, so CNA G left Resident #11 ' s room to go and help out the other CNAs with the electrical problem. After that CNA G went back to Resident #11 ' s room and her tv was off. Resident #11 was complaining she wanted her tv back on. CNA G tried to help her but some tv ' s sometimes turn off by themselves. Because CNA G could not turn on the tv Resident #11 did not want to go to sleep and wanted the tv on. CNA G could not turn on the tv and left to help the other patients. <BR/>During an interview on 01/18/24 at 3:52 PM with ADON B, she stated she worked the night of the alleged incident on 12/14/23 that Resident #11 was alleged about. ADON B stated she was informed by Resident #11 that CNA G would not let her watch tv when and it was time to go to sleep. ADON B stated the remote and tv were easy to operate and staff should have no trouble with operating it and turning it on. ADON B stated that there were no issues with the remote and tv not working as far as she knew. ADON B was re-read CNA G ' s witness statement and stated she would not know why CNA G would make a comment about not being able to turn on the tv. ADON B stated that night CNA G did not report to me that the remote or tv were not working or turning on. ADON B stated that was not good customer service and CNA G should have got another staff to help her turn on the tv. ADON B stated it was Resident #11 ' s right to be able to watch tv. <BR/>During an interview on 01/18/24 at 4:36 PM with Resident #11, she stated the day of the incident, 12/14/23, she really wanted her tv on, but CNA G wanted her to go to sleep as it was late in the evening. Resident #11 stated she wanted to watch her shows and did not know why CNA G would not let her watch her shows. <BR/>During an interview on 01/19/24 at 11:00 AM with the Administrator, she stated when she conducted the investigation for the alleged incident regarding Resident #11 and CNA G she had read each witness statement and did not find anything concerning with the witness statements. The witness statement was re-read to the Administrator. The Administrator stated CNA G told her she tried turning on Resident #11 ' s television but it would not turn on. The Administrator stated it was not confirmed if the electrical problem, the facility had that night had anything to do with the television not turning on. The Administrator stated CNA G did not place a work order in for either the remote control or the television. The Administrator stated it was expected for staff to place work orders for equipment not being operable. The Administrator stated CNA G did not inform the nursing staff of the issue with the television. The Administrator stated she was not told if CNA G or the nurse went to go educate Resident #11 regarding the electrical problem which could have been possibly related to the television not turning on. The Administrator stated that Resident #11 had the right to watch television if she wanted too. <BR/>During an interview on 01/22/24 at 11:42 AM with the DON, she stated her, and the Administrator conducted the investigation regarding the alleged allegation of Resident #11 not being allowed to watch tv. The DON stated she reviewed each witness statement. The DON stated she did not find anything concerning or alarming with the witness statements. CNA G ' s witness statement was re-read to the DON. The DON stated the tv was not working but did not know if the remote was not working either. The DON stated she did not know if the buttons were pushed on the tv itself to test out if the remote was not working to see if the tv would turn on to rule out that it was in fact the remote and not the tv. The DON stated the facility had an electrical problem that night but was not confirmed if that was the reason why the tv was not working. The DON stated CNA G should have asked for help from staff to try to turn on the tv. The DON stated she does not have access to see work orders and did not ask CNA G if she had placed a work order for the tv not working. The DON stated it was expected for staff and CNA G to put in a work order for the tv not working. The DON stated it was Resident #11 ' s right to watch tv because she was a human being. The DON stated the risk to resident would not be allowing the resident to exercise and express their rights. <BR/>Record review of the facility Resident Rights policy dated 11/28/16 revealed, Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of The United States. <BR/>Respect and Dignity - The resident has a right to be treated with respect and dignity. <BR/>Self-Determination - The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. <BR/>The resident has a right to choose activities and schedules (including sleeping and waking times) with his or her interests. <BR/>The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to respect a resident's right to personal privacy during personal care for 1 of 10 residents ( Resident #12) reviewed for respect and dignity. <BR/>The facility failed to close the curtain and provide privacy when changing Resident #12. <BR/>This failure could place residents at risk of diminished quality of life. <BR/>Findings included: <BR/>Record review of Resident #12 ' s face sheet dated 01/19/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #12 ' s quarterly MDS dated [DATE] revealed Resident #12 was cognitively intact to be able to recall and make daily decision BIMS (BIMS a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 12. Functional limitation in range of motion was marked for upper and lower extremity for impairments on both sides. Activities of daily show substantial/maximal assistance for dressing and partial/moderate assistance form nursing staff for toileting. Resident #12 was always incontinent. Resident #12 was diagnosed with Diabetes Mellitus, Depression, and muscle weakness (no muscle strength). <BR/>Record review of Resident # 12 ' s care plan dated 08/30/16 revealed an activities of daily living deficit related to history of functional impairment. Resident #12 required two staff to assist with toileting, transfers, and bed mobility. Care plan does not indicate anything regarding Resident #12 ' s activities of daily living for dressing and if assistance was needed from nursing staff. <BR/>During an observation on 01/19/24 at 9:59 am, Resident #12 ' s room door was left opened, CNA F had provided perineal care to be seen from outside the hallway, he was seen without a brief on the Hoyer lift with private areas exposed. CNA F did a Hoyer transfer alone. <BR/>During an interview on 01/19/24 at 10:01 am, CNA F stated she should had closed the door while providing perineal care. CNA F did not give reason for not closing Resident #12 ' s door; stated Resident #12 was left exposed and was a dignity and privacy concern. <BR/>During an interview on 01/19/24 at 10:03 am, Resident #12 was alert and oriented to person and place. Resident #12 stated he would have preferred to have the door closed so Resident #12 ' s private parts would had not been exposed for people to be seen when passing by. <BR/>During an interview on 01/22/24 at 10:07 am, CNA H stated she had received training upon hire and annually regarding privacy. CNA H stated she was expected to close the door and/or privacy curtain when providing perineal care to any of the residents. CNA H stated risks of not closing doors were privacy rights violated by been exposed. CNA H stated they were responsible for ensuring privacy was provided during perineal care. <BR/>During an interview on 01/22/24 at 10:13 am, LVN J stated all staff were responsible for ensuring privacy was provided when perineal care was provided. LVN J stated charge nurses were responsible for overseeing privacy was respected and was done when doing their rounds. LVN J stated she had not witnessed staff providing perineal care with door and/or privacy curtain left opened. LVN J stated if she were to witness privacy not being provided, she was trained to educate the staff on privacy rights. LVN J stated not providing privacy was a risk of violation of their privacy rights and dignity. <BR/>During an interview on 01/22/24 at 10:46 am, the DON stated all staff were responsible for ensuring privacy was provided during perineal care. All staff were expected to close privacy curtains and/or doors when providing perineal care. The DON stated the charge nurse was responsible of ensuring CNAs closed doors/ privacy curtains when providing perineal care at least every 2 hours while conducting their rounds. Th DON stated all staff were trained in privacy rights upon hire and annually. The DON stated risks included residents been seen by other people when passing by their room. <BR/>During an interview on 01/22/24 at 12:44 pm, the Administrator stated staff were expected to close doors and/or privacy curtains when providing perineal care. Th Administrator stated she was not sure when the last time staff received an in-service on respecting and providing privacy during perineal care. The Administrator stated she would not have felt comfortable if she was being assisted with perineal care and the door was left open; she stated she would have felt exposed. <BR/>Record review of the facility Resident Rights policy dated 11/28/16 revealed, Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of The United States. <BR/>Respect and Dignity - The resident has a right to be treated with respect and dignity. <BR/>Privacy and confidentiality - The resident has a right to personal privacy and confidentiality of his or personal and medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an alleged violation of injury of unknown origin immediately to the administrator of the facility and to other officials (including to state survey agency) in accordance with State law and according to their policy for 1 (Resident # 13) of 2 residents reviewed for allegations of injury with unknown origin. <BR/>The facility failed to report Resident #13 ' s injury of unknown origin related to her dislocated jaw to State Office. <BR/>This failure could place all residents at risk for abuse and/or neglect by not immediately reporting allegations of injuries of unknown origin to the proper authorities at the facility. <BR/>Findings Include: <BR/>Resident #13 <BR/>Record review of Resident #13 ' s face sheet dated 01/18/2024 revealed an [AGE] year-old female who was admitted on [DATE]. <BR/>Record review of Resident #13 ' s history and physical dated 06/08/2023 revealed admitting diagnoses of debility (weakness caused by an illness, injury, or aging) post observation and isolation due to exposure to coronavirus complicated by underlying dementia and chronic comorbidities. <BR/>Record review of Resident #13 ' s quarterly MDS dated [DATE] revealed a BIMS score of 04, she was severely cognitive impaired and required extensive assistance with one-person physical assist for eating. <BR/>Record review of Resident #13 ' s care plan last reviewed on 12/12/23 revealed focus area for ADL self-care performance deficit related to limited mobility with interventions for eating that requires staff participation. <BR/>Record review of Resident #13 ' s SBAR dated 12/31/23 revealed noticed patient with poor appetite, she needs frequent monitoring to make her increase her fluid and meal intake. This was noticed on 12/26/23. Patient was diagnosed with URI she has been on antibiotics. MD was notified and new orders were continue monitoring and encouraging fluids. Resident #13 was her own responsible party. <BR/>Record review of Resident 13 ' s transfer form dated 01/01/2024 revealed she was transferred to hospital. The document did not give reason for transfer. <BR/>Record review of Resident #13 ' s progress note written by LVN A dated 01/01/2024 revealed Resident ' s mouth remained opened without ability to shut or speak. Resident is DNR though writer was concerned with change in condition. Resident was sent to local emergency room for evaluation. <BR/>Record review of Resident #13 ' s local hospital discharge summary report dated 01/18/2024 revealed admission information: Resident #13 presenting with decreasing oral intake of fluids and evidence of urinary tract infection with sepsis (the body's extreme response to an infection). However, in addition of the above the patient has been found after being admitted to the hospital that she has a spontaneous dislocation of the jaw which apparently was the cause of her difficulty to have adequate oral intake of fluids and food. <BR/>During an interview om 01/18/2024 at 9:43 am, Hospital Staff stated Resident #13 was transferred to the hospital with concerns of low blood pressure and low oxygen saturation level. Hospital Staff stated the facility did not notify the hospital of Resident #13 inability to close her jaw and was concerned. Hospital Staff stated they identified Resident #13 dislocated jaw shortly after she was admitted for treatment. <BR/>During an interview on 01/18/2024 at 10:12 am, DON stated she had been notified by LVN A that she was sending out Resident #13 to the hospital for further evaluation due to being lethargic, altered mental status and low oxygen saturation level. The DON stated the facility does follow up with local hospital for updates. The DON stated she received referral paperwork on January 10th where she read Resident #10 had a dislocated jaw and was pending surgery for g-tube for feeding. The DON stated she was concerned on the dislocation of the jaw and asked the nurses and CNAs to follow up on any bruising and determine if Resident #12 had a recent fall that may had contributed. The DON stated Resident #13 had a decrease in appetite and was reported to MD, they thought it was a decline due to coronavirus infection. The DON stated the facility continued to monitor and after she talked to staff, she was not able to determine a possible cause for Resident #13 dislocation of jaw. The DON stated she assumed the dislocated jaw occurred while she was at the hospital but did not call the hospital to question the charge nurses. The DON stated it would be considered an injury of unknown origin and was not sure if she had to report to State Office due to the dislocated jaw found at the hospital. <BR/>During an interview on 01/18/2024 at 11:05 am, Regional Compliance Nurse stated she was notified by the DON that Resident #13 had been sent out for further evaluation after a change in condition was later told about her dislocated jaw. Regional Compliance Nurse stated she asked the DON if Resident #13 had sustained a recent fall, if she followed up with staff to check if they noticed bruising or anything out the normal on her face in which she (DON) stated no evidence of recent falls, bruising or abnormalities to face noticed. Regional Compliance Nurse stated it was expected for DON to had followed up with hospital to verify if Resident #13 had been admitted with the dislocated jaw, if she had been and the facility did not identify a source of cause the dislocated jaw would be considered an injury of unknown origin. Regional Compliance Nurse stated the dislocated jaw should had been reported to State Office. <BR/>Record review of the facility Abuse/Neglect policy dated 03/29/18 revealed, The facility will provide and ensure the promotion and protection of resident rights. It was each individuals ' responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. <BR/>Reporting &ndash; Any person having reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, State and or Adult Protective Services. Stated law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. <BR/>Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility Administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 07/10/19. <BR/>If the allegations involve abuse or result in serious bodily injury, the report was to be made within 2 hours of the allegation. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all alleged violations involving abuse, neglect, and exploitation and injuries of unknown origin were thoroughly investigated for 1 (Resident #13 ) of 5 residents reviewed for abuse and neglect. <BR/>The facility did not thoroughly investigate Resident #13 ' s injury of unknown origins. <BR/>This failure could place residents at risk for abuse, neglect, and decreased quality of life. <BR/>Findings include: <BR/>Record review of Resident #13 ' s face sheet dated 01/18/2024 revealed an [AGE] year-old female who was admitted on [DATE]. <BR/>Record review of Resident #13 ' s history and physical dated 06/08/2023 revealed admitting diagnoses of debility post been seen under observation and isolation due to exposure to coronavirus complicated by underlying dementia and chronic comorbidities. <BR/>Record review of Resident #13 ' s quarterly MDS dated [DATE] revealed a BIMS score of 04, she was severely cognitive impaired. Required extensive assistance with one-person physical assist for eating. <BR/>Record review of Resident #13 ' s care plan last reviewed on 12/12/23 revealed focus area for ADL self-care performance deficit related to limited mobility with interventions for eating that requires staff participation. <BR/>Record review of Resident #13 ' s SBAR dated 12/31/23 revealed noticed patient with poor appetite, she needs frequent monitoring to make her increase her fluid and meal intake. This was noticed on 12/26/23. Patient was diagnosed with URI she has been on antibiotics. MD was notified and new orders were continue monitoring and encouraging fluids. Resident #13 was her own responsible party. <BR/>Record review of Resident 13 ' s transfer form dated 01/01/2024 revealed she was transferred to hospital. The form did not specify reason for transfer. <BR/>Record review of Resident #13 ' s progress note written by LVN A dated 01/01/2024 revealed Resident ' s mouth remained opened without ability to shut or speak. Resident is DNR though writer was concerned with change in condition. Resident was sent to local emergency room for evaluation. <BR/>Record review of Resident #13 ' s local hospital discharge summary report dated 01/18/2024 revealed admission information: Resident #13 presenting with decreasing oral intake of fluids and evidence of urinary tract infection with sepsis. However, in addition of the above the patient has been found after being admitted to the hospital that she has a spontaneous dislocation of the jaw which apparently was the cause of her difficulty to have adequate oral intake of fluids and food. <BR/>During an interview om 01/18/2024 at 9:43 am, Hospital Staff stated Resident #13 was transferred to the hospital with concerns of low blood pressure and low oxygen saturation level. Hospital Staff stated the facility did not notify the hospital of Resident #13 inability to close her jaw and was concerned. Hospital Staff stated they identified Resident #13 dislocated jaw shortly after she was admitted for treatment. <BR/>During an interview on 01/18/2024 at 10:12 am, DON stated she had been notified by LVN A that she was sending out Resident #13 to the hospital for further evaluation due to lethargic, altered mental status and low oxygen saturation level. The DON stated the facility does follow up with local hospital for updates. The DON stated she received referral paperwork on January 10th where she read Resident #10 had a dislocated jaw and was pending surgery for g-tube for feeding. The DON stated she was concerned on the dislocation of the jaw and asked the nurses and CNAs to follow up on any bruising and determine if Resident #13 had a recent fall that may had contributed. The DON stated Resident #13 had a decrease in appetite and was reported to MD, they thought it was a decline due to coronavirus infection. The DON stated the facility continued to monitor and after she talked to staff, she was not able to determine a possible cause for Resident #13 dislocation of jaw. The DON stated she assumed the dislocated jaw occurred while she was at the hospital but did not call the hospital to question the charge nurses to gather information on findings. The DON although she was able to rule out abuse and neglect, no in-service was provided to the facility staff. The DON stated she did not document her internal investigation related to Resident #13 dislocated jaw, and did not give reason for not documenting. The DON stated risks included residents still being at risk for abuse and neglect. The DON stated she should had followed up with hospital staff to gather details on incident and should had in-service the staff on abuse and neglect. <BR/>During an interview on 01/18/2024 at 11:05 am, Regional Compliance Nurse stated she was notified by DON that Resident #13 had been sent out for further evaluation after a change in condition was later told about her dislocated jaw. Regional Compliance Nurse stated she asked DON if Resident #13 had sustained a recent fall, if she followed up with staff to check if they noticed bruising or anything out the normal on her face in which she (DON) stated no evidence of recent falls, bruising or abnormalities to face noticed. Regional Compliance Nurse stated it was expected for DON to had followed up with hospital to verify if Resident #13 had been admitted with the dislocated jaw, if she had been and the facility did not identify a source of cause the dislocated jaw would be considered an injury of unknown origin. Regional Compliance Nurse stated it was expected for DON to do an in-service on abuse and neglect or even fall prevention to address the incident in hopes of preventing similar incident to re-occur. <BR/>During an interview on 01/18/2024 at 11:49 am, MD stated he treated Resident #13 at the hospital when she was sent out for further evaluation. MD stated he had treated Resident #13 for several years. MD stated the facility would had not known the cause for Resident #13 dislocated jaw. MD stated when he assessed Resident #13 at the hospital and noticed she could not close her mouth and had difficulty speaking and did not see evidence of forced trauma to location. MD stated the facility could had asked him for update and he would had notified them that Resident #13 dislocated jaw could have been a slow process related her socket in jaw. MD stated while Resident #13 was in the hospital the staff were able to place her jaw back in place but was dropped shortly after. MD stated Resident #13 required surgery to keep jaw in place. <BR/>During an interview on 01/19/2024 at 10:47 am, LVN A stated she was the nurse in charge who sent out Resident #13 to hospital for further evaluation. LVN A stated Resident #13 had already been on close monitoring due to decrease in appetite, she had a urinary infection and had recently recovered from coronavirus as well. LVN A stated the morning Resident #13 was sent out to the hospital, she was in her bed and would not answer any questions. LVN A stated this was unusual for Resident #13 and noticed she was not able to speak and close her mouth completely. LVN A stated she noticed the change around 8 am, and she had started shift at 6 am and did not have her mouth open like that. LVN A stated she decided to send Resident #13 out for further evaluation to be assessed and notified, MD, and family for courtesy since Resident #13 was her own responsible party. <BR/>Record review of the facility Abuse/Neglect policy dated 03/29/18 revealed, The facility will provide and ensure the promotion and protection of resident rights. It was each individuals ' responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. <BR/>Investigation - Comprehensive investigations will be the responsibility of the administrator and or abuse preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. <BR/>The Abuse Preventionist and or Administrator will conduct a thorough investigation of the incident(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that the assessment accurately reflected the resident ' s status for 2 (Resident #4 and Resident #8) of 5 resident reviewed for accuracy of MDS assessment, in that: <BR/>Resident #4 ' s annual MDS did not accurately reflect the residents ' behaviors in the annual MDS. <BR/>Resident #8 ' s annual MDs did not accurately reflect the residents ' behaviors in the annual MDS. <BR/>This deficient practice could affect residents at the facility who had been assessed for behaviors and could contribute to inadequate care. <BR/>Findings included: <BR/>Resident #4 <BR/>Record review of Resident #4 ' s face sheet dated 01/18/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #4 ' s facility history and physical dated 05/18/23 revealed a [AGE] year-old female diagnosed with psychiatric behavior with aggression and paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly). <BR/>Record review of Resident #4 ' s annual MDS dated [DATE] revealed a Preadmission Screening and Resident Review condition as serious mental illness. Resident #4 had a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 3. MDS indicated zero (no behavioral symptoms) for behaviors. Resident #4 was diagnosed with Non-Alzheimer ' s Disease, Psychotic Disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), Schizophrenia (a serious mental disorder in which people interpret reality abnormally), depression, and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). <BR/>Record review of Resident #4 ' s care plan dated 12/17/21 revealed Resident #4 requires anti-psychotic medication due to history of Schizophrenia (a serious mental disorder in which people interpret reality abnormally). Monitor/record/report to medical doctor adverse reactions of psychoactive medications &ndash; behavior symptoms usual to the person. Resident #4 had the potential to demonstrate physical behaviors due to Schizophrenia (a serious mental disorder in which people interpret reality abnormally). Local behavioral authority to be consulted as needed. If resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Notify the charge nurse of any physically abusive behaviors. <BR/>During an interview on 01/19/24 at 6:17 PM with MDS Coordinator C and MDS Coordinator D, MDS Coordinator C, she stated that Resident #4 does have behaviors. MDS Coordinator D stated she was diagnosed with history of behaviors. MDS Coordinator C stated her MDS does not reflect the behaviors accurately in the section. MDS Coordinator D stated not documenting accurately would affect the reimbursement. MDS Coordinator C stated it was the MDS departments responsibility for ensuring the MDS assessments were documented accurately. <BR/>Resident #8 <BR/>Record review of Resident #8 ' s face sheet dated 01/19/23 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #8 ' s facility history and physical dated 04/06/23 revealed a [AGE] year-old male diagnosed with severe intellectual disability, anxiety, and Major depressive Disorder (it affects how you feel, think and behave and can lead to a variety of emotional and physical problems). <BR/>Record review of Resident #8 ' s annual MDS dated [DATE] revealed a Preadmission Screening and Resident Review condition as intellectual disability. Resident #4 had a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score that was not taken for whatever reason. Behaviors was marked zero revealing Resident #8 had no behaviors when Resident #8 really did have behaviors. Resident #8 was diagnosed with Seizure Disorder (abnormal electrical brain activity), Depression, and Serve Intellectual Disabilities (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills). <BR/>Record review of Resident #8 ' s care plan dated 01/15/24 revealed Resident #8 required antidepressants. Monitor/document/report to medical doctor anger, sadness, crying, shame, guilt, worthlessness, and suicidal ideations. Focus care plan dated 10/06/23 revealed had a behavior problem related to verbal outburst and throwing the middle finger when upset. Keep resident safe during outbursts and away from other residents. Notify local crisis intervention of physical outbursts. Redirect resident when outbursts occur. Assess for overstimulation or cause of outburst. Focused care plan dated 10/27/23 revealed had the potential to demonstrate physical behaviors, anger, poor impulse control related to biting himself ort biting objects. If the resident had physical behaviors towards another resident immediately intervene to protect the residents involved and call for assistance. Notify the charge nurse of any physically abusive behaviors. <BR/>During an interview on 01/19/24 at 6:17 PM with MDS Coordinator C and MDS Coordinator D, MDS Coordinator C, she stated he has behaviors with getting upset and will hit everything and everyone. MDS Coordinator C stated Resident #8 also bites himself and was verbally aggressive. MDS Coordinator C stated Resident #8 ' s MDS was not accurate. MDS Coordinator C stated there was no risks to not having it documented in the behavior section of the MDS. MDS Coordinator D stated it only affected the reimbursement. <BR/>During an interview on 01/22/24 at 10:46 AM with the DON. The DON stated she was not familiar with the working of MDS, but that Resident #4 and Resident #8 should have had behaviors documented in his and her MDS. The DON stated there was a risk of not documenting accurately. <BR/>Record review of the facility Resident Assessment policy dated 2003 revealed, A comprehensive assessment will be completed within 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument (RAI). <BR/>The facility will examine each resident and review the minimum date set expanded core elements specified in the RAI no less than once every three (3) months and as appropriate. Results must be recorded to assure continued accuracy of the assessment. <BR/>Each assessment will be conducted or coordinated with the appropriate participation of health professionals. Each individual who completes a portion of the assessment must sign and verify the accuracy of that portion of the assessment. <BR/>Record review of the facility Documentation policy dated 05/2015 revealed, Documentation was the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in the nursing documentation, such as assessment, care plans, nursing progress notes, flow sheets, medications, incident reports, and summary sheets. <BR/>Goal &ndash; the facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

**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 includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care 48 hours of a resident ' s admission for 2 (Resident #2) of 5 residents reviewed for baseline care plan, in that:. <BR/>Resident #2 did not have a baseline care plan that addressed his history of falls. <BR/>This failure could have placed newly admitted residents at risk of not receiving the care and services and continuity of care. <BR/>Findings include: <BR/>Record review of Resident #2 ' s face sheet dated 01/13/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #2 ' s facility history and physical dated 12/28/23 revealed a [AGE] year-old male diagnosed with Dementia and history of falls. <BR/>Record review of Resident #2 ' s admission MDS dated [DATE] revealed Resident #2 to be cognitively intact to be able to recall and make daily decision BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 13. Devices used was a wheelchair. Activities of daily living for toileting was substantial/maximal assistance (nursing staff does more than half of the effort to assist) from nursing staff. Resident #2 was frequently incontinent. Resident #2 was diagnosed with Non-Alzheimer ' s Dementia and Cerebrovascular Accident (an interruption in the flow of blood to cells in the brain), anxiety disorder (a persistent feeling of anxiety or dread), nontraumatic subdural hemorrhage (a rare entity that presents gradually progressive neurological symptoms with an emphasis on the absence of any previous pathological or traumatic precedents), and history of falling. Resident #2 was also marked for fall history as a 1 indicating resident had a fall sometime in the last month prior to admission/entry or reentry. <BR/>Record review of Resident #2 ' s progress notes dated 12/21/23 revealed, Patient arrived via private vehicle. Resident has history of falls and requires x1 assist with transfers. <BR/>Record review of Resident #2 ' s baseline care plan dated 01/13/24 revealed there was not focus area for falls. <BR/>Record review of Resident #2 ' Event Note dated 12/31/23 revealed, Resident stated fell trying to clean himself after using the bathroom. <BR/>Record review of Resident #2 ' s Fall assessment dated [DATE] revealed high risk, scored at a 10. Resident #2 had intermittent confusion with 1-2 falls in the past 3 months. Resident #2 was chair bound. <BR/>During an interview on 01/13/23 at 3:53 PM with LVN O, she stated Resident #2 had an unwitnessed fall on 12/31/23. LVN O stated Resident #2 had a history of falls but did not review the baseline care plan nor the comprehensive care plan to see the focus area of falls for Resident #2. LVN O stated the purpose of the baseline care plan was to be informed of the resident care needs. LVN O sated she had not received any formal training from the facility regarding care plans. LVN O stated she did not recall if she learned about care plans in nursing school. LVN O stated when residents are admitted to the facility the MDS department was responsible for creating the baseline care plan. <BR/>During an interview on 01/13/24 at 5:12 PM with the Administrator and the DON, the DON stated, Resident #2 had an unwitnessed fall on 12/31/23. The Administrator stated her, and the DON conducted the investigation with Resident #2. The DON stated Resident #2 had a history of falling. The DON stated upon admission the nursing staff will start of the baseline care plan (within 24 hours) and every department will add their portion to it. The DON stated the purpose of a baseline care plan was to have a baseline on how the resident came from another facility to the current facility. The Administrator stated the purpose of a baseline care plan was so the facility staff know the baseline of the resident on how to care for the resident. The DON stated she did not see anything in Resident #2 ' s baseline care plan that address his falls. The DON stated she believed it would be important to have falls in the baseline care plan because if the resident falls, the facility would know how to care for the resident. It was noted when asked if the nurses in the facility were trained on care plans the DON did not answer and looked over at the Administrator and asked her if they were. The Administrator stated the DON and ADONs ensure the nurses are trained on the baseline care plans. <BR/>During an interview on 01/19/24 at 6:17 PM with MDS Coordinator C and MDS Coordinator D, MDS Coordinator C, she stated the admitting nurses were responsible for creating the resident baseline care plan. MDS Coordinator C stated she was familiar with Resident #2, and he did have a history of falls. MDS Coordinator C stated the purpose of a baseline care plan was so anyone providing care would get familiar with the resident ' s care. The MDS Coordinator D stated the nurses had 48 hours to generate the baseline care plan. MDS Coordinator C stated she did not see a focus area for falls for Resident #2 in his baseline care plan. MDS Coordinator D stated when the admitting nurse was creating the baseline care plan, they need to be reviewing the resident packet they came to the facility with. MDS Coordinator C stated Resident #2 ' s history and physical and face sheet it did indicate Resident #2 did have a history of falling. MDS Coordinator C and MDs Coordinator D did not indicate what or if there was a risk if the baseline care plan did not have falls as the focus. <BR/>Record review of the facility Baseline Care Plan not dated revealed, Completion and implementation of the baseline care plan within 48 hours of a resident ' s admission was intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. <BR/>This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care plan. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 5 (Resident # 3, #4, #5, #7, and #8 ) of 12 residents reviewed for care plans. <BR/>The facility failed to implement a comprehensive person-centered care plan for Resident #7 ' s history of falls. <BR/>The facility failed to implement a comprehensive person-centered care plan to address elopement risk for Residents #3, #4, #5, #7, and #8. <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include: <BR/>Resident #7 <BR/>Record review of Resident #7 ' s face sheet dated 01/19/24 revealed admission on [DATE] and re-admission on [DATE] to the facility with diagnoses of unspecified lack of coordination, abnormalities of gait and mobility, disorganized schizophrenia, muscle wasting and atrophy, muscle weakness, unsteadiness on feet, and unspecified dementia. <BR/>Record review of Resident #7 ' s care plan dated 11/21/23 revealed at risk for wandering. Assess for fall risk. Care plan did not indicate anything regarding the focus area of falls. <BR/>Record review of Resident #7 ' s Event Note dated 11/20/23 revealed bruising to left knee, left lower leg, left ankle bruising. <BR/>Record review of Resident #7 ' s Fall Assessments dated 01/19/24 revealed from there were only fall assessments completed from 02/13/20-08/09/23. No fall assessment was conducted for the Event note that was completed on 11/20/23. <BR/>Resident #3 <BR/>Record review of Resident #3 ' s face sheet dated 01/18/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #3 ' s facility history and physical dated 07/25/23 revealed a [AGE] year-old female diagnosed with Dementia and Major Depression Disorder (affects how you feel, think and behave and can lead to a variety of emotional and physical problems). <BR/>Record review of Resident #3 ' s quarterly MDS dated [DATE] revealed a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 3. Resident #3 was diagnosed with Alzheimer Disease, Non-Alzheimer ' s Disease, and Depression. <BR/>Record review of Resident #3 ' s elopement risk assessment dated [DATE] revealed a score of 13, high risk of elopement. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident # 3 ' s care plan dated revealed no focus area and/or interventions to address elopement risk. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet dated 01/18/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #4's facility history and physical dated 05/18/23 revealed a [AGE] year-old female diagnosed with psychiatric behavior with aggression and paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly). <BR/>Record review of Resident #4's annual MDS dated [DATE] revealed a Preadmission Screening and Resident Review condition as serious mental illness. Resident #4 had a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 3. MDS indicated zero (no behavioral symptoms) for behaviors. Resident #4 was diagnosed with Non-Alzheimer's Disease, Psychotic Disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), Schizophrenia (a serious mental disorder in which people interpret reality abnormally), depression, and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). <BR/>Record review of facility assessment scoring report sheet dated 01/01/20-01/19/24 reviewed Resident #4 had a score of 13 for elopment risk. <BR/>Record review of Resident #4's care plan dated 12/17/21 revealed no focus area for elopement. <BR/>Resident #5 <BR/>Record review of Resident #5 ' s face sheet dated 01/18/24 revealed admission on [DATE] to the facility. Resident #5 was a [AGE] year-old female diagnosed with Dementia and Psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). <BR/>Record review of Resident #5 ' quarterly MDS dated [DATE] revealed a moderately cognition to be able to recall and make daily decision BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score which was not taken for whatever reason. Resident #5 was diagnosed with Cerebrovascular Accident (an interruption in the flow of blood to cells in the brain), Non-Alzheimer ' s Dementia, Depression, Psychotic Disorder (affect brain function by altering thoughts, beliefs or perceptions) and Adjustment Disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior) with Depressed Mood (Feelings of sadness, hopelessness, crying and lack of joy from things that used to bring you pleasure). <BR/>Record review of Resident #5 ' s Elopement assessment dated [DATE] revealed a elopement risk score of 18. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident #5 ' care plan dated 01/22/24 revealed no focus area for elopement. <BR/>Resident #8 <BR/>Record review of Resident #8 ' s face sheet dated 01/19/23 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #8 ' s facility history and physical dated 04/06/23 revealed a [AGE] year-old male diagnosed with severe intellectual disability, anxiety, and Major depressive Disorder (it affects how you feel, think and behave and can lead to a variety of emotional and physical problems). <BR/>Record review of Resident #8 ' s annual MDS dated [DATE] revealed a Preadmission Screening and Resident Review condition as intellectual disability. Resident #4 had a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score that was not taken for whatever reason. Behaviors was marked zero revealing Resident #8 had no behaviors when Resident #8 really did have behaviors. Resident #8 was diagnosed with Seizure Disorder (abnormal electrical brain activity), Depression, and Serve Intellectual Disabilities (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills). <BR/>Record review of Resident #8 ' s elopement risk assessment dated [DATE] revealed a score of 14, high risk. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident #8 ' s care plan dated 01/15/24 revealed no focus area for elopement. <BR/>During an interview on 01/19/24 at 6:17 PM with MDS Coordinator C and MDS Coordinator D, MDS Coordinator C, she stated the comprehensive care plans should have had falls and elopement care planned for Resident #7, #3, #4, #5, #8. MDS Coordinator D stated there could be a risk of not care planning falls and elopement. MDS Coordinator stated the risk could be a resident elopement from the facility. MDS Coordinator C stated anytime there was an elopement assessment completed for a resident that meant it would need to be care planned for the resident. MDS Coordinator C stated the DON, ADON, and the MDS department were responsible for overseeing that the comprehensive care plans are accurate. <BR/>During an interview on 01/22/24 at 10:46 AM with the DON, she stated residents with elopement risk should have elopement as a focus area in their care plans. The DON stated the charge nurse will update the care plans and the DON and ADONs will oversee to make sure it was done. The DON stated that Resident #7 had no focus area for falls and had overlooked the fall for the comprehensive care plan. The DON stated Residents #3, #4, #5, and #8 had no focus for elopement because she did not look for it on the comprehensive care plan as she did not know it needed to be care planned. The DON stated the risk of not including the elopement in the comprehensive care plan could be identifying resident elopement risk and monitoring of the resident. <BR/>During an interview on 01/22/24 at 12:44 PM with the Administrator, she stated she was not too familiar with comprehensive care plans and asked to refer to the DON regarding care plans. <BR/>Record review of the facility Elopement Assessment Scoring Report dated 01/01/20-01/19/24 was review revealed there were 30 residents on it to include Residents #3, #4, #5, #8. <BR/>Record review of the facility Preventive Strategies to Reduce Fall Risk dated 10/05/16 revealed, Policy: The goal of fall prevention strategies was to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident ' s mobility. <BR/>Residents at risk will be care planned for fall prevention. <BR/>After risk was assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will educate on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. <BR/>Record review of the facility comprehensive care plan policy not dated revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. <BR/>The comprehensive care plan will describe the following: <BR/>The services that are to be furnished to attain and maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. <BR/>Record review of the facility Elopement Prevention policy 01/2023 revealed, Every effort will be made to prevent elopement episode while maintaining the least restrictive environment for residents who are at risk for elopement. <BR/>All residents who area at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. <BR/>The resident ' s care plan will be modified to indicate the resident was at risk for elopement episodes. <BR/>Interventions into elopement episodes will be entered onto the resident ' s care plan and medical record. <BR/>Record review of the facility Elopement Response policy dated 10/27/10 revealed, After an elopement the care plan coordinator will reevaluate the resident ' s care plan. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure residents were provided supervision and assistive devices to prevent accidents for 2 of 10 (Resident #1 and Resident #12) residents reviewed for accidents. <BR/>The facility failed to provide supervision to prevent the elopement of Resident #1. <BR/>Staff failed to respond to the door alarm when the resident exited the facility. Resident #1 was outside, unsupervised by staff for approximately 1 hours, and suffered lacerations and abrasions. <BR/>This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/19/24. The IJ template was provided to the Administrator. The IJ was removed on 01/20/24, but the facility remained out of compliance at a scope of actual harm and severity level of isolated because the facility failed to have a system in place to ensure residents are monitored when facility door alarms sound off. <BR/>The facility failed to conduct safe transfers for Resident #12, CNA F did a one-person transfer with Hoyer lift. <BR/>These failure could place residents at risk of harm and injuries due to lack of supervision and failure to follow protocols. <BR/>Findings include: <BR/>Resident #1 <BR/>Record review of Resident #1 ' s face sheet dated 01/19/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #1 ' s facility history and physical dated 11/20/23 revealed a [AGE] year-old male diagnosed with anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), mental illness (disorders that affect your mood, thinking and behavior), and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). <BR/>Record review of Resident #1 ' s admission MDS dated [DATE] revealed a moderately cognitive impairment to be able to recall and make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 7. Resident #1 had a behavior of wandering. Activities of daily living revealed Resident #1 to be independent with eating, oral hygiene, toileting, dressing, toilet transfers, sit to stand, lying to sitting on side of bed, and be able to walk 150 feet but only 10 feet on uneven surfaces. Resident #1 was diagnosed with Coronary Artery Disease (caused by plaque buildup in the wall of the arteries that supply blood to the heart), Seizure Disorder (abnormal electrical brain activity), anoxic brain damage, cardiomyopathy, and lack of coordination (Uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), muscle weakness (no muscle strength), and cognitive communication deficit (difficulty with thinking and how someone uses language). <BR/>Record review of Resident #1 ' s care plan dated 12/06/23 [sic] revealed at risk for elopement as evidenced by anoxic brain damage. Assess/record/report to medical doctor risk factors for potential elopement such as - wandering. Repeated request to leave facility, statements such as, I ' m leaving (no date was indicated for this comment), I ' m going home (no date was indicated for this comment), attempts to leave facility, elopement attempts from previous facility. <BR/>Supervise closely and make regular compliance rounds whenever resident was in room. Determine the reason the resident was attempting to elope. Is the resident looking for something or someone? Does it indicate the need for more exercise? Intervene as appropriate. <BR/>Resident #1 was at risk for wandering. Impaired safety awareness. Assess for fall risk. <BR/>Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. <BR/>Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? <BR/>If a resident was exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. <BR/>Resident #1 was on anticoagulant therapy. Avoid activities that could result injury. Take precautious to avoid falls. <BR/>Record review of Resident #1 ' s Elopement Risk assessment dated [DATE] revealed high risk for elopement score of 12. Moderately impaired - decision poor, cues/supervision required. Elopement was signed and locked on 11/30/23 instead of being locked on 11/20/23 when Resident #1 was admitted to facility. <BR/>Record review of Resident #1 ' s Elopement Risk assessment dated [DATE] revealed high risk for elopement score of 11. Moderately impaired - decision poor, cues/supervision required. It was unknown why an elopement assessment was conduct as Resident #1 was no longer returned to the facility. <BR/>Record review of Resident #1 ' s Fall Risk assessment dated [DATE] revealed a moderate score of 8. Resident #1 had intermittent confusion. <BR/>Record review of Resident #1 ' s Order Recap dated 11/20/23 revealed on anticoagulant - monitor for bruising, nosebleeds, for prolonged bleeding from wound. <BR/>Review of weather records for 11/30/23 between 6:15 am to 7:45 am, the temperature was 51-53 degrees Fahrenheit, there was light rain, and wind gusts from 30 to 37 miles per hour. [https://www.wunderground.com/history/daily/us/tx/el-paso/KELP/date/2023-11-30 accessed 2/2/24]. <BR/>Record review of Resident #1 ' s progress notes written by LVN A dated 11/30/23 revealed, at 8:30 am - As per nursing 06:00 am staff CNA (unidentified) noticed resident was not in his room. Checked on dining room and receptionist where resident always stays. Code orange elopement) was activated. Family, DON, Administrator, police department, medical doctor notified. <BR/>10:04 am - As per 6am CNA staff started doing rounds and got into patient room later around 7:00 am. <BR/>Record review of sister facility ' s progress notes dated 11/30/23, where Resident #1 transferred, following the elopement, revealed Resident arrived via car accompanied by family member at 10:00 AM. According to family member he eloped from previous facility and was found wandering streets in the Westside of the city until he was picked up by the police. Police then transported Resident #1 to a family member residential address that he remembered. Family member was then contact and picked up Resident #1 and bought him here. Resident #1 looked disheveled (things other than hair that have a messy or untidy appearance) in appearance. Walking in socks because his shoes were still wet from the rain. Head to toe assessment - laceration and abrasion noted to facial area/upper right brow/forehead. Large dark discoloration to left side of ribs. <BR/>Record review of Resident #1 ' s skin assessment from sister facility dated 11/30/23 revealed Resident #1 with the following: <BR/>a dark painful bruise to left side of ribs 14cm by 9cm. <BR/>Right pinky finger with a skin tear 0.3cm by 0.3cm. <BR/>Right side abrasion above upper brow 6cm by 5.5cm. <BR/>Right cheek abrasion 2cm by 2cm. <BR/>Left palm abrasion 5cm by 4cm. <BR/>Right palm abrasion 7cm by 4cm. <BR/>Left knee abrasion 3.5cm by 3.5cm. <BR/>Right knee abrasion 6cm by 3.5 cm. <BR/>Left top of foot abrasion 4.5cm by 2cm. <BR/>Right elbow abrasion 2cm by 2cm. <BR/>Right side laceration above upper brow 0.5cm by 0.5cm <BR/>Left side laceration near orbital 1cm linear laceration. <BR/>Right side of sacral area laceration, crescent shaped 0.5cm. <BR/>Skin findings - redness to neck and chest <BR/>Record review of the x-ray conducted, by the sister facility, after the resident transferred from this facility, of Resident #1 dated 11/30/23 revealed X-Ray to right rib status post fall, pain, bruising. <BR/>Findings: Multiple radiographs of ribs were obtained. They show no fracture or other focal bony abnormality. There was no evidence for pneumothorax (a collapsed lung), pleural effusion (an unusual amount of fluid around the lung), pleural thickening (develops when scar tissue thickens the delicate lining around the lungs (the pleura) or pulmonary contusion (an injury to the lung parenchyma in the absence of laceration to lung tissue or any vascular structures). The view of the chest shows no abnormality area. <BR/>Record review of the Resident #1 ' s Event Note dated 11/30/23 revealed, As per nursing, 06:00AM - staff CNA noticed resident was not in his room. Checked on dining room and receptionist area where resident likes to stay. Code Orange was activated. Family, DON, Administrator, police department, medical doctor was notified. <BR/>Note What door exited - Unknown <BR/>Note How long missing - Unknown <BR/>Record review of city streets on google maps dated 01/19/24 revealed near the facility was a busy two-way intersection (265.24 ft away) with a speed limit of 35 miles per hour. Further up the street near the facility was another four-way busy intersection (1,222.46 ft away) with a speed limit of 45 miles per hour. <BR/>Record review of facility 3613-A that was submitted to state agency dated 12/07/23 revealed - Timeline - <BR/>&middot; <BR/>5AM resident was seen in his bed asleep <BR/>&middot; <BR/>5:30 AM resident was given his morning medications <BR/>&middot; <BR/>5:40 AM CNA observed resident walking around his room <BR/>&middot; <BR/>6:15 AM LVN heard back door alarm going off, she run to check and did not see anyone. <BR/>&middot; <BR/>6:25 AM Construction workers saw an old man walking around the parking lot, did not mention anything since they did not know he was a resident of the facility. <BR/>&middot; <BR/>6:35 AM Code Orange was initiated. Staff searched the premises and nearby stores and gas stations. <BR/>&middot; <BR/>7:12 AM EPPD notified of a missing person <BR/>&middot; <BR/>7:45 AM EPPD took resident to mothers <BR/>&middot; <BR/>8:45 AM resident arrived at sister facility and rehab <BR/>&middot; <BR/>Transferred to sister facility as per family <BR/>Record review of Detective e-mail dated 01/22/24 revealed Resident #1 was found at 7:50 AM on local retailer 1.29 miles (2.08 km). Resident #1 was alert and the weather was unknown at that time. <BR/>During an observation and interview on 01/19/24 at 10:36 am, Surveyor A and Administrator opened hallway 1 exit door for alarm to ring. LVN K and CNA L responded to door alarm. No administrative staff were observed responding to the door alarm. LVN K stated when exit door alarm rings she was to open the door and check the outside premises to ensure no residents were observed outside. LVN K stated she would then do a head count and ensure all her residents were accounted for and notify DON. <BR/>During an interview on 01/19/2024 at 10:43 am, LVN K stated when exit door alarms ring all staff were expected to respond to the exit door and assist to include housekeeping, CNAs, nurses, and administration staff. LVN K stated the lack of response from staff when door alarm rang was concerning. LVN K stated only her and CNA L responded to the door alarm. LVN K stated she had 5 CNAs on that side of the building. LVN K stated she knew 2 CNAs were busy with changing residents, CNA K responded, was not aware of CNA S whereabouts and CNA R was out on break. <BR/>During an observation and interview on 01/19/24 at 11:13 am, SW office was the closest office to hallway 1. The SW denied hearing a door alarm ring. <BR/>During an interview on 01/19/23 at 11:00 AM with the Administrator, she stated she was notified of Resident #1 missing from ADON E at 6:50 AM, in which the nursing staff could not find him. The Administrator stated she had instructed ADON E to check all the rooms in the facility. The Administrator stated a CNA went in Resident #1 ' s room to get him up for the day and could not find him. The Administrator stated she had informed the ADON E that she would start looking outside when she got to the facility. The Administrator stated Resident #1 did not have a history of elopement in their facility and the past facility he came from. The Administrator stated Resident #1 did not have a wander guard as the facility was a wander guard free facility. The Administrator stated the local police department did not give the facility the police report of Resident #1 and did not know why. The Administrator stated the back door leading to the back patio was going off in the morning around 6 AM. The Administrator stated LVN A responded to the door and turned off the alarm. The Administrator stated LVN A looked outside and saw no one and other staff members responded but once seeing LVN A had responded turned around and went back to their work areas. The Administrator stated the facility staff did not do a perimeter check around the facility. The Administrator stated it was not documented that a head count was conducted to make sure no other residents were missing. The Administrator stated it was expected for facility staff to respond immediately to door alarms and check to see what was going on or if anybody needed assistance. The Administrator stated she in-serviced the facility staff in regard to whenever a door alarm goes off that facility staff have to respond and not go back to what they are doing. The Administrator stated Resident #1 exited through the back door. The Administrator stated the facility implemented other interventions such as shortening the front door lock from 30 seconds to 15 seconds, changing the code on the doors, and conducting audits on residents with elopement. The Administrator stated the facility made every effort to prevent elopement. The Administrator stated as per their facility Elopement Prevention policy the facility did not think about placing all their wandering residents in the same hallway. <BR/>During an observation and interview on 01/19/24 at 11:17 am, Surveyor B opened exit door on hallway 2 (furthest away from receptionist/ dining room area) for alarm to ring. Administrative staff offices were by the receptionist and dining room area. Surveyor A could faintly hear the door alarm ringing. No Administrative staff responded to door alarm. The Receptionist denied hearing a door alarm ringing. <BR/>During an interview on 01/19/24 at 1:33 PM with Sister Facility Administrator, he stated Resident #1 was readmitted to his facility. Sister Facility Administrator stated the family bought Resident #1 to the facility. Sister Facility Administrator stated the facility had photos of Resident #1 having bruises to the right side of face and bruises to hands/knees and ribs. Sister Facility Administrator stated a skin assessment was conducted. Sister Facility Administrator state the local police found Resident #1 and took him to his family member place. Sister Facility Administrator stated Resident #1 was soaking wet due to it raining outside. Sister Facility Administrator stated the facility had x-rays and results were negative for fractures. <BR/>During an interview on 01/19/24 at 2:23 PM with Police Officer, he stated a call was placed by the facility on 11/30/23 at 7:43 AM reporting a missing person. Police Officer stated Resident #1 was found at 7:50 AM. Police Office stated when missing persons are reported the officer responding was to create a report if they had sustained any injuries even if it was weather related. Police Officer stated there was not one made for this case. Police Officer stated could be possible he could be okay. Police Officer stated it did not indicate where the resident was found and he appeared okay. Police Officer stated Resident #1 was taken home. <BR/>During an interview on 01/19/24 at 3:08 PM with LVN A, she stated the day of the incident with Resident #1 the back door alarm was going off. LVN A stated she came in at 6:00 AM and it was going off. LVN A stated the back patio fence doors were not open. LVN A stated she turned off the back door alarm and did not see a Receptionist posted near the front entrance door, which was opposite of the back. LVN A stated she checked that no one was outside. LVN A stated LVN Q looked in the front entrance and did not see anyone. LVN A stated as soon as the missing person was announced the nursing staff all jumped in to help and search. LVN A stated she did not let the other nurses know that they needed to do a head count, but all of her residents were accounted for. LVN A stated the alarm went off and after the alarm went off she did her head count. <BR/>Record review of Family Members photos of Resident #1 dated 01/24/24, taken when Resident #1 was brought to their house, by police, revealed bleeding abrasion(s) to Resident #1 ' s right upper brow and right cheek, scrapes or scratches to both left and right knees, red marks. <BR/>Record review of facility training dated 01/19/24 When exiting be aware of surroundings, wait until door was locked to step away in-service not dated revealed it was given and signed by facility staff. <BR/>Record review of facility training Do not share door code with residents/family members not dated revealed it was given and signed by facility staff. <BR/>Record review of facility training Changing door code every 2 weeks not dated revealed it was given and signed by facility staff. <BR/>Record review of facility Remodel area Window door check for Hall 1, 2, 3, 4, 5, 6 dated September, October, November with no year revealed dates and times. <BR/>Record review of facility Assessment Scoring Report sheet dated 01/01/20-01/01/19/24 revealed 30 facility residents at risk of elopment. <BR/>Record review of the facility Elopement Prevention policy dated 01/2023 revealed, Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for resident who are at risk elopement. <BR/>If a resident was discovered to be missing, a search shall begin immediately. (See policy entitled Elopement Response.) <BR/>Use door locks that are out of reach/sight to prevent wanders from opening doors. <BR/>Use door alarms or monitoring devices to notify staff when residents try to leave the facility. <BR/>Consider putting wandering residents on the same unit with a single exit near the nursing station. <BR/>If applicable, consider the resident for a secured unit. <BR/>Physical Plant: All facility exits that residents have access to will have a device in place to alert staff of elopement attempts. <BR/>Wander guard System <BR/>Keypad exit magnetic locks <BR/>Keyed Alarms <BR/>Secured Unit <BR/>Staff Training: Staff will receive training during their orientation process and then annually regarding - Elopement prevention, Operation of all exit devices, and Actions to take if elopement occurs. <BR/>Record review of the facility Elopement Response policy dated 10/27/10 revealed, Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or was suspected, our elopement response plan will be immediately implemented. <BR/>Should an employee discover the resident was missing from the facility, he/she should: Make a thorough search of the building(s) and premises. <BR/>Make an extensive search of the surrounding area. <BR/>If unable to locate resident in the building, proceed as follows: After 30-minutes, if the resident has not been found, the following calls must be made: <BR/>Report missing resident to the police. <BR/>Post return resident evaluation and care: The facility will evaluate its elopement prevention program and all residents will be reassessed for elopement risk. <BR/>Record review of the facility elopement Drill or Actual Elopement Guide and in-service dated 04/10/23, 06/29/23, and 10/31/23 revealed, Instruction: elopement drills should be conducted monthly on different shifts at random times. The facility Administrator only provided these 3 in-services and failed to produce the other months as indicated to be done monthly. <BR/>Time how long it takes staff to begin looking and realize the resident/mascot cannot be found and initiate the elopement plan. <BR/>Evaluate the actions of the staff and the efficiency of the elopement plan. <BR/>Report the findings to the QAPI committee. <BR/>Record review of the facility Preventive Strategies to Reduce Fall Risk policy dated 10/05/16 revealed, Policy: The goal of fall prevention strategies was to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident ' s mobility. <BR/>Record review of the facility Assessment Scoring Report dated 01/01/20-01/19/24 revealed 30 resiudents with elopement risk. <BR/>Incident Reporting - Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s). <BR/>The Administrator and DON were informed on 01/19/24 at 4:40 PM that Immediate jeopardy (IJ) had been identified and copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. <BR/>The following Plan of Removal submitted by the facility was accepted on 1/20/2024 at 10:16 am. <BR/>The Plan of Removal revealed the facility took the following actions: <BR/>Starting 1/19/24, facility staff were in-serviced by the DON/ADON on the following: <BR/>All active employee during shift where alarm is heard should Immediately respond to alarm and check the surrounding external areas when alarm goes off. <BR/>Charge nurses are responsible to do a head count when the door alarm goes off. The head count will be completed within 15min. If resident is not accounted for, charge nurse will initiate code orange. <BR/>The nurse will complete the head count and document on facility system, 24-hour report, and will report to the administrator. <BR/>If all residents are accounted for charge nurse will page overhead speaker, code orange all clear. <BR/>Installation of stop alarms will be completed by 1/19/24 by 8:00pm and alarms will be on, ON mode, at all times. <BR/>Stop alarms were tested upon installation by Maintenance director to ensure that it is audible throughout the facility including dining room and offices. <BR/>New staff/Agency staff will be educated during orientation. <BR/>All staff not in-service on 1/19/2024 in person or on the phone will be in-serviced before the start of their shift. <BR/>On 1/19/24, the maintenance director of the facility did the following: <BR/>Stop alarms are being installed by 1/19/24 by 8:00pm in all exit doors to ensure the alarm sound is loud enough to reach offices and dining rooms. <BR/>The medical director was notified of this plan on January 19, 2024, and an off-cycle QAPI plan was initiated regarding this event, completion date 1/20/24 9:00 am <BR/>This affected Resident #1 and had the potential to affect 30 other residents with wandering/exit seeking behaviors, <BR/>Residents are identified by the Elopement risk assessment in facility system. <BR/>Monitoring: <BR/>The DON and/or designee will monitor that headcount, outdoor checks, and sign-out sheets are used properly and completed at least five times per week. <BR/>The administrator, DON, and/or designee will do elopement drills weekly to ensure staff are responding immediately to door alarms. <BR/>Maintenance director/designee will be responsible for testing alarms 2 times a week to ensure alarms are working properly. <BR/>Interviews, observations and Record Review to confirm implementation of the Plan of Removal were conducted as follows: <BR/>Observations on 01/20/2024: <BR/>10:16 am, admin opened door to hallway 3. CNA U, 2 staff from down the hallway in hallway 1 respond. CNA W and CNA G, 2 maintenance personnel in the hallway looked over to door. <BR/>10:20 am, admin opened hallway 6 alarm. CNA I, Housekeeping Aide, HR, LVN X, Transportation Aide, LVN Y, and CNA F responded. <BR/>10:25 am, hallway 1 door was pushed alarm went off. LVN M, CNA U, CNA W, CNA Z, Housekeeping Aide, SCNA BB, and Maintenance Assistant all responded immediately within 5 seconds of pushing the exit door. <BR/>10:27 am, hallway 1 door was pushed alarm went off. Could hear in reception SW responded and receptionist was with family but notified Administrator. <BR/>10:38 AM - Maintenance Director turn on the alarm system and the doors in the hallway closed and exit doors opened. Facility staff were seen responding from all over the facility. Charge nurses were seen taken head count of the residents. An all clear was given after the head count was taken. <BR/>Interviews on 01/20/24: <BR/>CNA I, Housekeeping Aide, HR, LVN N, LVN X, Transportation Aide, LVN Y, CAN F confirmed in-services provided regarding code orange, response to exit door alarms, assist with head count, search outside premises/perimeter to ensure no residents were found outside, police notification, stated they could identify elopement risk residents in PCC and/or elopement binders that were located in nurses station and receptionist area. <BR/>During an interview on 01/20/24 beginning at 10:30 AM with CNA I, Housekeeping Aide, HR, LVN N, LVN X, Transportation Aide, LVN Y, CAN F confirmed in-services provided regarding code orange, response to exit door alarms, assist with head count, search outside premises/perimeter to ensure no residents were found outside, police notification, stated they could identify elopement risk residents in PCC and/or elopement binders that were located in nurses station and receptionist area. <BR/>During an interview on 01/20/24 at 11:30 AM with ADON E, she stated she had worked the night shift on 01/19/24 and was in-serviced with the door alarm response. ADON E stated it was procedures to responding to the door alarm soundings. ADON E stated when the door alarms sounds then everyone had to respond to the door that was alarming. ADON E stated facility staff where to also go outside and check the perimeter of the facility to see of there were any residents outside. ADON E stated the nurses were to conduct a head count of all the residents to ensure they were all in the facility. ADON E stated if all residents were accounted for then an all clear could be call, if not then a Code Orange (Indicating Elopement) would have to be initiated. ADON E stated if the resident was not found within 30 minutes, then the local police would have to be notified. <BR/>During an interview on 01/20/24 at 11:58 AM with CNA T, she stated she was in-serviced on when the door alarm goes off the facility staff have to rush to the door that ' s sounding. CNA T stated two or three staff have to go outside and search the surrounding areas of the facility. CNA T stated if the resident was not found then they call a Code Orange (Indicating Elopement) and the Administrator gets notified. CNA T stated a head count was to be done by the nurses. CNA T stated after 30-minutes of looking for the missing resident then the facility staff call the police. CNA T stated if the resident was found then the nurse gets notified and an all clear gets called. <BR/>During an interview on 01/20/24 at 11:58 AM with the DON, she stated when a door alarm goes off the nurses need to conduct a head count of all the residents to ensure they are all accounted for. The DON stated when a door alarm goes off all staff are to respond to the door alarm that was going off. The DON stated staff are to search the perimeter for any residents. The DON stated the managers will be responsible for ensuring the nurses are doing the head count of the residents. The DON stated the nurses will also review the sign in/out sheets to make sure the residents are accounted for and the DON and ADONs will oversee that the nurses are doing the checks. The DON stated Maintenance Director will check the outdoor combination locks. The DON stated there was a check sheet for maintenance checking the outdoor combination locks. The DON stated the Administrator, and the DON will be in charge of conducting the Elopement Drill every week with the assistance of an alert resident or a stuff animal. The DON stated the focus of the elopement drill was to check for staff response and timing. <BR/>During an interview on 01/20/24 at 12:28 PM with the Administrator, she stated the DON will ensure that nurses are doing a head count when a door alarm goes off. The Administrator stated there was a spread sheet that was created to document the headcounts. The Administrator stated the outdoor checks are when the facility staff go outside and check the perimeter of the facility to see if there are any residents. The Administrator stated her, and the DON were responsible for checking the headcount and outdoor checks on the spread sheet to ensure the staff are doing the headcount and outdoor checks. The Administrator stated the elopement drill were to be conducted weekly on different times and days. The Administration stated they were looking to see the response time and how staff work together with deflating task with the elopement drill. The Administrator stated these drills will be record on the Elopement Drill Form. The Administrator stated the Maintenance Director will checking the door alarms to make sure they are working properly (making sure they are ringing) and will be recorded on a sign on/off sheet. The Administrator stated the sheets will be turned in at the end of each week for her to review. <BR/>Record review of facility in-service dated 01/19/24 revealed it was given and signed by facility staff The in-service indicated when a door alarm goes off, charge nurse are responsible to do a head count within 15 minutes if resident not accounted for. Charge nurse will initiate Code Orange <BR/>Record review of facility in-service dated 01/19/24 revealed it was given and signed by facility staff. The in-service indicate the nurse will complete the head count and document on facility system, 24-hours report, and will be reported to the administrator. <BR/>Record review of facility in-service dated 01/19/24 revealed it was given and signed by facility staff. The in-service indicate If all residents are accounted for change nurse with page overhead speaker, code orange all clear <BR/>Record review of facility Call police after 30-mintues of resident missing in-service dated 01/19/24 revealed it was given and signed by facility staff. <BR/>Record review of facility Check and walk the perimeter when a door alarm goes off in-service dated 01/19/24 revealed it was given and signed by facility staff. <BR/>Record review of fac[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure respiratory care was provided in a manner consistent with professional standards of practice for 1 (Resident#10) of 2 residents reviewed for respiratory care in that: <BR/>The facility failed to place Resident #10 ' s nasal cannula in a clear labeled bag while not in use. <BR/>These deficient practices could place residents at risk for infection due to improper care practices. <BR/>Findings Include: <BR/>Record review of Resident #10 ' s face sheet dated 01/22/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #10 ' s facility history and physical dated 08/03/23 revealed an [AGE] year-old female diagnosed with Type 2 Diabetes Mellitus, Asthma, Alzheimer ' s Disease, multiple of falls, and Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). <BR/>Record review of Resident #10 ' s quarterly MDS dated [DATE] revealed a severe cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 2. Resident #10 does have a behavior of delusions and wandering. Resident #10 needs partial/moderate assistance for nursing staff to sit to stand, chair/bed to chair transfer, toilet transfer. Resident #10 was total dependent on showers. Resident #10 was diagnosed with Alzheimer ' s, asthma, and muscle weakness (no muscle strength), and lack of coordination (Uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements). Resident was not marked for oxygen therapy as the MDS was done on 10/12/23 before Resident #10 needed oxygen. <BR/>Record review of Resident #10 ' s order recap dated 01/05/24 revealed change nasal cannula as needed. Check oxygen saturation every shift and as needed and every shift. May use oxygen at 2 liter per minute via nasal cannula every shift. <BR/>Record review of Resident #10 ' s Care Plan dated 08/22/22 revealed Resident #10 has asthma and was at risk for respiratory distress. Give medications as ordered. Give nebulizer treatments and oxygen therapy as ordered. <BR/>Observation on 01/13/24 at 1:13 PM revealed Resident #10 ' s nasal cannula to be placed on top of the concentrator unbagged. The nasal cannula part where it goes into your nose had a slight tint color as well as some parts of the oxygen tubing. <BR/>During an interview on 01/13/24 at 1:20 PM with the family member, she stated the nursing staff always just placed Resident #10 ' s nasal cannula on the concentrator unbagged. <BR/>During an interview on 01/13/24 at 1:25 PM with MDS Coordinator C, she stated nasal cannulas are to be bagged if not in use. MDS Coordinator C stated the risk of not bagging the nasal cannula could be infection to the resident. <BR/>Observation and interview on 01/22/24 at 10:25 AM with the DON, she stated Resident #10 ' s nasal cannula should be changed as needed or once a week. The DON stated Resident #10 ' s nasal cannula being unbagged and placed on the concentrator was unacceptable. The DON stated Resident #10 ' s nasal cannula should have been placed in a clear baggy that was labeled with the date. The DON stated that was so the nursing staff would know when to change the nasal cannula. The DON stated Resident #10 ' s nasal cannula had been used. The DON stated not bagging the nasal cannula was a risk to Resident #10 with an infection. <BR/>Record review of the facility Infection Control Plan: Overview policy dated 2019 revealed, The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. <BR/>On 01/22/24 at 9:00 AM with the Administrator, she stated the facility did not have an oxygen policy specifically about nasal cannulas being bagged. <BR/>Record review of the facility Oxygen Administration policy dated 02/13/07 revealed, Oxygen therapy includes the administration of oxygen in liters per minute by cannula or face mask to treat hypoxemia conditions caused by pulmonary or cardiac diseases. <BR/>The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. <BR/>The resident will be free from infection. <BR/>Changing the tubing (including any nasal prongs or mask) that was in use on one patient when it malfunctions or becomes visibly contaminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 (Resident #11) of 3 residents reviewed for urinary catheter care. <BR/>Resident #11's catheter bag did not have a catheter bag cover exposing the catheter bag filled with urine<BR/>This failure could have compromised residents' dignity for those who require urinary catheter care. <BR/>Findings include: <BR/>Record review of Resident #11's face sheet dated 02/14/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #11's facility history and physical dated 11/06/23 revealed a [AGE] year-old male diagnosed with schizophrenia (a serious mental disorder in which people interpret reality abnormally) and bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode)). <BR/>Record review of Resident #11's quarterly MDS dated [DATE] revealed an intact cognition to be able to recall and make daily decisions BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 13. Resident #11 was dependent on nursing staff for toileting. Resident #11 had an indwelling catheter. <BR/>Record review of Resident #11's care plan dated 01/13/24 revealed indwelling catheter - check for kinks and maintain the drainage bag off the floor, ensure tubing is anchored to the resident's leg or linens so that tubing was not pulling on the urethra, monitor and document intake and output as per facility policy, and for signs of discomfort on urination and frequency. <BR/>Observation on 02/15/24 at 9:47 AM revealed Resident #11 was lying down in the bed with an indwelling catheter. The indwelling catheter was hanging from the bed and did not have a cover. <BR/>Observation and interview on 02/15/24 at 9:54 AM with LVN J, she stated Resident #11's indwelling catheter bag needed to have a cover for Resident #11's dignity, his privacy, and infection control. LVN J stated it was everyone's responsibility for ensuring the indwelling catheter bag had a covers. <BR/>During an interview on 02/15/24 at 10:28 AM with the ADON G, she stated indwelling catheters were to be placed on the edge of the bed hanging with a cover for privacy. ADON G stated not having a cover could result in a negative outcome for the resident's dignity. ADON G stated it was the nurses and CNAs responsibility to ensure there was a privacy cover on the indwelling catheter bag. <BR/>During an interview on 02/15/24 at 11:00 AM with the Area Director of operations, stated DON was suspended, so no interview regarding the indwelling catheter was conducted with DON. <BR/>Record review of the facility's Catheter Insertion, Male/Female policy and procedure manual dated 2003 revealed, An indwelling catheter provides continuous bladder drainage in residents with a neurogenic bladder or urinary disfunction.<BR/>Catheter Change/Replacement - Catheters that are encrusted so that urinary outflow was blocked should be changed. <BR/>Record review of the facility's Resident Rights policy manual dated 11/28/16 revealed, Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.<BR/>Respect and Dignity - The resident has a right to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to implement written policies that prohibit and prevent abuse for one (Resident #2) of four residents reviewed for abuse<BR/>The facility failed to implement their abuse policy when they failed to report, investigate and protect residents from further potential abuse when Resident #2 made an allegation of sexual abuse <BR/>An IJ Immediate Jeopardy (IJ) was identified on 02/16/24. The IJ template was provided to the facility on [DATE] at 3:01 PM. While the IJ was removed on 02/17/24, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor its plan for effectiveness.<BR/>This failure could place all residents at risk for sexual abuse/exploitation and other abuses by not immediately following the facility policy and procedure manual of recognizing, reporting, investigating, allegations of sexual abuse/exploitation and other abuses. <BR/>Findings Include:<BR/>Record review of the facility Abuse/Neglect policy and procedure manual dated 03/29/18, revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. It was each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.<BR/>Sexual Abuse: Non-consensual sexual contact of any type with a resident.<BR/>Reporting - Any person having reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, state and or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons.<BR/>Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriate of resident properly or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet criteria of Provider Letter 19-17 dated 07/10/19. <BR/>Investigation - Comprehensive investigations will be the responsibility of the administrator and or the Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated.<BR/>Record review of Resident #2's face sheet dated 02/13/24, revealed admission on [DATE] to the facility. <BR/>Record review of Resident #2's most recent facility history and physical in the system dated 12/21/20, revealed a [AGE] year-old female (present age [AGE] year-old) diagnosed with Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), Vascular Dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage, and cachexia (a complicated metabolic syndrome related to underlying illness and characterized by muscle mass loss with or without fat mass loss). <BR/>Record review of Resident #2's quarterly MDS dated [DATE], revealed a moderate impaired cognition BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 11 to be able to make daily decision and recall information. Resident #2 needed partial/moderate (half the help) assistance from nursing staff to help in showering/bathing. Resident #2 was diagnosed with Non-Alzheimer's Dementia, muscle wasting, lack of coordination, and muscle weakness (no muscle strength). <BR/>Record review of Resident #2's care plan dated 12/19/20, revealed for bathing she required two staff for assistances. Care plan dated 12/19/20 revealed impaired cognitive function or impaired thought processes due to Dementia. Engage the resident in simple, structed activities that avoid overly demanding tasks. Monitor/document/report to medical doctor any changes in cognitive function, specially changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding other, level of consciousness, mental status. <BR/>Record review of Resident #2's [NAME] (documentation on the facility system that CNAs use to view resident care) dated 02/17/24, revealed bathing: requires staff x2 for assistance. <BR/>Record review of Resident #2's shower report dated 02/02/24 at 8:16 PM and 02/09/24 at 5:57 PM, revealed CNA H had showered/bathed Resident #2. <BR/>Record review of CNA H's time sheet dated 02/02/24 and 02/09/24, revealed he had been working on Resident #2's shower days on Friday 02/02/24 and 02/09/24. Resident #2 showers on Mondays, Wednesdays and Fridays of every week. <BR/>Record review of Resident #2's Weekly Assessments, Event Note Assessments, all other Assessments dated 02/12/24, revealed, from 02/02/24 to 02/13/24 did not indicate any assessments were conducted for the sexual abuse/exploitation allegation of Resident #2. <BR/>Record review of Resident #2's Progress Notes dated 02/12/24 revealed, from 02/02/24 to 02/13/24, did not indicate any assessments were conducted or any information regarding the sexual abuse/exploitation allegation of Resident #2. <BR/>Record review and observation of text message provided to surveyor between LVN F, LVN E, and DON 02/02/24 at 5:17 PM read as follows: LVN F when you get a chance can you go talk to Resident #2, she told the Business Office Assistant that when CNA H or CNA O bath her they do something to her. <BR/>At 5:25 PM - LVN F stated, Yes I will.<BR/>At 5:28 PM - DON stated, thank you, let me know what she says. <BR/>At 6:08 PM - LVN F stated, Resident #2 says she feels CNA H touches her inappropriately when he's bathing her. <BR/>At 6:13 PM - DON stated, OMG (oh my god). <BR/>LVN F stated, Shouldn't the Social Worker and Administrator have interviewed Resident #2. I feel like that's serious allegations.<BR/>LVN E stated, Resident #2 says that when CNA H's washing her he washes her Parts and she feels him put his fingers inside of her. <BR/>DON - stated she would talk to her on Monday (unknown which Monday). <BR/>LVN F stated, No one came to help out. <BR/>Nothing else follows in the text message in regard to the sexual abuse/exploitation outcry from Resident #2. <BR/>During an interview on 02/12/24 at 4:42 PM, with LVN F, he stated that he had received a text message on 0202/24 from the DON revealing that Resident #2 was stating CNA H was touching her in her private parts during shower/bath time. LVN F stated he and LVN E went to go speak with Resident #2 on 02/02/24 after he received the text message from the DON; in which she told them that CNA H was touching her and would stick his fingers inside of her when he showered her and did not want CNA H to shower her anymore. LVN F stated he thought it was a serious allegation and thought the Administrator and Social Worker would be the ones to go interview Resident #2 regarding her allegation. <BR/>During an interview on 02/12/24 at 5:12 PM with LVN E, she stated the DON had sent LVN F a text message wanting for LVN F to go speak to Resident #2 about her allegation. LVN E stated that she went with LVN F to go talk to Resident #2 in which she stated that CNA H had touched her in her private parts. LVN E stated the DON and Administrator should have been the ones to go and interview Resident #2. LVN E stated Resident #2 claimed that CNA H would penetrate her through the shower chair and would go underneath the bottom of the shower chair. <BR/>During an interview on 02/13/24 at 1:00 PM with Resident #2, she stated she had reported to LVN F that Resident #2 had been touching her down there when CNA H showers her. Resident #2 stated CNA H will put on his music and dance while he showers her. Resident #2 stated she did not have strength and was weak to fight back against CNA H. Resident #2 stated this happened everytime CNA H would shower her. Resident #2 stated she did not want CNA H around her and did not feel safe around him. Resident #2 stated she had not reported at first due to feeling embarrassed. <BR/>During an interview on 02/13/24 at 1:35 PM with the DON, she stated that Resident #2 had made an outcry of sexual abuse/exploitation to the Business Office Assistant on 02/02/24. The DON stated the Business Office Assistant was told by Resident #2 that CNA H had touched Resident #2 in her private area. The DON stated she had instructed LVN F to go and speak with Resident #2 regarding the sexual abuse/exploitation outcry and report back to her what she had said. The DON stated she was still working on the investigation. The DON stated she had not done any assessments on Resident #2. The DON stated LVN E had done a body assessment for Resident #2, but it was not documented. The DON stated if it was not documented it did not happen. The DON stated she could not recall the exact date of Resident #2's sexual abuse/exploitation outcry. The DON stated she had not imputed anything into the computer. The DON stated there was no reason for the delay for not documenting and doing an assessment on Resident #2. The DON stated she would consider an outcry of sexual abuse/exploitation to be very important. The DON stated CNA H was not suspended and was still working at the facility and would not be able to answer why CNA H was not suspended. The DON stated CNA H was still working after the incident and there still existed a risk to the resident(s) of being sexually abuse/exploited. The DON stated it had not been reported to state survey agency and had no reason for the delay to notify state survey agency. The DON stated the Administrator was to report abuse and neglect allegations/incidents. The DON stated she had not reported it to the Administrator and said she had no explanation why she did not report it to her. <BR/>During an interview on 02/13/24 at 2:55 PM with the Administrator, she stated she was unaware of the alleged allegation from Resident #2 of sexual abuse/exploitation. The Administrator stated she was just notified right now of the sexual abuse/exploitation outcry for Resident #2 from LVN F. The Administrator stated she was told by LVN F that Resident #2 had alleged CNA H had touched her inappropriately. The Administrator stated LVN F told the DON about what Resident #2 had alleged. The Administrator stated she was not told by the DON what Resident #2 had alleged. The Administrator stated once an outcry of an allegation has been made, it needed to be reported to the Abuse Coordinator which was her. The Administrator stated she would take measures to talk to the resident and see what had happened as well as suspend the staff to ensure the safety of the Resident #2 until the conclusion of the investigation. The Administrator stated there could be a risk if the outcome was proven correct in that CNA H did do the sexual abuse/exploitation. The Administrator stated she had sent CNA H home immediately as soon as she found out. The Administrator stated she still needed to go speak to Resident #2. The Administrator stated she did not know if a body assessment was conducted for Resident #2. The Administrator stated she did not report it to state survey agency as she was not notified of the sexual abuse/exploitation allegation. The Administrator stated facility staff were trained on abuse, neglect, and exploitation and facility staff did not follow the facility abuse policy protocol for reporting. The Administrator stated it would have been protocol for the nurses to do a body assessment. <BR/>During an interview on 02/13/24 at 4:35 PM with the Social Worker, she stated she was just notified of the alleged allegation made of sexual abuse/exploitation from Resident #2 and was conducting interviews with the facility residents. The Social Worker stated Resident #2 had told her that she had reported CNA H. The Social Worker stated Resident #2 told her that CNA H touches her in her private parts and when he wipes her that he sticks his fingers in her. The Social Worker stated Resident #2 commented that CNA H puts on the music and begins to dance to it while he was showering her. The Social Worker stated Resident #2 had not reported it when it was happening because she felt embarrassed to report it and ashamed to tell her (family member). The Social Worker stated Resident #2 did not feel safe when CNA H was working at the facility. <BR/>During an interview on 02/16/24 at 2:08 PM with the Administrator, she stated that law enforcement was not notified on 02/02/24. The Administrator stated during the investigation a head-to-toe assessment of Resident #2 was done by LVN F and LVN E indicating no harm to Resident #2. The Administrator stated the facility only contacts the police if there was harm. The Administrator stated both LVN F and LVN E did the body assessment but was only verbally communicated but there was not documentation of the incident or assessment. <BR/>During an interview on 02/16/24 at 2:26 PM with LVN F, he stated he was never told to do a body assessment on Resident #2. LVN F stated there was no body assessment done on 02/02/24. LVN F stated he would have to have had a physician order or a directive from his DON to conduct the body assessment which there were none of. LVN F stated he was not trained or certified on assessing residents who claim sexual abuse/exploitation. LVN F stated he did not know what to look for. LVN F stated if he was looking for anything it would be bruises or marks on Resident #2. LVN F stated he recommended for Resident #2 to have been sent out to the hospital to have a rape kit done. LVN F stated on 02/13/24 he was told to go assess Resident #2. <BR/>During an interview on 02/16/24 at 2:39 PM with LVN E, she stated she was never told to do a head-to-toe body assessment on Resident #2 on 02/02/24. LVN E stated she quickly checked Resident #2's thigh and opened up her brief to see if there was any bruises or marks but did not know what to look for as she was not trained or certified to conduct a sexual assessment on a resident. LVN E stated when a resident claims sexual abuse/exploitation that they were sent out to the hospital to go get checked out. LVN E stated on 02/13/24, she was directed to go assess Resident #2. <BR/>During an interview on 02/17/24 at 5:02 PM with the Regional Nurse, she stated the facility nurses were not trained or certified to do sexual assessments but could assess the resident externally to see if there was any bruises or markings. <BR/>Record review of the facility's Documentation policy and procedure manual dated 2003 revealed, Documentation was the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has a legal requirement regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessments, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets weekly, daily, monthly, discharge).<BR/>Goal- The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. <BR/>The facility will ensure that information was comprehensive and timely and properly signed. <BR/>Document completed assessments in a timely manner and per policy. <BR/>Complete documentation in narrative nursing notes as needed in a timely manner.<BR/>Daily documentation x72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability.<BR/>Record review of the facility Event Reporting: Completion Of (Regional Nurse stated this was the facility's accident policy) policy and procedure not dated revealed, Investigation: The investigation should be completed by the DON/Administrator or designee. The investigation report documents a though investigation of the events of the reported Event including person, equipment, and materials that were involved. The investigation report must include what actions were taken to prevent subsequent Events and signatures of the individuals as indicated on the form.<BR/>The facility will complete an Event report on variances that occur with the facility. Variances include falls, skin tears, bruises, abrasions, lacerations, fractures, choking, burns, elopement, or behavior that affects others. <BR/>Record review of the facility Bath, Tub/Shower policy and procedures dated 2003, revealed, The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level.<BR/>The resident will experience improved comfort and cleanliness by bathing.<BR/>Become familiar with type and pattern of bathing, assistance or aids needed, skin condition, presence of dress or casts.<BR/>Remain with the resident if he was weak or assistance was needed in washing. <BR/>The Administrator and DON were informed on 02/16/24 at 3:01 PM, that an Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested.<BR/>02/16/24 at 5:19 PM - Area Director of operations submitted 1st Plan of Removal.<BR/>02/16/24 at 6:27 PM - Facility was notified of the 1st denied Plan of Removal.<BR/>02/16/24 at 7:51 PM - Administrator submitted 2nd Plan of Removal.<BR/>02/17/24 at 11:12 AM - Facility notified of 2nd denied Plan of Removal. <BR/>02/17/24 at 11:50 AM - Administrator was notified of approved Plan of Removal.<BR/>The Plan of Removal revealed the facility took the following actions: <BR/>Interventions:<BR/>One on One in-service on Abuse Reporting with the Administrator, DON, and Social Worker by Area Director of Operation on 2/13/2024 at 4:30 pm <BR/>Staff working with Alleged perpetrators have been interviewed by ADO. The resident is doing ok; no distress was noted, and the resident was able to voice concerns. <BR/>The alleged perpetrator was suspended on 2/13/2024 at 4:30 pm, pending the outcome of the investigation. Investigation completed on 2/14/2024.<BR/>Resident safety surveys were initiated by the social worker on 2/13/2024, and no abuse incidents have been reported. Completion date of 2/13/2024 <BR/>DON was suspended on 2/16/24 at 4:30 pm, pending the outcome of the investigation. <BR/>The following in-services were initiated on 2/13/2024 by Administrator/ADO: Any staff member not present or in-service on 2/13/2024 will not be allowed to assume their duties until in-service.<BR/>o <BR/>All Staff<BR/>Abuse/Neglect<BR/>Abuse/Neglect Reporting<BR/>Who to Report Abuse/Neglect to<BR/>All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report. Completion date 2/17/2024<BR/>o <BR/>The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services.<BR/>New staff will be in service during orientation. <BR/>Any employees who are allegedly involved in any abuse will be suspended pending investigation.<BR/>The medical director was notified of the immediate jeopardy situation on 2/16/2024 at 4:40. <BR/>Monitoring<BR/>The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review.<BR/>The administrator will submit documentation of the investigation with Resident and Staff interviews, as well as weekly follow-up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with the outcome of the investigation.<BR/>The Area Director will monitor abuse allegations reported and check the real-time system, which monitors keywords like abuse x 4 weeks' documentation and PCC for any incidents and accidents.<BR/>The QA committee will review findings of abuse allegations and investigations monthly and make changes to the system as needed.<BR/>On 02/17/24 at 11:55 AM Verification phase began with the facility approved Plan of Removal. <BR/>During an interview on 02/17/24 at 11:57 AM with the Administrator and Area Director of Operations, the Area director of Operations stated on 02/13/24 at 4:30 PM she had already in-serviced the Administrator, DON, and Social Worker regarding Abuse Reporting. The Administrator stated on 02/13/24 at 4:30 PM CNA H was suspended pending the outcome of the investigation for Resident #2. The Area Director of Operations stated on 02/16/24 at 4:30 PM the DON was suspended pending the outcome of the investigation. The Area Director of Operations stated the facility had completed the investigation on 02/14/24, for Resident #2 and was found to be unconfirmed. The Administrator stated on 02/13/24 a Safety Survey of the residents was conducted by the Social Worker and found no abuse incidents had been reported by the residents. The Administrator stated the facility was moving forward with termination of CNA H with unrelated issues to the alleged allegation. The Administrator stated Resident #2 stated she was doing fine, able to voice concerns, and no distress was noted. The Administrator and Area Director of Operations stated on 02/13/24 an in-service was initiated by both Administrator and Area Director of Operations for Abuse/Neglect, Abuse/Neglect Reporting, and Who to report Abuse/Neglect too. The Administrator stated facility staff not present, during the in-service will not be allowed to resume their duties until in-serviced. The Administrator stated on 02/17/24 all in-services provided to facility staff had to be communicate back to the presenter acknowledging they understood what was being in-serviced on. The Administrator stated quizzes were given and examples had to be provided by the in-service-e confirming understanding of the material. The Administrator stated new employees would be in-serviced on during orientation. The Administrator stated all alleged employees involved in an allegation will be suspended pending the outcome of the investigation. <BR/>The Area Director of Operation stated on 02/16/24 at 4:40 PM the Medical Director was notified of the Immediate Jeopardy, commenting that the facility will have to get better. The Area Director of Operation stated the Administrator was to report any and all allegations of abuse and submit all documentation for investigations conducted which would be reviewed by Area Director of Operations and Risk Management. The Area Director of Operations stated the Administrator was also to submit interviews with staff and residents related to investigations four times a week to ensure safety/satisfaction outcomes. The Area Director of Operations stated the facility system will be checked for key words like abuse four times a week for incidents or accidents that might have happened or have been documented. The Administrator stated an off-cycle Quality Assurance meeting was held on 02/16/24 at 5:00 PM, regarding the Immediate Jeopardy and follow ups will be held monthly to see if adjustments are needed to abuse allegations and investigations. <BR/>During an interview on 02/17/24 at 12:42 PM with LVN P, he stated, he had received an in-service on abuse. LVN P stated that any kind abuse had to be reported to the Administrator immediately. LVN P stated during the in-service it was talked about the 5 different types of abuses such as emotional, verbal, physical, sexual, and financial abuse to include injuries of unknown origin. LVN P stated that the in-servicer did test his knowledge on the material by asking him questions and giving him a quiz on it. <BR/>During an interview on 02/17/24 at 12:48 PM with LVN Q, he stated, he received an in-service on abuse and neglect. LVN Q stated as soon as an alleged allegation was made or suspect, it must be reported immediately to the Administrator. LVN Q stated he was asked questions about the in-service he had received and had to answer them. <BR/>During an interview on 02/17/24 at 12:42 PM with LVN I, she stated, she had received several in-services such as abuse. LVN I stated she was told of the different types of abuses and if she saw or suspected abuse happening who to report it to. LVN I stated she had to report abuse to the Administrator who was the Abuse Coordinator. LVN I stated she was questioned on the in-service like it was a test. <BR/>During an interview on 02/17/24 at 1:15 PM with MA R, she stated, she was in-serviced on abuse and neglect. MA R stated any suspected or seen abuse had to be report to the Abuse Coordinator which was the Administrator. MA R stated she was questioned on what was in-serviced.<BR/>During an interview on 02/17/24 at 1:23 PM with ADON G, she stated, she had received an in-service regarding abuse and neglect. ADON G stated they told her what constitutes abuse and neglect and who to report it to. ADON G stated abuse was reported to the Administrator immediately. ADON G stated she was questioned over the in-service(s) of abuse to check her knowledge. <BR/>During an interview on 02/17/24 at 1:31 PM with CNA T, she stated, an in-service of abuse was given to her. CNA T stated it entailed what abuse was and the different types. CNA T stated she was questioned over the material being presented. CNA T stated any kind of abuse had to be reported immediately to the Administrator. <BR/>During an interview on 02/17/24 at 1:43 PM with CNA U, she stated, she was in-serviced on abuse regarding the different types of abuse. CNA U stated staff were to report if someone talks bad or physically hits a resident. bad or physically hits them. CNA U stated it had to be reported to the Administrator. CNA U stated she had received a quiz on the in-service. <BR/>During an interview on 02/17/24 at 1:52 PM with LVN V, she stated, she had received an in-service on abuse and neglect on 02/16/24. LVN V stated to report anything the facility staff felt was abuse and who to report it to. LVN V stated it was to be reported to the Abuse Coordinator which was the Administrator. LVN V stated she was asked questions about what they felt it was reportable and why. <BR/>Record review of the facility Monitoring Tools dated 02/17/24, revealed, the following:<BR/>In-Services - The Administrator will audit all new employee filles to ensure in-services are being completed.<BR/>Ensure Quizzes are being completed - Administrator will gather quiz sheet 3 per day. <BR/>Record review of the facility In-services dated 02/13/24, 02/14/24, 02/16/24 revealed, the following:<BR/>Abuse Reporting/Investigation<BR/>Abuse and Neglect<BR/>After the Plan or Removal and Monitoring: The Administrator was informed the Immediate Jeopardy was removed on 02/17/24 at 3:35 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor it's plan for effectiveness.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an alleged violation of injury of unknown origin immediately to the administrator of the facility and to other officials (including to state survey agency) in accordance with State law and according to their policy for 1 (Resident # 13) of 2 residents reviewed for allegations of injury with unknown origin. <BR/>The facility failed to report Resident #13 ' s injury of unknown origin related to her dislocated jaw to State Office. <BR/>This failure could place all residents at risk for abuse and/or neglect by not immediately reporting allegations of injuries of unknown origin to the proper authorities at the facility. <BR/>Findings Include: <BR/>Resident #13 <BR/>Record review of Resident #13 ' s face sheet dated 01/18/2024 revealed an [AGE] year-old female who was admitted on [DATE]. <BR/>Record review of Resident #13 ' s history and physical dated 06/08/2023 revealed admitting diagnoses of debility (weakness caused by an illness, injury, or aging) post observation and isolation due to exposure to coronavirus complicated by underlying dementia and chronic comorbidities. <BR/>Record review of Resident #13 ' s quarterly MDS dated [DATE] revealed a BIMS score of 04, she was severely cognitive impaired and required extensive assistance with one-person physical assist for eating. <BR/>Record review of Resident #13 ' s care plan last reviewed on 12/12/23 revealed focus area for ADL self-care performance deficit related to limited mobility with interventions for eating that requires staff participation. <BR/>Record review of Resident #13 ' s SBAR dated 12/31/23 revealed noticed patient with poor appetite, she needs frequent monitoring to make her increase her fluid and meal intake. This was noticed on 12/26/23. Patient was diagnosed with URI she has been on antibiotics. MD was notified and new orders were continue monitoring and encouraging fluids. Resident #13 was her own responsible party. <BR/>Record review of Resident 13 ' s transfer form dated 01/01/2024 revealed she was transferred to hospital. The document did not give reason for transfer. <BR/>Record review of Resident #13 ' s progress note written by LVN A dated 01/01/2024 revealed Resident ' s mouth remained opened without ability to shut or speak. Resident is DNR though writer was concerned with change in condition. Resident was sent to local emergency room for evaluation. <BR/>Record review of Resident #13 ' s local hospital discharge summary report dated 01/18/2024 revealed admission information: Resident #13 presenting with decreasing oral intake of fluids and evidence of urinary tract infection with sepsis (the body's extreme response to an infection). However, in addition of the above the patient has been found after being admitted to the hospital that she has a spontaneous dislocation of the jaw which apparently was the cause of her difficulty to have adequate oral intake of fluids and food. <BR/>During an interview om 01/18/2024 at 9:43 am, Hospital Staff stated Resident #13 was transferred to the hospital with concerns of low blood pressure and low oxygen saturation level. Hospital Staff stated the facility did not notify the hospital of Resident #13 inability to close her jaw and was concerned. Hospital Staff stated they identified Resident #13 dislocated jaw shortly after she was admitted for treatment. <BR/>During an interview on 01/18/2024 at 10:12 am, DON stated she had been notified by LVN A that she was sending out Resident #13 to the hospital for further evaluation due to being lethargic, altered mental status and low oxygen saturation level. The DON stated the facility does follow up with local hospital for updates. The DON stated she received referral paperwork on January 10th where she read Resident #10 had a dislocated jaw and was pending surgery for g-tube for feeding. The DON stated she was concerned on the dislocation of the jaw and asked the nurses and CNAs to follow up on any bruising and determine if Resident #12 had a recent fall that may had contributed. The DON stated Resident #13 had a decrease in appetite and was reported to MD, they thought it was a decline due to coronavirus infection. The DON stated the facility continued to monitor and after she talked to staff, she was not able to determine a possible cause for Resident #13 dislocation of jaw. The DON stated she assumed the dislocated jaw occurred while she was at the hospital but did not call the hospital to question the charge nurses. The DON stated it would be considered an injury of unknown origin and was not sure if she had to report to State Office due to the dislocated jaw found at the hospital. <BR/>During an interview on 01/18/2024 at 11:05 am, Regional Compliance Nurse stated she was notified by the DON that Resident #13 had been sent out for further evaluation after a change in condition was later told about her dislocated jaw. Regional Compliance Nurse stated she asked the DON if Resident #13 had sustained a recent fall, if she followed up with staff to check if they noticed bruising or anything out the normal on her face in which she (DON) stated no evidence of recent falls, bruising or abnormalities to face noticed. Regional Compliance Nurse stated it was expected for DON to had followed up with hospital to verify if Resident #13 had been admitted with the dislocated jaw, if she had been and the facility did not identify a source of cause the dislocated jaw would be considered an injury of unknown origin. Regional Compliance Nurse stated the dislocated jaw should had been reported to State Office. <BR/>Record review of the facility Abuse/Neglect policy dated 03/29/18 revealed, The facility will provide and ensure the promotion and protection of resident rights. It was each individuals ' responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. <BR/>Reporting &ndash; Any person having reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, State and or Adult Protective Services. Stated law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. <BR/>Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility Administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 07/10/19. <BR/>If the allegations involve abuse or result in serious bodily injury, the report was to be made within 2 hours of the allegation. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all alleged violations involving abuse, neglect, and exploitation and injuries of unknown origin were thoroughly investigated for 1 (Resident #13 ) of 5 residents reviewed for abuse and neglect. <BR/>The facility did not thoroughly investigate Resident #13 ' s injury of unknown origins. <BR/>This failure could place residents at risk for abuse, neglect, and decreased quality of life. <BR/>Findings include: <BR/>Record review of Resident #13 ' s face sheet dated 01/18/2024 revealed an [AGE] year-old female who was admitted on [DATE]. <BR/>Record review of Resident #13 ' s history and physical dated 06/08/2023 revealed admitting diagnoses of debility post been seen under observation and isolation due to exposure to coronavirus complicated by underlying dementia and chronic comorbidities. <BR/>Record review of Resident #13 ' s quarterly MDS dated [DATE] revealed a BIMS score of 04, she was severely cognitive impaired. Required extensive assistance with one-person physical assist for eating. <BR/>Record review of Resident #13 ' s care plan last reviewed on 12/12/23 revealed focus area for ADL self-care performance deficit related to limited mobility with interventions for eating that requires staff participation. <BR/>Record review of Resident #13 ' s SBAR dated 12/31/23 revealed noticed patient with poor appetite, she needs frequent monitoring to make her increase her fluid and meal intake. This was noticed on 12/26/23. Patient was diagnosed with URI she has been on antibiotics. MD was notified and new orders were continue monitoring and encouraging fluids. Resident #13 was her own responsible party. <BR/>Record review of Resident 13 ' s transfer form dated 01/01/2024 revealed she was transferred to hospital. The form did not specify reason for transfer. <BR/>Record review of Resident #13 ' s progress note written by LVN A dated 01/01/2024 revealed Resident ' s mouth remained opened without ability to shut or speak. Resident is DNR though writer was concerned with change in condition. Resident was sent to local emergency room for evaluation. <BR/>Record review of Resident #13 ' s local hospital discharge summary report dated 01/18/2024 revealed admission information: Resident #13 presenting with decreasing oral intake of fluids and evidence of urinary tract infection with sepsis. However, in addition of the above the patient has been found after being admitted to the hospital that she has a spontaneous dislocation of the jaw which apparently was the cause of her difficulty to have adequate oral intake of fluids and food. <BR/>During an interview om 01/18/2024 at 9:43 am, Hospital Staff stated Resident #13 was transferred to the hospital with concerns of low blood pressure and low oxygen saturation level. Hospital Staff stated the facility did not notify the hospital of Resident #13 inability to close her jaw and was concerned. Hospital Staff stated they identified Resident #13 dislocated jaw shortly after she was admitted for treatment. <BR/>During an interview on 01/18/2024 at 10:12 am, DON stated she had been notified by LVN A that she was sending out Resident #13 to the hospital for further evaluation due to lethargic, altered mental status and low oxygen saturation level. The DON stated the facility does follow up with local hospital for updates. The DON stated she received referral paperwork on January 10th where she read Resident #10 had a dislocated jaw and was pending surgery for g-tube for feeding. The DON stated she was concerned on the dislocation of the jaw and asked the nurses and CNAs to follow up on any bruising and determine if Resident #13 had a recent fall that may had contributed. The DON stated Resident #13 had a decrease in appetite and was reported to MD, they thought it was a decline due to coronavirus infection. The DON stated the facility continued to monitor and after she talked to staff, she was not able to determine a possible cause for Resident #13 dislocation of jaw. The DON stated she assumed the dislocated jaw occurred while she was at the hospital but did not call the hospital to question the charge nurses to gather information on findings. The DON although she was able to rule out abuse and neglect, no in-service was provided to the facility staff. The DON stated she did not document her internal investigation related to Resident #13 dislocated jaw, and did not give reason for not documenting. The DON stated risks included residents still being at risk for abuse and neglect. The DON stated she should had followed up with hospital staff to gather details on incident and should had in-service the staff on abuse and neglect. <BR/>During an interview on 01/18/2024 at 11:05 am, Regional Compliance Nurse stated she was notified by DON that Resident #13 had been sent out for further evaluation after a change in condition was later told about her dislocated jaw. Regional Compliance Nurse stated she asked DON if Resident #13 had sustained a recent fall, if she followed up with staff to check if they noticed bruising or anything out the normal on her face in which she (DON) stated no evidence of recent falls, bruising or abnormalities to face noticed. Regional Compliance Nurse stated it was expected for DON to had followed up with hospital to verify if Resident #13 had been admitted with the dislocated jaw, if she had been and the facility did not identify a source of cause the dislocated jaw would be considered an injury of unknown origin. Regional Compliance Nurse stated it was expected for DON to do an in-service on abuse and neglect or even fall prevention to address the incident in hopes of preventing similar incident to re-occur. <BR/>During an interview on 01/18/2024 at 11:49 am, MD stated he treated Resident #13 at the hospital when she was sent out for further evaluation. MD stated he had treated Resident #13 for several years. MD stated the facility would had not known the cause for Resident #13 dislocated jaw. MD stated when he assessed Resident #13 at the hospital and noticed she could not close her mouth and had difficulty speaking and did not see evidence of forced trauma to location. MD stated the facility could had asked him for update and he would had notified them that Resident #13 dislocated jaw could have been a slow process related her socket in jaw. MD stated while Resident #13 was in the hospital the staff were able to place her jaw back in place but was dropped shortly after. MD stated Resident #13 required surgery to keep jaw in place. <BR/>During an interview on 01/19/2024 at 10:47 am, LVN A stated she was the nurse in charge who sent out Resident #13 to hospital for further evaluation. LVN A stated Resident #13 had already been on close monitoring due to decrease in appetite, she had a urinary infection and had recently recovered from coronavirus as well. LVN A stated the morning Resident #13 was sent out to the hospital, she was in her bed and would not answer any questions. LVN A stated this was unusual for Resident #13 and noticed she was not able to speak and close her mouth completely. LVN A stated she noticed the change around 8 am, and she had started shift at 6 am and did not have her mouth open like that. LVN A stated she decided to send Resident #13 out for further evaluation to be assessed and notified, MD, and family for courtesy since Resident #13 was her own responsible party. <BR/>Record review of the facility Abuse/Neglect policy dated 03/29/18 revealed, The facility will provide and ensure the promotion and protection of resident rights. It was each individuals ' responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. <BR/>Investigation - Comprehensive investigations will be the responsibility of the administrator and or abuse preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. <BR/>The Abuse Preventionist and or Administrator will conduct a thorough investigation of the incident(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that resident assessments were accurate for 3 (Resident #88, Resident #196, and Resident #198) of 5 residents reviewed for accuracy of resident assessments. <BR/>The facility failed to accurately identify the need for oxygen therapy for Resident #88 admission MDS dated [DATE] and Resident #196 ' s admission MDS dated [DATE]. <BR/>The facility failed to accurately identify the need for intervenors therapy for Resident #198 ' s admission MDS dated [DATE]. <BR/>This deficient practice could place residents at risk of not receiving a completed initial assessment which could result in necessary care and services based on their individually assessed needs. <BR/>Findings included: <BR/>Resident #88 <BR/>Record review of Resident #88 ' s face sheet dated 05/29/24, revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #88 ' s facility history and physical dated 03/22/24, revealed a [AGE] year-old male diagnosed with tongue and thyroid cancer and alcohol cirrhosis. <BR/>Record review of Resident #88 ' s admission MDS dated [DATE], revealed a severely impaired cognition to be able to recall or make daily decision with a BIMS (tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 5. Resident #88 was diagnosed with cancer, muscle weakness (no muscle strength), and adult failure to thrive. Does not include that Resident #88 has trouble with shortness of breath. The MDS was not marked for oxygen therapy. <BR/>Record review of Resident #88 ' s order recap dated 05/01/24, revealed oxygen via nasal cannula at 2 liters per minute via nasal cannula continuously every shift. <BR/>Record review of Resident # ' s care plan dated 05/13/24, revealed oxygen therapy related to shortness of breath. Oxygen at blank (the amount of oxygen was not added and left blank) liters per minute per nasal cannula. <BR/>Observation on 05/28/24 at 8:18 PM, the oxygen concentrator was running in Resident #88 ' s room and could be heard outside in the hallway. No Oxygen Sign was put up outside of Resident #88 ' s room. <BR/>Observation and interview on 05/28/24 at 8:39 AM, Resident #88 was sitting down on her wheelchair eating breakfast. Resident #88 was wearing a nasal cannula with the concentrator on. Resident #88 stated she was on oxygen and needed it to breathe. <BR/>Resident #196 <BR/>Record review of Resident #196 ' s face sheet dated 05/29/24, revealed admission on [DATE] to the facility. Resident #196 was a [AGE] year-old female diagnosed with acute respiratory failure with hypoxia (a condition where you don ' t have enough oxygen in the tissues in your body). <BR/>Record review of Resident #196 ' s admission MDS dated [DATE], revealed an intact cognition to be able to recall or make daily decisions with a BIMS (tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 15. Resident #196 was diagnosed with respiratory failure. Shortness of breath and oxygen therapy were not marked on the MDS. <BR/>Record review of Resident #196 ' s order recap dated 05/23/24, revealed may use oxygen at 2 liters per minute via nasal cannula for oxygen saturations greater than 90 percent. May attempt to wean off oxygen every shift. <BR/>Record review of Resident #196 ' s care plan dated 05/24/24, revealed oxygen therapy. Oxygen at blank (it was left blank) liters per minute per nasal cannula. Resident #196 has shortness of breath. Notify the charge nurse if the resident was having trouble breathing. <BR/>Observation on 05/28/24 at 8:17 AM, the oxygen concentrator was running in Resident #196 ' s room and could be heard outside in the hallway. No Oxygen Sign was put up outside of Resident #196 ' s room. <BR/>During an interview on 05/28/24 at 8:37 AM, with Resident #196, he stated he was on oxygen and had to use it. <BR/>Resident # 198 <BR/>Record review of Resident #198 ' s face sheet dated 05/29/24, revealed admission on [DATE] to the facility. <BR/>Record review of Resident #198 ' s hospital history and physical dated 05/14/24, revealed a 67-year -old male diagnosed with Diabetes, End-stage renal disease, and chronic right foot wounds. <BR/>Record review of Resident #198 ' s admission MDS dated [DATE], revealed a moderately impaired cognition to be able to recall or make daily decisions with a BIMS (tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 12Resident #198 was diagnosed with Diabetes. The MDS was not marked for IV Medications. <BR/>Record review of Resident #198 ' s order recap dated 05/23/24, revealed ceftriaxone sodium intravenous solution. Use 1 gram intravenously one time a day for osteomyelitis for 3 weeks. <BR/>Record review of Resident #198 ' s care plan dated 05/24/24, revealed antibiotic therapy related to infection osteomyelitis. Administer medication as ordered. <BR/>Observation and interview on 05/28/24 at 9:07 AM, Resident #198 was in his room sitting down on the bed. Resident #198 had an IV with dressing on his right inner arm dated 05/24/24. Resident #198 stated he was on antibiotics and was getting them through the IV line. <BR/>During an interview on 05/31/24 at 01:50 PM, with the MDS Coordinator, he stated the MDS department used nursing and CNA's information to generate the MDS for each resident. The MDS Coordinator stated anytime something happens with a resident the MDS assessment will be updated as needed. The MDS Coordinator stated if the resident was on oxygen, then it does need to be reflected in the MDS assessment. The MDS Coordinator stated residents with intravenous lines also need to be reported into the MDS assessment. The MDS Coordinator stated it was the responsibility of nursing to add them. The MDS coordinator stated there was no negative outcome, because when someone was admitted they were treating the resident for a baseline care and as the resident resides more in the facility the care plan will be updated. <BR/>Record review of the facility Resident Assessment policy dated 2003, revealed, Comprehensive assessment will be completed with 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument. <BR/>The assessment will include - Special treatments or procedures. <BR/>The results of the assessment are used to develop, review, and revise the resident's comprehensive plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to provide the necessary services to maintain good grooming and personal hygiene care for 4 (Resident #83, Resident #5, Resident #66 and Resident #18) of 5 residents reviewed for ADL care. <BR/>Resident #18 did not have her brief changed on a timely basis and was not turned as needed. <BR/>The facility failed to ensure facility staff provided showers, personal grooming for Resident #83, Resident #5, and Resident #14. <BR/>This failure could place residents at risk of not receiving assistance with personal care which could cause pain, skin breakdown, and low self-esteem. <BR/>Findings Included: <BR/>Resident #83 <BR/>Record review of Resident #83's Face Sheet admission date was 11/21/2022 at the facility. <BR/>Record review of Resident #83's History and Physical dated 11/22/2022 indicates Resident #83 was a [AGE] year-old female who had a diagnosis of End Stage Renal Disease, hypertension, Type 2 diabetes, and osteomyelitis. <BR/>Record review of Resident #83's MDS Quarterly dated 02/27/23 documented a BIMS score of 14 indicating no cognitive impairments. It also demonstrated she was extensive assistance with two-person assistance with ADLs including personal hygiene. It was also indicated bathing as total dependence with one person assistance. <BR/>Record review of Resident #83's Comprehensive Care Plan dated 03/17/2023 documented resident had ADL self-care in which she will maintain or improve current level of function with personal hygiene. Will need two-person assistance with bathing and did not indicate how often resident was to be showered/bathed. <BR/>Record review of Resident #83's Task Response History for bathing support provided - from 02/26/23 to 03/27/23, revealed 7 showers with one-person physical assist have only been conducted for that provided time period and the rest is marked as ADL activity itself did not occur. Task Response History for type of bath for 02/26/23 shown x15 did not occur. <BR/>Record review of Resident #83's Schedule for March 2023 provided by the facility demonstrates Resident #83 as having QShift bathing. It shows Resident #83 was showered every day from 03/01/23 to 03/28/23 with PRN bathing (x11) when resident had not showered for 15 days in the month. <BR/>Record review of Resident #83's Survey Report for March 2023, for bathing revealed (x19) 8.8s which indicates Total Dependence - Activity itself did not occur. <BR/>Record review of facility shower list for the east wing for four different days which two are undated (other 03/22/23, 03/20/23, 03/19/23) revealed Resident #83 was not showered two times as there was no CNA initials. CNAs are to initial after showering the resident had been completed.<BR/>Observation on 03/26/2023 at 8:30 a.m., Resident #83 was lying in bed in a gown face shiny with oil, hair was uncombed. <BR/>Interview on 03/28/23 at 4:40 PM ADON F stated he looked at Resident #83's orders, progress notes, and the MDS Survey Report for bathing. ADON F stated it was marked with an 8 which indicates the bathing/showers did not occur. ADON F stated the risk to the Resident #83 would be false documentation, skin issues, hygiene, and infection. <BR/>Interview on 03/28/23 at 4:45 PM ADON B stated the facility uses the facility shower list were CNAs initial for accountability in the CNA Assignment Book. <BR/>Interview on 03/29/23 at 9:28 AM MDS B stated the Survey Report for March 2023 for Resident #83 reveals the dated and times resident was showered or not revealed Resident #83 was not showered. <BR/>Interview and record review on 03/29/23 at 9:30 AM with MDS A and MDS B both stated if the date was marked with an 8 on the survey report, then it indicated that the resident was not showered for the day. MDS A stated resident was not showered. MDS B stated the showering schedule needed to be put into the care plan for Resident #83 which it was not in his care plan. MDS B stated the care plan did not mention anything about the shower schedule. MDS B stated the risk to not showering would be their dignity and infection. <BR/>Resident #5 <BR/>Record review of Resident #5's Face Sheet admission date was 06/15/2005 and was readmitted on [DATE] at the facility. <BR/>Record review of Resident #5's History and Physical dated 08/19/2021 indicates Resident #5 was a [AGE] year-old female with a diagnosis dementia with behavioral disturbances and Alzheimer's with delusional psychotic features. <BR/>Record review of Resident #5's MDS Quarterly dated 03/14/2023 documented a BIMS score of 3 and was left unmarked on her cognitive impairment or independence. It also demonstrated Resident #5's ADLs was extensive assistance one person assistance with personal hygiene, dressing, and bathing (physical help). It also documents a diagnosis of schizophrenia, Alzheimer's disease, non-Alzheimer's dementia, is at risk for pressure ulcers. <BR/>Record review of Resident #5's Comprehensive Care Plan dated 02/24/2023 indicated ADLs self-care will maintain current level of function with one person assistance with dressing and personal hygiene/oral with one person participation with bathing in the care plan. <BR/>Record review of Resident #5's Schedule for March 2023 provided by the facility demonstrates Resident #5 as having Q-Shift bathing as T-TH-SAT with PRN bathing (x11) for showering/bathing. <BR/>Record review of facility shower list for the east wing for four different days which two are undated (other 03/22/23, 03/20/23, 03/19/23) revealed Resident #5 was not showered two times as there was no CNA initials. CNAs are to initial after showering the resident had been completed. <BR/>Interview on 03/28/23 at 4:45 PM ADON B stated the facility uses the facility shower list were CNAs initial for accountability in the CNA Assignment Book. <BR/>Interview on 03/29/23 at 9:28 AM MDS B stated the Survey Report for March 2023 for Resident #5 revealed the dates and times resident was showered or not revealed Resident #5 was not showered. <BR/>Observation on 03/29/23 at 9:29 AM MDS B review the MDS Survey Report for March 2023 for Resident #5. <BR/>Observation on 3/26/23 at 4:37 PM revealed Resident #5 hair was not combed and was disheveled. <BR/>Observation on 3/27/23 at 12:14 PM revealed Resident #5 hair was not combed and was disheveled. <BR/>Observation on 3/27/23 at 4:01 PM revealed Resident #5 hair was not combed and was disheveled. <BR/>Observation on 3/28/23 at 10:09 AM revealed Resident #5 hair was not combed and was disheveled. <BR/>Interview on 03/29/23 at 9:30 AM with MDS A and MDS B both stated if the date was marked with an 8 then it indicated that the resident was not showered for the day. MDS B stated he had not been showered. MDS B stated the showering schedule needed to be put into the care plan and on PCC for Resident #5. MDS B stated the care plan did not mention anything about the shower schedule in the care plan. MDS B stated the risk to not showering would be their dignity and infection. <BR/>Resident #66 <BR/>Record Review of Resident #66 Face Sheet dated 3/27/23 documented in part a [AGE] year-old male, admitted on [DATE]. <BR/>Record Review of Resident#66 Quarterly MDS dated [DATE] documented Resident #66 had a BIMS of 6 indicating he was severely cognitively impaired. Resident #66 required extensive assistance with one person assistance for personal hygiene, and dressing. Resident #66 is wheelchair-bound and requires total dependence for bathing with one person's assistance. Section I revealed active diagnosis of abnormalities of gait and mobility and lack of coordination. <BR/>Record Review of Care Plan dated 4/18/21 documented Resident #66 had an ADL self-care performance deficit. Resident #66 required assistance with personal hygiene, and bathing and did not indicate a shower schedule. <BR/>Record Review of Resident #66 March bathing task scheduled record indicated Resident #66 only received 6 baths and all other days were marked as this activity did not occur indicating Resident #66 was not showered. <BR/>Interview with Resident #66 on 3/26/23 at 02:59 PM revealed he was not getting his showers as scheduled. Resident #66 stated, they are times when I get maybe 2 showers a week and I know I am scheduled to receive 3 baths per week. <BR/>Resident #18 <BR/>Record review of Resident #18's admission MDS dated [DATE] documented that she was [AGE] years old and was admitted to the facility on [DATE]. Her diagnoses included a broken lower left leg (displaced comminuted fracture of shaft of left tibia). Her BIMS was 13 (cognitively intact). She needed extensive assistance from one person to dress and perform personal hygiene. She did not walk and did not move around the facility during the lookback period. She was totally dependent on one staff member for baths. She required extensive assistance from two people to move around in bed, to transfer between surfaces, and to use the toilet. She was always incontinent of bowel and bladder. She was at risk of developing pressure ulcers. <BR/>In an interview on 03/26/23 at 10:15 AM Resident #18 stated that when she turned on her call light because she had urinated and needed a brief change, staff members did not come for a long time. She was unable to specify how long it took. She said that most of the time it took them too long. She also said she had diarrhea a few weeks back and she had to wait a long time for staff to change her soiled brief. <BR/>In an interview on 03/27/23 at 10:28 AM Resident #18 stated that she had to wait a long time to get changed. She was not able to remember any particular dates or times. She stated that the only time NAs came to check on her was when she turned on the light and that the only times they turned her was when they changed the wound dressing on her back, which was every other day. <BR/>Record review of Resident #18's Point of Care Response History for 02/28/2023 - 03/28/2023 documented that she was not turned on any shift on two days and turned only once on four days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide the necessary treatment and services based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries for 1 (Resident #198) of 3 residents reviewed for pressure ulcers. <BR/>LVN E failed to notify the Wound Care Nurse that Resident #198 ' s dressing for his right heel and calf was not placed according to physician orders exposing the unstageable right heel. <BR/>This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health. <BR/>Findings included: <BR/>Record review of Resident #198 ' s face sheet dated 05/29/24, revealed an admission on [DATE] to the facility. <BR/>Record review of Resident #198 ' s hospital history and physical dated 05/14/24, revealed a 67-year &ndash;old male diagnosed with Diabetes, End-stage renal disease, and chronic right foot wounds. <BR/>Record review of Resident #198 ' s admission MDS dated [DATE], revealed a moderately impaired cognition with a BIMS (tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 12. Resident #198 was diagnosed with Diabetes. <BR/>Record review of Resident #198 ' s order recap dated 05/22/24, revealed, Santyl external ointment 250 unit/grams. Phone - apply 1 application trans-dermally every shift related to pressure ulcer of right heel, unstageable. Hydrophera blue foam dressing over wound bed after applying Santyl and cover with bordered gauze dressing once a day and as needed. <BR/>Record review of Resident #198 ' s care plan dated 05/21/24, revealed, Pressure ulcers to the lower right calf-unstageable and right heel unstageable. Ensure heels are floats with pillows, requires cushion to their wheelchair or geri-chair. There was no intervention to administer order as prescribed by physician. Care planned dated 05/21/24, revealed, had diabetes mellitus. Nurse to monitor foot care needs. <BR/>Observation on 05/28/24 at 9:07 AM, LVN E was seen coming out of Resident #198 ' s room. <BR/>Observation on 05/28/24 at 9:17 AM, Resident was sitting down on his bed. Right leg had a dressing from his foot up to his calf/knee area. It was dated 05/27 with the initials of the Wound Care Nurse. The dressing from the right foot was open and covering the front of the foot. The dressing had some discoloration of reddish-brown substance. The right heel was not covered with the dressing exposing the unstageable wound. <BR/>Observation and interview on 05/28/24 at 3:16 PM, revealed Resident #198 ' s right leg dressing had been changed. The dressing was marked 05/28 with the initials. The dressing was wrapped completely from the foot/heel up towards underneath the knee/calf area. The right leg was being floated on a wedge. Resident #198 stated the Wound Care Nurse had gone in and changed his dressing. <BR/>Observation on 05/29/24 at 2:37 PM, revealed Resident #198 ' s right leg dressing had been changed with the date of 05/29 with the initialed. Dressing was wrapped up all completely from foot/heel up to the knee/calf area. <BR/>Observation on 05/30/24 at 3:49 PM, revealed Resident #198 ' s right leg dressing had been changed and initialed. It was completely wrapped from the foot/heel to the underneath the knee/calf area. <BR/>During an interview on 05/30/24 at 10:15 AM, with LVN E, she stated she was coming out of Resident #198 ' s room and had seen his right leg dressing. LVN E stated she had informed the Wound Care Nurse that the dressing needed to be changed. LVN E stated Resident #198 ' s dressing was not okay to be left exposing the unstageable wound. LVN E stated the risk was the wound getting worse. <BR/>During an interview on 05/30/24 at 10:54 AM, with the Wound Care Nurse, he stated Resident #198 had a right heel and upper calf unstageable wounds pressure ulcers. The Wound Care Nurse stated he conducts daily wound care on Resident #198 but had not got to him yet as he was doing other wound care on other residents. The Wound Care Nurse stated on 05/28/24, LVN E did not notify him about the dressing needing to be re-done or looked at. The Wound Care Nurse stated the wound being exposed and touching the floor was an infection control issue. The Wound Care Nurse stated the LVN E should have changed the dressing or notified him immediately. <BR/>During an interview on 05/30/24 at 1:13 PM, with the DON, she stated Resident #198 wound dressing for his right leg unstageable wound needed to be wrapped up completely. The DON stated if a nurse seeing a resident who has a dressing that needs to be re-done should immediately change it or notify the Wound Care Nurse immediately. The DON stated not changing the dressing or notifying the Wound Care Nurse could be a risk of infection, especially for Resident #198 who had his heel exposed and touching the floor. <BR/>During an interview on 05/31/24 at 4:33 PM, with the Wound Care Nurse, he stated the upper calf wound was healing fast and the heel was improving but slowly and not getting worse. <BR/>Record review of the facility Skin Integrity Management policy dated 10/05/16, revealed, Wound care should be perform as ordered by the physician. <BR/>Record review of the facility Pressure Injury: Prevention, Assessment and Treatment dated 08/12/16, revealed, Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection. <BR/>Record review of the facility Skin Assessment policy dated 08/15/24, revealed, It was the policy of this facility to establish a method whereby nursing can assess a resident ' s skin integrity to allow of appropriate intervention be initiated in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure that residents received the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible for 1 (Resident #11) of 5 residents reviewed for indwelling catheters in that:<BR/>Resident #11's indwelling catheter tubing was full and cloudy and evaluated on a wedge not being able to drain downwards properly. <BR/>These failures placed residents at risk of collection tube becoming full and allowing urine to flow back into the bladder that could result in a urinary tract infection.<BR/>Findings include: <BR/>Record review of Resident #11's face sheet dated 02/14/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #11's facility history and physical dated 11/06/23 revealed a [AGE] year-old male diagnosed with schizophrenia (a serious mental disorder in which people interpret reality abnormally) and bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode)). <BR/>Record review of Resident #11's quarterly MDS dated [DATE] revealed an intact cognition to be able to recall and make daily decisions BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 13. Resident #11 was dependent on nursing staff for toileting. Resident #11 had an indwelling catheter. <BR/>Record review of Resident #11's care plan dated 01/13/24 revealed indwelling catheter - check for kinks and maintain the drainage bag off the floor, ensure tubing is anchored to the resident's leg or linens so that tubing was not pulling on the urethra, monitor and document intake and output as per facility policy, and for signs of discomfort on urination and frequency. <BR/>Observation on 02/15/24 at 9:47 AM revealed Resident #11 was lying down in the bed with an indwelling catheter. The indwelling catheter tubing was cloudy. The catheter tubing was all the way full. The indwelling catheter tubing was hanging off a wedge creating a back flow to the resident. <BR/>Observation and interview on 02/15/24 at 9:54 AM with LVN J, she stated Resident #11's indwelling catheter was full and looked cloudy. LVN J stated the way the indwelling catheter tubing was positioned could create blockage and back flow resulting in a risk of urinary tract infection. LVN J stated it was everyone's responsibility for ensuring the indwelling catheter tubing was positioned properly. <BR/>During an interview on 02/15/24 at 10:28 AM with the ADON G, she stated tubing should be straight and not kinked allowing flow downwards to the catheter bag. ADON G stated the indwelling catheter tubing being kinked or elevated could cause back flow resulting in urinary retention and a urinary tract infection. ADON G stated it was the nurses and CNAs responsibility to ensure there the tubing was positioned correctly and not kinked. <BR/>During an interview on 02/15/24 at 11:00 AM with the Area Director of operations, stated DON was suspended, so no interview regarding the indwelling catheter was conducted with DON. <BR/>Record review of the facility's Catheter Insertion, Male/Female policy and procedure manual dated 2003 revealed, An indwelling catheter provides continuous bladder drainage in residents with a neurogenic bladder or urinary disfunction.<BR/>Catheter Change/Replacement - Catheters that are encrusted so that urinary outflow was blocked should be changed. <BR/>Record review of the facility's Resident Rights policy manual dated 11/28/16 revealed, Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.<BR/>Respect and Dignity - The resident has a right to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure respiratory care was provided in a manner consistent with professional standards of practice for 1 (Resident#10) of 2 residents reviewed for respiratory care in that: <BR/>The facility failed to place Resident #10 ' s nasal cannula in a clear labeled bag while not in use. <BR/>These deficient practices could place residents at risk for infection due to improper care practices. <BR/>Findings Include: <BR/>Record review of Resident #10 ' s face sheet dated 01/22/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #10 ' s facility history and physical dated 08/03/23 revealed an [AGE] year-old female diagnosed with Type 2 Diabetes Mellitus, Asthma, Alzheimer ' s Disease, multiple of falls, and Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). <BR/>Record review of Resident #10 ' s quarterly MDS dated [DATE] revealed a severe cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 2. Resident #10 does have a behavior of delusions and wandering. Resident #10 needs partial/moderate assistance for nursing staff to sit to stand, chair/bed to chair transfer, toilet transfer. Resident #10 was total dependent on showers. Resident #10 was diagnosed with Alzheimer ' s, asthma, and muscle weakness (no muscle strength), and lack of coordination (Uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements). Resident was not marked for oxygen therapy as the MDS was done on 10/12/23 before Resident #10 needed oxygen. <BR/>Record review of Resident #10 ' s order recap dated 01/05/24 revealed change nasal cannula as needed. Check oxygen saturation every shift and as needed and every shift. May use oxygen at 2 liter per minute via nasal cannula every shift. <BR/>Record review of Resident #10 ' s Care Plan dated 08/22/22 revealed Resident #10 has asthma and was at risk for respiratory distress. Give medications as ordered. Give nebulizer treatments and oxygen therapy as ordered. <BR/>Observation on 01/13/24 at 1:13 PM revealed Resident #10 ' s nasal cannula to be placed on top of the concentrator unbagged. The nasal cannula part where it goes into your nose had a slight tint color as well as some parts of the oxygen tubing. <BR/>During an interview on 01/13/24 at 1:20 PM with the family member, she stated the nursing staff always just placed Resident #10 ' s nasal cannula on the concentrator unbagged. <BR/>During an interview on 01/13/24 at 1:25 PM with MDS Coordinator C, she stated nasal cannulas are to be bagged if not in use. MDS Coordinator C stated the risk of not bagging the nasal cannula could be infection to the resident. <BR/>Observation and interview on 01/22/24 at 10:25 AM with the DON, she stated Resident #10 ' s nasal cannula should be changed as needed or once a week. The DON stated Resident #10 ' s nasal cannula being unbagged and placed on the concentrator was unacceptable. The DON stated Resident #10 ' s nasal cannula should have been placed in a clear baggy that was labeled with the date. The DON stated that was so the nursing staff would know when to change the nasal cannula. The DON stated Resident #10 ' s nasal cannula had been used. The DON stated not bagging the nasal cannula was a risk to Resident #10 with an infection. <BR/>Record review of the facility Infection Control Plan: Overview policy dated 2019 revealed, The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. <BR/>On 01/22/24 at 9:00 AM with the Administrator, she stated the facility did not have an oxygen policy specifically about nasal cannulas being bagged. <BR/>Record review of the facility Oxygen Administration policy dated 02/13/07 revealed, Oxygen therapy includes the administration of oxygen in liters per minute by cannula or face mask to treat hypoxemia conditions caused by pulmonary or cardiac diseases. <BR/>The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. <BR/>The resident will be free from infection. <BR/>Changing the tubing (including any nasal prongs or mask) that was in use on one patient when it malfunctions or becomes visibly contaminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the residents' goals and preferences for one (Resident #49) of 12 residents reviewed for pain control .<BR/>The facility failed to ensure that Resident #49's request, and physician's order to administer Tylenol 4 (Acetaminophen-Codeine Oral Tablet 300-60 MG) were carried out in a timely manner.<BR/>This failure could put residents at increased risk for pain and decreased quality of life. <BR/>Findings included: <BR/>Record review of Resident #49's face sheet dated 05/31/2024 revealed she was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE].<BR/>Record review of Resident #49's History and Physical dated 4/4/2024 revealed she had a past medical history of chronic pain in her lower extremities (legs). She had paraplegia (paralysis of the lower body) and polyneuropathy (damaged nerves) for which she was prescribed Lyrica and Ibuprofen.<BR/>Record review of Resident #49's quarterly MDS dated [DATE] revealed she had a BIMS score of 13 (cognitively intact). She had experienced pain frequently over the five lookback days that frequently affected her sleep. Her pain had caused her to occasionally limit her day-to-day activities. Her worst pain over the previous five days had been at an 8 on a zero to ten scale, with zero being no pain and ten as the worst pain. <BR/>Record review of Resident #49's MAR dated 5/5/2024 revealed she received 3 Gabapentin capsules (300 MG each) three times a day to address autonomic neuropathy (nerve damage that can cause pain); 600 MG of Ibuprofen every 6 hours as needed for pain, and Tylenol with Codeine #3 300- 30 MG every 4 hours as needed for pain. <BR/>In interviews on 05/28/2024 at 8:15 AM and on 05/29/24 at 09:49 AM , Resident #49 expressed concern that the facility had not been responsive to her requests for more effective pain medications. She said she had been taking Tylenol 3 but had asked the doctor for Tylenol 4. She said the doctor said it would be ordered, but she had never received it. <BR/>In an interview on 05/29/24 at 09:49 AM Resident #49 she said she asked the doctor for Tylenol 4 for her pain. She said the doctor said it would be ordered, but it had been a week or two since she had asked the doctor for the increase in medications . She said she wanted to change to a different doctor because her current physician was not responding to her needs. <BR/>Record review of Resident #49's nursing progress note by LVN F dated 4/11/24 at 1:31 PM revealed the resident had informed Physician O that the Tylenol #3 was not working and wanted Tylenol #4. Physician O informed the nurse to change the order and the order was changed. <BR/>Record review of Resident #49's April 2024 MAR revealed an order for Acetaminophen-Codeine Oral Tablet 300-<BR/>60 MG one tablet by mouth every 4 hours as needed for pain. No medication was documented as having been administered. <BR/>Record review of Resident #49's nursing progress note by LVN F dated 4/16/24 at 9:34 AM revealed a new order was received from Physician O's nurse practitioner to discontinue the Tylenol #4 order and switch back to the Tylenol #3 order as before. The note did not give a reason for the change. <BR/>Record review of Resident #49's physician orders revealed an order dated 05/15/2024 and discontinued on 05/21/2024 for Acetaminophen-Codeine 300-60 MG Tablet to be given every four hours as needed for pain. Resident #49 had another order for Acetaminophen-Codeine 300-60 MG Tablet to be given every four hours as needed for pain dated 05/26/2024 and 5/28/24.<BR/>Review of Resident #49's MAR for May revealed that Acetaminophen-Codeine 300-60 MG Tablets were not administered during those time periods. <BR/>Record review of Resident #49's nursing progress note by LVN F dated 5/21/24 revealed an order was received from Physician O's nurse practitioner to discontinue the Tylenol #4 at that time. <BR/>Record review of Resident #49's nursing progress note by LVN F dated 05/30/2024, revealed she spoke to Physician O who asked the nurse to contact the pharmacy to see if they need a triplicate or a signed prescription on a prescription pad, and that the LVN learned from the pharmacy that the pharmacy was unable to get Tylenol #4 because it had been on back order for months and unaware when will be able to get it. LVN F's note indicated that she informed Physician O of this issue. <BR/>In an interview on 05/30/2024 at 12:00 PM, Physician O stated he had written an order for Resident #49's Tylenol #4 but was just told that it was on back-order the past two months per pharmacy. He stated that Resident #49had been on Tylenol III but wanted Tylenol IV . <BR/>In an interview on 05/31/24 at 09:34 AM, LVN F revealed she had received Resident #49's Physician order for Tylenol #4 and that she had entered the order, and it should appear on Resident #49's April 2024 MAR. She stated that the status right now was that the order was discontinued. She said she called the pharmacy on 05/30/2024 to see if the pharmacy needed a prescription or a triplicate and was told the medication was on back order. LVN F said the resident was sent to the pain center and had been getting Tylenol 3 as needed. The LVN said the Tylenol 3 was usually effective not in alleviating the pain but in dropping the level of the pain. She said she had spoken to the ADON, with a corporate level staff member, and with the DON about the issue in getting the resident the Tylenol 4. LVN F stated that the potential impact on the resident was that she could lose confidence in the facility and doctor (now she wants to switch). She said she did not know if the resident's pain control would be better. She said the resident could have depression due to being in constant pain and less motivation for movement or activities. <BR/>In an interview on 5/31/24 at 3:34 PM, the DON revealed that the nurses should have been following up to see what the delay was in obtaining Tylenol #4 for Resident #49. If they had followed up, they might have received the pain medication or heard sooner it was on back order and sought a solution. The DON said that the risk to the resident was that her pain may not have been as well-controlled as it could have been. A policy and procedure on pain management was requested .<BR/>Record review of the facility policy Pain Management, Assessment Scale dated 5/25/16 revealed complaints of pain would be assessed and effectively managed through prescribed medications and comfort measures and all available resources of the facility.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, 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 food and nutrition services, in that: <BR/>1. <BR/>Food products in dry storage, freezer, and in refrigerator were not correctly labeled, wrapped, or were expired. <BR/>2. <BR/>Staff were not wearing hairnets properly. <BR/>3. <BR/>Freezer was dirty. <BR/>4. <BR/>Food temperatures were not taken prior to serving meals. <BR/>5. <BR/>Staff did not wash hands after touching hair on the serving line. <BR/>These failures could affect residents by placing them at risk of food borne illness. <BR/>Findings include: <BR/>Observation and interview on 3/26/23 at 8:03 AM initial tour was conducted with Kitchen Aide P. Kitchen Aide P stated dessert in plastic containers (total of 11) were not labeled and should have been labeled with date they were prepared and chicken wings in freezer and sausages did not have date of when it was opened and should have been dated with date it was opened. The Kitchen Aide P stated the freezer was dirty with some spillage of unknown kind and stated the freezer was supposed to be cleaned weekly and stated it did not appear it had been cleaned recently, she stated there was spillage of some kind and dirt under the frozen goods. Kitchen Aide P stated the bins of flour (1 bin) and rice (1 bin) did not have labels with dates should be dated when they were filled. Kitchen Aide P stated she received training upon hire on food storage and labeling and sanitary conditions. Kitchen Aide P stated all kitchen staff were in charge of ensuring all goods were properly labeled and dated and kitchen supervisors were in charge of conducting checks as well. Kitchen Aide P stated kitchen managers were the ones in charge of taking food temperatures before meals and stated they did not keep a food temperature log. Kitchen Aide P stated she had not seen a temperature log for several days or seen the kitchen managers write down food temperatures anywhere. <BR/>Interview on 3/26/23 at 8:10 AM the Kitchen Supervisor stated they have not had a food temperature log for several days and they have been writing food temperatures down on scratch sheet of paper. The Kitchen Supervisor stated she did not have today's food temperatures for breakfast meals because they were running behind in the morning and did not have a chance to take the food temperatures. The Kitchen Supervisor stated by not taking food temperature could place residents at risk of acquiring food borne illness by not ensuring foods were served at appropriate food temperatures. <BR/>Observation and interview on 3/26/23 at 11:25 AM Dietary Manager stated all foods were required to be dated and labeled, he stated the items in the refrigerator were labeled on the food tray to not have to write on all items item by item (picture submitted to evidence shows 11 desserts in plastic containers not labeled [NAME] food tray that does not have a label with date).The Dietary Manager stated the staff should be cleaning the freezer at least weekly to not expose frozen goods to cross contamination. The Dietary Manager stated the flour and rice bins should have been dated and would get to it soon, stated he should have dated them when they were filled. The Dietary Manager obtained a copy of March ' s food temperature log with breakfast temperature for today recorded. The Dietary Manager stated she had filled out the form after State Surveyor left the kitchen and the information documented was not accurate for today ' s breakfast temperatures, The Dietary Manager stated food temperatures should be recorded before serving meals and not after they had served for accuracy in documentation and accuracy in temperatures. <BR/>Observation on 3/26/23 at 11:56 AM Kitchen Aide was on the serving line preparing meal trays to be distributed, her bangs were not covered with the hair net. The Kitchen Aide touched her bangs to fix them off her face 4 times and continued to serve food using kitchen utensils every time. The Kitchen Aide did not wash hands, use hand sanitizer, and was not wearing gloves each time she touched her hair and continued to serve food. <BR/>Interview on 3/26/23 at 12:50 PM Dietary Manager stated all staff who assisted with meal service were required to wash hands before assisting and could use hand sanitizer few times before having to wash again. The Dietary Manager stated hair nets were required to cover all hair and if staff were to touch hair while serving food on serving line they should be stepping aside to wash hands. The Dietary Manager stated the DON had conducted several hand hygiene in-services in the past addressing when they should be washing their hands. The Dietary Manager stated by not wearing hairnets appropriately and not washing hands after touching hair while at serving line was a cross contamination issue. <BR/>Interview on 3/26/23 at 1:13 PM Kitchen Aide Q stated she should have been wearing her hair net correctly which included bangs being covered. The Kitchen Aide Q stated she should have stepped away to wash hands or use hand sanitizer each time she fixed her hair, and her failure could place residents at risk of cross contamination leading to some type of infection. The Kitchen Aide Q stated she received training of hand washing and hair nets upon hire. <BR/>Record review of Daily Food Temperature Control Policy dated 2012 revealed We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges. 2- Prior to meal service, the cook shall take the temperature of all hot and cold foods. 3- Temperatures are recorded on the Temperature Log Form. <BR/>Record review of Dietary Food Service Personnel Policy and Procedures dated 2012 revealed Sanitation and Food Handling: 2- hair nets or hats covering the hairline are worn at all times. 3- wash your hands before starting work, touching something that is not clean and then handling food can cause food poisoning. <BR/>Record review of Storage Refrigerators policy dated 2012 revealed All storage refrigerators shall be maintained clean and have proper temperature for food storage and to ensure a proper environment and temperature for food storage. 4- storage refrigerators shall be kept cleaned and organized. Spills are to be wiped up immediately. 5- food must be covered when stored, with date label identifying what is in the container.

Based on interviews and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1alleged allegation of stealing of medications reviewed for allegations of misappropriation of property. <BR/>The facility failed to ensure the DON followed the internal abuse policy, report allegations of abuse to State Office, and conduct thorough abuse allegation investigation. <BR/>These failures could place all residents at risk of continued abuse by not immediately following the facility policy of abuse, neglect, exploitation, or misappropriation - reporting and investigating. <BR/>Findings included: <BR/>During an interview on 05/30/24 at 2:32 PM, with the DON, she stated she had received a report from LVN D. The DON stated LVN D tends to makes malicious allegation towards other nurses. The DON stated LVN D made a malicious report to her on 05/28/24, regarding LVN K taking medications from the residents. The DON stated she followed up with LVN K and no one had reported any missing medications. The DON stated she had just started her investigation. The DON stated she did not report it to the Administrator. The DON stated as per the facility policy and protocol it had to be reported to the state agency, which was not reported too. <BR/>During an interview on 05/30/24 at 3:15 PM, with the Administrator, Regional Compliance Nurse, and the DON. The Regional Nurse stated during a conversation with the DON on 05/30/24, the DON had reported to her that LVN D had told her that LVN K was stealing medications from the residents. The Administrator stated she was unaware of the situation. The Administrator and Regional Compliance Nurse stated it should have been reported to the state agency when the facility received the allegation. <BR/>Record review of the facility Abuse/Neglect policy dated 03/29/18, revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. It was each individual ' s responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. <BR/>Misappropriation of Resident Property: the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident ' s belongings or money without the resident ' s consent. <BR/>Reporting &ndash; Any person having reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, state and or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. <BR/>Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident properly or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet criteria of Provider Letter 19-17 dated 07/10/19. <BR/>Record review of the facility Event Reporting: Completion Of policy and procedure not dated revealed, Investigation: The investigation should be completed by the DON/Administrator or designee. The investigation report documents a though investigation of the events including person, equipment, and materials involved. The investigation report must include what actions were taken to prevent subsequent Events and signatures of the individuals as indicated on the form. <BR/>Record review of facility Long Term Care Regulatory Provider Letter dated 07/10/19, revealed, A Nursing facility must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: <BR/>Abuse, Neglect, Exploitation, Misappropriation, Drug Theft, Death due to unusual circumstances, Fire, Emergency situations that pose a threat to resident health and safety. <BR/>State and federal law requires an owner or employee of nursing facility who has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation caused by another person to report the abuse, neglect or exploitation. Nursing facility must report all suspected or alleged incidents involving abuse, neglect, exploitation or mistreatment of resident property. A Nursing facility must report these incidents to the HHSC CII section.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience for two (Resident #4 and Resident #5) of three residents reviewed for freedom from physical restraints. The facility failed to ensure Residents #4, and Resident #5 did not have pillows under their mattresses which restricted his movement from getting off the bed and were not required to treat his medical symptoms. This failure could put residents at risk of unnecessary restriction of their movements. Resident #4 Record review of Resident #4's face sheet dated 10/24/2025, revealed, admission on [DATE] to the facility. Resident #4 was a [AGE] year-old female diagnosed with Alzheimer's disease, abnormal posture and gait, neurocognitive disorder with Lewy bodies dementia (proteins that disrupt normal brain function), cognitive communication deficit (difficulties in communication), schizophrenia (brain disorder that affects how the brain processes information), major depressive disorder (sadness, hopelessness, and lack of activities), history of COVID-19 (Coronavirus, similar to a common cold, some cases can lead to respiratory distress), protein-calorie malnutrition (does not get enough protein and calories to maintain proper health), insomnia (lack of sleep), generalized muscle weakness (muscles can't work as hard as they should), anxiety (feeling of worry, nervousness, or fear), hypothyroidism (thyroid gland that does not make enough hormones), age related osteoporosis (bones that are weaker and more likely to break), hypertension (high blood pressure), peripheral vascular disease (circulation of the blood vessels), and Tourette's disorder (uncontrollable movement or sounds known as tics). Record review of Resident #4's admission MDS dated [DATE], revealed a severely impaired cognition BIMS score of 00 to be able to recall or make daily decisions. Functional abilities self-performance revealed extensive assistance (staff provides weight-bearing support assistance) for rolling left or right in bed, sitting to lying, lying to sitting on side of bed. Resident #4 was limited assistance (staff provided guided maneuvering of limbs or other non-weight- bearing assistance) for transfers from bed to chair, wheelchair, standing position. Record review of Resident #4's History and Physical, dated 07/08/2025, revealed, readmission to acute hospital secondary to a fall sustaining an acute fracture of the right femur neck (a hip fracture). Record review of Resident #4's care plan dated 05/19/2025, revealed, ADLs for bed mobility/transfers requiring supervision as needed. At a high risk for falls unaware of safety needs, ambulates without walker. Interventions to supervise closely and make regular compliance rounds whenever the resident was in room. Pillows were not care planned to prevent falls for Resident #4. Care plans had no medically needed devices indicating the Resident needed a pillow or device tucked into the bed sheet. During an observation and interview on 10/24/2025 at 10:00am, revealed Resident #4 was lying in bed. The surveyor went up to Resident #4 who was lying next to a long body pillow that was tucked underneath Resident's bed sheets. Attempted an interview with Resident #4 and the only response was hello. In an interview on 10/24/2025 at 10:09 am, CNA A stated she had been working at the facility for 9 months and worked the morning shift. CNA A stated she was trained on restraints. The last training was last month in September 2025 and was instructed not to add any barriers to Residents that don't allow them from moving freely especially Residents who were fall risk. CNA A walked to Resident #4's room where she witnessed the pillow tucked underneath the bed sheet and Resident #4 lying in bed. CNA A stated, The pillow is used to keep the resident from falling out of the bed because the resident is a constant mover and staff does not want the resident to fall. So, they either place a triangle holder but when staff do not have one, staff will add pillows. CNA A stated fall precautions used where the bed was to the lowest position, floor mats in place, and call lights in reach for all residents. In an interview on 10/24/2025 at 02:25pm the DON was presented with pictures showing Resident #4 with pillows tucked under her bed sheets. The DON stated that the procedure was used to be for repositioning the patient if medically needed. The DON stated that Resident #4 was still capable of getting out of her bed so the pillow being inserted under the bedsheet was not a restraint, but all staff took training on not inserting pillows under bedsheets. Resident #4 does not need any device or pillow for medical needs. In an interview on 10/24/2025 at 02:38 PM, LVN B stated she was the LVN and charge nurse and worked only Monday-Friday from 6AM-2pm. LVN B was shown a picture that had been taken by the surveyor during rounds showing the pillows tucked underneath the bed sheets of residents to prevent them from falling. LVN B stated that the picture showing the pillow tucked under the bed sheets was considered a restraint. LVN B stated that the facility had trained all staff not to do that (referring to the pillow put under the sheet), and it was not medically necessary. LVN B stated Resident #4 had no care plan in her records indicating a medical device, and Resident #4 had been able to ambulate on her own. LVN B stated she had never seen anyone perform this restraint before and did not know if it was something they did to try to keep the residents safe from falling out of bed. CNA's and LVN's, along with all nursing staff, were trained the same way and took responsibility for ensuring these restraints were not being used on residents. Charge nurses were responsible for verifying that these residents were not applied to residents. Charge nurses were also responsible for rounding on residents every 2-3 hours or more if needed. The risk for a resident having that type of restraint could be that the resident could have fallen over the pillow, resulting in a higher and potentially more severe fall. The resident could have become trapped between the wall or bed sheets such as a resident arm or torso, and that practice was not a safe or appropriate situation for residents from safely getting out of bed. A pillow tucked under the bed sheet was considered a restraint because it restricted the residents movement and limited their freedom to move or reposition themselves. Fall Interventions are low beds, floor mats, nurse rounds, CNAs also have documentation in PCC (an electronic health record system tailored for the needs of skilled nursing facilities) on what residents are labeled as a fall risk. In an interview on 10/24/2025 at 03:25 PM, LVN C stated she had worked at the facility for 16 years on the long-term side of the facility. LVN C stated staff had been trained not to place any type of devices or pillows underneath the bed sheets which were considered restraints. LVN C stated if a resident could not move the pillow or device, then it was considered a restraint. LVN C was shown the picture of Resident #4 with a pillow tucked under the bed sheets, and LVN C stated that it was indeed a restraint. LVN C stated staff were not trained to insert any type of pillow or devices under the bed sheets. LVN C stated that the ADON's and the charge nurses on the floors were responsible for overseeing that staff did not apply any of these restraints to the residents. LVN C stated the charge nurses mad sure they conducted rounds every couple of hours to ensure residents were receiving the care they needed. LVN C stated a resident could be at risk of being trapped between the wall or bed sheet and could sustain an injury. Resident #5Record review of Resident #5's face sheet dated 10/24/2025, revealed, admission on [DATE] and re-admission on [DATE] Resident #5 was a 90-[NAME] old male diagnosis with muscle weakness (muscles can't work making it hard to perform everyday activities), cerebral infraction (Stroke), dysphagia (difficulty swallowing), lack of coordination (uncontrolled movements or task), cognitive communication deficit (problems with communication), aphasia following cerebral infarction (difficult in communication after stroke), combined forms of age-related cataract, bilateral (in both eyes), acute myocardial infarction (heart attack), unspecified atrial fibrillation (irregular heartbeat), Dementia (affecting the memory), Alzheimer's disease (memory loss). Record review of Resident #5's history and physical dated 06/19/2025, revealed, readmission for Traumatic subdural hemorrhage (bleeding that occurs inside the skull) under total care skilled nursing.Record review of Resident #5's admission MDS dated [DATE], revealed, a severely impaired cognition BIMS score of 03 to be able to recall or make daily decisions. Functional limitation in range of motion revealed number 2 (impairment on both sides) on both upper extremity (Shoulder, elbow, Wrist, hand) and lower extremity (Hip, Knee, ankle foot). Functional abilities were all listed as 1 (Dependent - A helper completed all the activities for the residents. Helper does ALL the effort. Residents does none of the effort to complete the activity. Or the assistance of 2 or more helpers was required for the residents to complete the activity). The resident had a 0 (no) mark for no falls since admissions.Record review of Resident #5's care plan dated 09/16/2025, revealed that resident did not have any focus points on any fall hazards, goals or interventions. During an observation and interview with Resident #5, on 10/24/2025 at 04:53pm, revealed Resident #5 had bed at the lowest position as well as a floor fall mat and was lying at a 45-degree angle in bed. Resident #5 acknowledged the surveyor and stated that he was good. Resident #5 was not coherent and could not remember dates, times, or where he was. Resident # 5 was unaware of why there was a pillow shoved/propped under his bed sheet on his right-side shoulder. In an interview on 10/24/2025 at 03:39 PM, CNA D stated she had been employed at the facility for 18 years and works the morning shift from 6AM-2PM. CNA D stated she had received all training regarding restraints. She stated the training was provided by ADON's and DON's during which staff were instructed not to use pillows or devices for positing or prompting residents. A picture was shown to CNA D, and she stated that the pictures of Resident #5 were a restraint. Resident #5 could had been placed at risk by not being able to get out of bed as it restricts him from movement and reposition, and at risk of injury from attempting to get up or becoming trapped within the bed sheets and the wall. In an interview on 10/24/2025 at 04:23 PM, the Administrator stated that restraints were defined as anything that impeded a resident from performing an action. Pictures were shown to the Administrator, and she stated that if the item impeded the resident, then it was considered a restraint. The Administrator did not provide a direct yes or no answer when asked whether the pictures reflected restraints on residents. The Administrator was unable to identify specific risk on Resident #4 and Resident #5, and she continued to repeat that if it impeded the resident, then it was a restraint.Record review of the facility training dated 08/29/2025 titled Restraint Reduction in Nursing facilities revealed all staff had completed the training as it was a mandated course for September 2025.Record review of the facility's policy titled, Resident Rights, SS 03-09a revealed The resident has a right to be treated with respect and dignity including: 1. The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the residents' medical symptoms. Record review of the facility's policy titled, Nursing policy and procedure Manual; Abuse/Neglect revised 03/29/2018 revealed The resident has the right to be free from abuse, neglect, misappropriation of residents' property, and exploitation as defined in this subpart. This includes but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.Record review of the facility's policy titled, Restraint Mini Manual; Restraints, MM RE 03-3.0revealed, It is the policy of this facility to maintain an environment that prohibits the use of restraints for discipline or convenience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 5 (Resident # 3, #4, #5, #7, and #8 ) of 12 residents reviewed for care plans. <BR/>The facility failed to implement a comprehensive person-centered care plan for Resident #7 ' s history of falls. <BR/>The facility failed to implement a comprehensive person-centered care plan to address elopement risk for Residents #3, #4, #5, #7, and #8. <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include: <BR/>Resident #7 <BR/>Record review of Resident #7 ' s face sheet dated 01/19/24 revealed admission on [DATE] and re-admission on [DATE] to the facility with diagnoses of unspecified lack of coordination, abnormalities of gait and mobility, disorganized schizophrenia, muscle wasting and atrophy, muscle weakness, unsteadiness on feet, and unspecified dementia. <BR/>Record review of Resident #7 ' s care plan dated 11/21/23 revealed at risk for wandering. Assess for fall risk. Care plan did not indicate anything regarding the focus area of falls. <BR/>Record review of Resident #7 ' s Event Note dated 11/20/23 revealed bruising to left knee, left lower leg, left ankle bruising. <BR/>Record review of Resident #7 ' s Fall Assessments dated 01/19/24 revealed from there were only fall assessments completed from 02/13/20-08/09/23. No fall assessment was conducted for the Event note that was completed on 11/20/23. <BR/>Resident #3 <BR/>Record review of Resident #3 ' s face sheet dated 01/18/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #3 ' s facility history and physical dated 07/25/23 revealed a [AGE] year-old female diagnosed with Dementia and Major Depression Disorder (affects how you feel, think and behave and can lead to a variety of emotional and physical problems). <BR/>Record review of Resident #3 ' s quarterly MDS dated [DATE] revealed a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 3. Resident #3 was diagnosed with Alzheimer Disease, Non-Alzheimer ' s Disease, and Depression. <BR/>Record review of Resident #3 ' s elopement risk assessment dated [DATE] revealed a score of 13, high risk of elopement. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident # 3 ' s care plan dated revealed no focus area and/or interventions to address elopement risk. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet dated 01/18/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #4's facility history and physical dated 05/18/23 revealed a [AGE] year-old female diagnosed with psychiatric behavior with aggression and paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly). <BR/>Record review of Resident #4's annual MDS dated [DATE] revealed a Preadmission Screening and Resident Review condition as serious mental illness. Resident #4 had a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 3. MDS indicated zero (no behavioral symptoms) for behaviors. Resident #4 was diagnosed with Non-Alzheimer's Disease, Psychotic Disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), Schizophrenia (a serious mental disorder in which people interpret reality abnormally), depression, and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). <BR/>Record review of facility assessment scoring report sheet dated 01/01/20-01/19/24 reviewed Resident #4 had a score of 13 for elopment risk. <BR/>Record review of Resident #4's care plan dated 12/17/21 revealed no focus area for elopement. <BR/>Resident #5 <BR/>Record review of Resident #5 ' s face sheet dated 01/18/24 revealed admission on [DATE] to the facility. Resident #5 was a [AGE] year-old female diagnosed with Dementia and Psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). <BR/>Record review of Resident #5 ' quarterly MDS dated [DATE] revealed a moderately cognition to be able to recall and make daily decision BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score which was not taken for whatever reason. Resident #5 was diagnosed with Cerebrovascular Accident (an interruption in the flow of blood to cells in the brain), Non-Alzheimer ' s Dementia, Depression, Psychotic Disorder (affect brain function by altering thoughts, beliefs or perceptions) and Adjustment Disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior) with Depressed Mood (Feelings of sadness, hopelessness, crying and lack of joy from things that used to bring you pleasure). <BR/>Record review of Resident #5 ' s Elopement assessment dated [DATE] revealed a elopement risk score of 18. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident #5 ' care plan dated 01/22/24 revealed no focus area for elopement. <BR/>Resident #8 <BR/>Record review of Resident #8 ' s face sheet dated 01/19/23 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #8 ' s facility history and physical dated 04/06/23 revealed a [AGE] year-old male diagnosed with severe intellectual disability, anxiety, and Major depressive Disorder (it affects how you feel, think and behave and can lead to a variety of emotional and physical problems). <BR/>Record review of Resident #8 ' s annual MDS dated [DATE] revealed a Preadmission Screening and Resident Review condition as intellectual disability. Resident #4 had a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score that was not taken for whatever reason. Behaviors was marked zero revealing Resident #8 had no behaviors when Resident #8 really did have behaviors. Resident #8 was diagnosed with Seizure Disorder (abnormal electrical brain activity), Depression, and Serve Intellectual Disabilities (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills). <BR/>Record review of Resident #8 ' s elopement risk assessment dated [DATE] revealed a score of 14, high risk. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident #8 ' s care plan dated 01/15/24 revealed no focus area for elopement. <BR/>During an interview on 01/19/24 at 6:17 PM with MDS Coordinator C and MDS Coordinator D, MDS Coordinator C, she stated the comprehensive care plans should have had falls and elopement care planned for Resident #7, #3, #4, #5, #8. MDS Coordinator D stated there could be a risk of not care planning falls and elopement. MDS Coordinator stated the risk could be a resident elopement from the facility. MDS Coordinator C stated anytime there was an elopement assessment completed for a resident that meant it would need to be care planned for the resident. MDS Coordinator C stated the DON, ADON, and the MDS department were responsible for overseeing that the comprehensive care plans are accurate. <BR/>During an interview on 01/22/24 at 10:46 AM with the DON, she stated residents with elopement risk should have elopement as a focus area in their care plans. The DON stated the charge nurse will update the care plans and the DON and ADONs will oversee to make sure it was done. The DON stated that Resident #7 had no focus area for falls and had overlooked the fall for the comprehensive care plan. The DON stated Residents #3, #4, #5, and #8 had no focus for elopement because she did not look for it on the comprehensive care plan as she did not know it needed to be care planned. The DON stated the risk of not including the elopement in the comprehensive care plan could be identifying resident elopement risk and monitoring of the resident. <BR/>During an interview on 01/22/24 at 12:44 PM with the Administrator, she stated she was not too familiar with comprehensive care plans and asked to refer to the DON regarding care plans. <BR/>Record review of the facility Elopement Assessment Scoring Report dated 01/01/20-01/19/24 was review revealed there were 30 residents on it to include Residents #3, #4, #5, #8. <BR/>Record review of the facility Preventive Strategies to Reduce Fall Risk dated 10/05/16 revealed, Policy: The goal of fall prevention strategies was to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident ' s mobility. <BR/>Residents at risk will be care planned for fall prevention. <BR/>After risk was assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will educate on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. <BR/>Record review of the facility comprehensive care plan policy not dated revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. <BR/>The comprehensive care plan will describe the following: <BR/>The services that are to be furnished to attain and maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. <BR/>Record review of the facility Elopement Prevention policy 01/2023 revealed, Every effort will be made to prevent elopement episode while maintaining the least restrictive environment for residents who are at risk for elopement. <BR/>All residents who area at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. <BR/>The resident ' s care plan will be modified to indicate the resident was at risk for elopement episodes. <BR/>Interventions into elopement episodes will be entered onto the resident ' s care plan and medical record. <BR/>Record review of the facility Elopement Response policy dated 10/27/10 revealed, After an elopement the care plan coordinator will reevaluate the resident ' s care plan. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent significant medication errors for 1 of 7 residents (Resident #1) reviewed for pharmacy services. The facility failed to follow physician's order by administering Amiodarone (a heart medication used to control dangerous irregular heartbeats) to Resident #1 when he was not prescribed this medication. This failure placed the residents at risk of not receiving their medications as ordered by the physician, which could cause a serious allergic reaction and side effects.The findings included: Record review of Resident #1's face sheet dated 11/20/2025 revealed an [AGE] year-old male who was originally admitted to the facility on [DATE]. Record review of Resident #1's history and physical dated 7/5/25, revealed that Resident #1 was an [AGE] year-old male admitted to a local hospital on 06/18 with altered mental status and neglect concerns. Resident #1 was diagnosed with a left middle cerebral artery (MCA) stroke (blocked blood flow to the brain), urinary tract infection (infection of the urinary system), and metabolic encephalopathy (confusion due to infection and chemical imbalance). Due to dysphagia (inability to swallow safely), the resident underwent placement of a PEG tube (feeding tube placed directly into the stomach) on 07/03, which was required for enteral nutrition and medication administration due to unsafe oral intake. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 07, indicating moderately impaired cognition. Review of Section GG indicated the resident required substantial assistance with self-care and mobility and was dependent on staff for multiple activities of daily living due to limited physical and cognitive functioning. The MDS documented that the resident had impaired swallowing ability and required altered nutritional support due to his inability to safely swallow food or medications. The MDS Section K for swallowing and nutritional status, paragraph B reflected that the resident had a feeding tube, indicating that oral intake was not safe and that enteral feeding (providing nutrition, fluids and medications directly into the stomach or intestines through a feeding tube) methods were required. Record review of Resident #1's care plan dated 10/13/2025 revealed that the resident required tube feeding related to dysphagia and was dependent on a PEG tube (feeding tube placed directly into the stomach) for nutrition, hydration, and medication administration. The care plan documented that the resident was not safe for oral intake and required staff to administer feedings and medications through the PEG tube. The care plan directed staff to monitor tube placement, perform daily site care, keep the head of bed elevated during and after feedings, and monitor for complications including aspiration, infection, tube dislodgement, and intolerance of feedings. Record review of the facility's Employee Disciplinary Report dated 10/16/2025, revealed CMA B was placed on an investigatory suspension pending an investigation into allegations of administering Resident # 1 the wrong medication. The form was signed by the Human Resources staff and CMA B on 10/16/25. In an interview on 11/19/2025 at 10:41 AM Resident #1stated that a nurse had given him the wrong medication. Resident #1 stated that he did not know which medication it was, only that it was a white pill and a pink pill, and that the nurse placed the medication in his mouth for him to swallow. Resident #1 stated that his medications were supposed to be administered through his PEG tube per doctor's orders because it was not safe for him to swallow pills. The Resident said he told the staff he did not want the medications, but the nurse insisted he needed to take them, so he swallowed the pills. Resident #1 stated that after the staff gave him these medications, he reported the incident to a different nurse to make sure the right medications were being given to him. Resident #1 stated that after reviewing the medications he was supervised with, the nurse took him to the DON to report a medication error. Resident #1 stated that the staff monitored him for five days to make sure he did not develop complications from receiving the wrong medications. In an interview on 11/19/2025 at 10:55 AM, LVN A stated that CMAs (certified medication assistants) must verify a resident's medication orders before administering any medications to prevent medication errors. LVN A stated that reviewing the resident's care plan is also required to ensure medications are being given exactly as prescribed by following the seven R's that included the right dose, route, resident, medication, time and documentation. LVN A stated that when staff do not check the orders or the care plan, the risk of a medication error increases, which could cause the resident's health to worsen or make the resident sick if incorrect medication is administered. In an interview on 11/19/2025 at 12:37 PM, the NP stated that the resident experienced a medication error when he was given Amiodarone (a strong heart-rhythm medication used to treat dangerous irregular heartbeats) and Vitamin B12 (a vitamin used for anemia and nerve function), even though he was not prescribed either medication. The NP stated that Amiodarone can lower the heart rate and affect how the heart beats, and that giving it to someone who does not need it could cause dizziness, low blood pressure, weakness, or a dangerous change in heart rhythm. The NP stated the resident did not have any medical condition that would justify giving Amiodarone, making the error preventable. The NP stated he instructed the facility staff to check the residents' vitals throughout the day to make sure there were no negative reactions. The NP stated that all RNs, LVNs, and CMAs are required to verify the physician's orders before giving medications and that failing to do so places the resident at risk for harm. The NP stated that although the resident did not show an immediate reaction, the potential outcome of receiving unprescribed medications could have resulted in health complications such as dizziness, fainting and chest discomfort. Interviews was attempted on 11/20/2025 between 1:15 PM and 1:35 PM with CMA B to ask about the oversight on Resident # 1 review of his care plan that led to a medication error, but CMA B did not answer the phone. The investigator left a voicemail with identifying information, and a call back was requested. Phone calls were followed by a text message with identifying information requesting a call back, but CMA B did not contact the investigator. In an interview and observation conducted on 11/20/2025 at 1:30 PM, CMA C was observed reading the medication records for Resident # 2 and confirmed these medications were prescribed to the resident. CMA C explained to the investigator that CMAs need to confirm the seven Rs before supervising medications. CMA C stated that CMAs must never supervise medications to a resident if the medication was not ordered for them. CMA C stated that supervising the wrong medication such as Amlodipine to a resident who had not been prescribed with it could make the resident ill by lowering their blood pressure. She stated this could potentially result in injuries, dizziness, fainting, sickness, or hospitalization, depending on the resident's health condition. In an interview on 11/20/2025 at 1:46 PM, the DON stated she was notified that the CMA B had administered medications to Resident #1 that were not prescribed for him. The DON stated the incident involved Amiodarone (a heart-rhythm medication that slows the heart rate) and that the resident should not have been given any oral pills. The DON stated she immediately removed CMA B from the floor after learning that she confused residents while passing medications. The DON stated the physician was notified, and the Nurse Practitioner assessed Resident #1 to check for adverse reactions. The DON stated the resident's pulse was elevated due to anxiety but did not drop, and staff monitored his blood pressure for five days to ensure the medication error did not cause complications. The DON stated that administering unprescribed medications, especially Amiodarone, could cause a drop in blood pressure or heart rate, which could lead to health problems. The DON stated that RNs, LVNs, and CMAs are responsible for checking medication orders before administering any medications to prevent medication errors. Record review of the facility's in-services revealed that all staff from the facility had been trained on 10/16/25 by the DON on the 7 rights of medication administration, resident rights and Abuse Neglect and Exploitation. The DON stated that CMA B had been trained on all of these trainings upon being hired on April 7, 2023, and additionally, the DON had record of her observations of CMA B on 10/01/2025 where she had show proficiency on following the seven rights for medication administration, but CMA B had failed to comply with the training of the seven rights on 10/16/2025. In an interview on 11/21/2025 at 11:23 AM, LVN D reported that Resident #1 informed her he received medications orally from CMA B, specifically describing a white and a pink pill. LVN D stated the facility later identified that the medications involved were amiodarone, a medication used for heart rhythm problems such as atrial fibrillation (when the heart is beating out of rhythm), and vitamin B12, a nutritional supplement. LVN D reported that Resident #1 had a history of atrial fibrillation, and stated he was not at immediate risk from receiving amiodarone; however, she emphasized that he had no active order for amiodarone or oral medications at the time of the incident. LVN D reiterated that she questioned CMA B multiple times, but CMA B denied administering the medications. LVN D reported the incident to the DON and notified the NP and residents' family. LVN D stated that CMAs, LVNs, and RNs are responsible for verifying the MAR and prescriber orders before administering medications, ensuring accuracy, correct route, and resident safety. LVN D stated the potential negative outcomes from administering unprescribed or incorrect medications included allergic reactions, drug interactions, toxic effects due to unnecessary medications and hospitalizations. In an interview conducted on 11/21/2025 at 11:35 AM, the Administrator stated that the incident involved Resident #1 being administered oral amiodarone and vitamin B12 by CMA B, despite the resident not being prescribed those medications. The Administrator stated that Resident #1 reported receiving a white and a pink pill, which was later identified as those medications.The Administrator confirmed that amiodarone is a high-risk cardiac medication that should only be administered when prescribed and monitored. The Administrator stated that although the resident had a history of atrial fibrillation, he was not actively ordered amiodarone, making the administration a medication error. The Administrator emphasized that CMAs, LVNs, and RNs must always follow the MAR, check prescriber orders, and verify medication before administration, especially when supervising or administering high-risk medications. She stated the potential negative outcomes for administering amiodarone to a resident who did not need it could result in lowering the heard rate, dizziness and blood pressure drops which could complicate a residents' health. Record review of the facility's policy titled Medication Administration and General Guidelines, not dated, read in part: Medications be prepared, administered, and recorded only by licensed or otherwise legally authorized personnel who follow state regulations and facility procedures. Medications be administered exactly as ordered by the attending physician. If a dose appears incorrect, excessive, unclear, or inconsistent with the resident's condition, staff must contact the physician for clarification prior to administration. All current physician orders and medication schedules must be reflected on the resident's Medication Administration Record (MAR), and staff must verify each medication against the MAR before giving it. Staff must verify the identity of the correct resident using identification bands, photographs, the medical record, or verbal identification. Routine medications must be administered precisely as ordered, within one hour of the scheduled time, unless otherwise specified by the physician. If a medication is omitted, held, refused, or not given, staff must record the omission on the MAR, document the reason, and notify the physician as required. Staff must ensure the medication label matches the order on the MAR. If there is any discrepancy, unclear label, or questionable instruction, staff must not administer the medication until clarification is obtained. When medications require crushing, staff must follow manufacturer guidelines and ensure the MAR reflects that crushing is appropriate. Medications that are extended-release or enteric-coated must not be crushed. Staff must adhere to the Six Rights of Medication Administration:1. Right Dose2. Right Route3. Right Resident4. Right Medication5. Right Time6. Right Documentation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility to ensure resident's right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for 3 (Resident #13, Resident #57, and Resident #111) of four residents reviewed for notification of room change. 1-The facility failed to provide written notice of room transfer on 03/19/25 and 06/27/25 to Resident #13 or their Power of Attorney (POA), 5 days' notice must be given to the resident or responsible party prior to the move.2-The facility failed to provide written notice of room transfer on 04/11/25 to Resident #57 or their Responsible Party, 5 days' notice must be given to the resident or responsible party prior to the move.3-The facility failed to provide written notice of room transfer on 04/13/25 and 04/22/25 to Resident #111, 5 days' notice must be given to the resident or responsible party prior to the move.These facility failures placed all residents at risk of being displaced without notice and/or reason in order to accommodate other individuals. 1-Record review of Resident #13's face sheet dated 07/22/25 revealed resident was a [AGE] year-old female with an admission date of 03/19/25. Face sheet revealed Resident #13 had a medical and financial POA.Record review of Resident #13's history and physical dated 04/22/25 revealed resident was legally blind and had medical history of physical debility (physical weakness, fatigue, or lack of energy that can impact daily functioning).Record review of Resident #13's quarterly MDS (Minimum Data Set) dated 06/22/25 revealed a BIMS (Brief Interview for Mental Status) score of 3, indicating severely impaired cognitive status.Record review of census per the facility's electronic charting system revealed Resident #13 was transferred to different rooms on 03/19/25 and on 06/27/25.Record review of Resident #13's progress notes dated 03/19/25 by LVN F revealed resident was admitted to the facility from a hospital and was verbally aggressive to the staff upon arrival. Progress notes did not notate Resident #13 requesting a room change, or that a room change occurred on 03/19/25, both rooms within Hall 4. Record review of Resident #13's progress notes dated 06/27/25 by LVN E called Responsible Party on 06/27/25 but there was no answer, and resident was transferred to another room on 03/19/25, from Hall 4 to Hall 2 on 06/27/25. There was no documentation of the reason for room transfer, or that resident was given notice.2-Record review of Resident #57's face sheet dated 07/24/25 revealed a [AGE] year-old male with initial admission date 04/19/24 and re-admission date 06/25/25. Face sheet revealed Resident #57 had a Responsible Party.Record review of Resident #57's history and physical dated revealed medical diagnosis of hypertension (high blood pressure), severe anxiety, and Dementia with behavioral disturbances (Dementia is a decline of cognitive function that affects daily life, including memory, reasoning, and language skills).Record review of Resident #57's quarterly MDS dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment.Record Review of facility's Action Summary dated 07/24/25 revealed Resident #57 was transferred to different rooms within Hall 1 on 04/11/25.3-Record review of Resident #111's face sheet dated 07/24/25 revealed a [AGE] year-old female with admission date 02/04/25. Face sheet revealed Resident #111 was her own Responsible Party.Record review of Resident #111's history and physical dated 02/06/25 revealed medical diagnosis of Hypertension (high blood pressure), Diabetes Mellitus II (a chronic disease when a person has persistently high blood sugar levels), Acute Kidney Injury (sudden decrease in kidney function that can lead to the accumulation of waste products in the blood), and chronic kidney disease (a long-term kidney disease causing gradual loss of kidney function affecting kidney's ability to filter waste and excess fluids from your blood).Record review of Resident #111's quarterly MDS dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment.Record review of facility's Action Summary dated 07/24/25 revealed Resident #111 was transferred on 04/13/25, both rooms within Hall 1, and 04/22/25, to Hall 4.In an interview on 07/21/25 at 09:45 AM with Resident #13 stated she had been transferred to different rooms twice and she stated she did not know the reason for the transfers. Phone call attempt made to Resident #13's POA, message and callback request left. POA had not returned call prior to exit.In an interview on 07/24/25 at 2:40 PM with Resident #111 stated she was not provided written notice for room transfer on 04/13/25, both rooms in Hall 1, and for room transfer on 04/22/25 to Hall 4.In an interview on 07/24/25 at 2:43 PM with Resident #57 stated he was not provided written notice for room transfer on 04/11/25, both rooms within Hall 1.In a telephone interview on 07/24/25 at 2:48 PM with Resident #57's Responsible Party (RP), who stated the RP was not provided a written notice of room transfer on 04/11/25.In an interview on 07/24/25 at 12:40 PM with the ADON who stated that Resident #13 was verbally aggressive to residents that are not English speaking. She stated Resident #13 was transferred rooms on 03/19/25 because her roommate was not comfortable with Resident #13 since the roommate was primarily Spanish speaking. She stated Resident #13 was transferred rooms on 06/27/25 since resident was a skilled nursing resident and changed to a long-term resident. She stated Resident #13 had a Power of Attorney and she was unable to recall obtaining consent for immediate room transfers on 03/19/25 and 06/27/25. She stated she was not aware of the 5-day notification for room transfers. She stated the Social Worker was responsible for room transfer notification. The ADON stated room transfers without notification could place residents at risk for confusion or agitation due to sudden environment change.In an interview on 07/24/25 at 12:49 PM with Social Worker who stated she was not involved with room transfers or notification to residents or their Responsible Party (RP). She stated nursing was responsible for room transfers. The Social worker stated she was not aware of the 5-day notification for room transfers. The Social Worker stated she did not inform Resident #13, or their RP of room transfers during her stay. The Social Worker stated she did not provide any residents and/or their Responsible Party of room transfers.In an interview on 07/24/25 at 1:18PM with the DON who stated Resident #13 was transferred to another room on 03/19/25, both rooms in Hall 4, because of aggression to her initial roommate. The DON stated Resident #13 transferred rooms on 06/27/25, from Hall 4 to Hall 2, because she became a long-term resident. She stated nursing staff was responsible for room transfer notification. The DON stated self and the ADON failed to notify the residents of their room transfer with the 5-day notice. She stated if written notices for room transfers were provided to the residents, the facility would have copies. DON stated it was not done and could not provide a reason written notices were not provided.In an interview on 07/24/25 at 3:15 PM with the Administrator who stated Resident #13 was transferred on 03/19/25 because Resident #13 was upset her roommate in Hall 4 spoke primarily Spanish. She stated Resident #13 was transferred to another room in Hall 4 that day she was admitted [DATE]. She stated she was not familiar with the 5-day notification or written notice for room transfer. She stated she was not sure why Resident #57's RP was not notified of room transfer prior to change and his RP was involved in Resident #57's care. The Administrator stated there was no written notice of room transfers for residents. She stated the ADON and DON were responsible for room transfers. The Administrator stated she did was not sure how room transfers without notification could affect the residents.Record review of facility's policy Room Changes dated 07/11/25, read in part: -If a resident is asked to relocate to another room, 5 days' notice must be given to the resident or responsible party prior to the move. The resident or responsible party can waive the 5 days and move earlier. -The notice must be in writing and include the reason for the changes.

Based on interview and record review the facility failed to ensure the residents had information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency and the State Long-Term Care Ombudsman program in a language understood for 7 of 7 residents (Confidential Group). The facility failed to ensure the Ombudsman information was reviewed with residents in the facility and ensure the information was discussed on how to file a complaint with the State agency when residents interviewed in a confidential group meeting were unaware, they had a Long-Term Care Ombudsman Program, contact information for the Ombudsman or how to file a complaint with the State agency. This failure could affect the residents who reside in the facility, to not be aware of resources that were available to them.Findings included: Record review of monthly resident council minutes for the last 6 months on 7/24/2025 at 8:40 am revealed no documentation of discussion regarding information on filing a complaint directly with the state agency or review of ombudsman information. In a confidential group meeting at 9:00 a.m., (7) residents present stated they did not know how to contact the ombudsman and how to file a complaint with the state agency. The residents agreed they were given a brief overview of the program and the name of the Ombudsman.During an interview with Administrator on 07/24/2024 at 3:30 p.m., revealed that upon admission the admission packet should have information regarding addressing concerns and grievance procedures. She stated that that when residents were admitted she introduced herself as administrator and as abuse coordinator and if residents or residents' families had any concerns, they could file a grievance directly with her, DON or any staff member that they voiced concerns with. She stated that she did not provide information verbally regarding filing complaints directly with the state, unless the family of resident voices that they do not wish to file the complaint with facility staff and wish to do it directly with the state, then the facility provides state number and ombudsman information. She stated that during resident council meetings the topic on state agency information was not discussed with residents as it was not a part of the checklist that corporate provides staff to use. During an interview with Activities Director on 7/24/2025 at 4:45 pm revealed that during resident council meetings, she goes through a checklist that touches on each department. She stated that if there were any concerns brought up during the meeting she was responsible for writing down the grievance and she has 3 to 5 days to resolve it. It was then brought up during the next meeting. She stated that the facility has ombudsman information posted in the entrance of the facility. She stated that residents and families could ask staff if they wanted the state number. She stated that the residents were verbally told that they had the right to file a complaint directly with the state if they wished to do so. She stated that she did not document that she verbally explained the process of contacting the state agency to file a complaint. Record Review of facility admission packet titled Health Care Center Policies, Information and Required Notices table of contents listed a section for policy for raising and addressing concerns grievance procedure, however, raising and addressing concerns grievance procedure section, was not covered in the facility packet and state agency number and ombudsman numbers were also not included.Record Review of resident rights policy revised on 11/28/2016 revealed The facility must provide a notice of rights and services to the resident prior to or upon admission and during the residents stay. The resident has the right to receive notices orally (meaning spoken) and in writing (including braille) in a format and a language he or she understands including, a list of names, addresses (mailing or email) and telephone numbers of all pertinent State regulatory and informational agencies. Resident advocacy group such as the State Survey Agency, the State licensure office, the state long term care ombudsman program, the protection and advocacy agency . A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding return to the community.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to provide the necessary services to maintain good grooming and personal hygiene care for 4 (Resident #83, Resident #5, Resident #66 and Resident #18) of 5 residents reviewed for ADL care. <BR/>Resident #18 did not have her brief changed on a timely basis and was not turned as needed. <BR/>The facility failed to ensure facility staff provided showers, personal grooming for Resident #83, Resident #5, and Resident #14. <BR/>This failure could place residents at risk of not receiving assistance with personal care which could cause pain, skin breakdown, and low self-esteem. <BR/>Findings Included: <BR/>Resident #83 <BR/>Record review of Resident #83's Face Sheet admission date was 11/21/2022 at the facility. <BR/>Record review of Resident #83's History and Physical dated 11/22/2022 indicates Resident #83 was a [AGE] year-old female who had a diagnosis of End Stage Renal Disease, hypertension, Type 2 diabetes, and osteomyelitis. <BR/>Record review of Resident #83's MDS Quarterly dated 02/27/23 documented a BIMS score of 14 indicating no cognitive impairments. It also demonstrated she was extensive assistance with two-person assistance with ADLs including personal hygiene. It was also indicated bathing as total dependence with one person assistance. <BR/>Record review of Resident #83's Comprehensive Care Plan dated 03/17/2023 documented resident had ADL self-care in which she will maintain or improve current level of function with personal hygiene. Will need two-person assistance with bathing and did not indicate how often resident was to be showered/bathed. <BR/>Record review of Resident #83's Task Response History for bathing support provided - from 02/26/23 to 03/27/23, revealed 7 showers with one-person physical assist have only been conducted for that provided time period and the rest is marked as ADL activity itself did not occur. Task Response History for type of bath for 02/26/23 shown x15 did not occur. <BR/>Record review of Resident #83's Schedule for March 2023 provided by the facility demonstrates Resident #83 as having QShift bathing. It shows Resident #83 was showered every day from 03/01/23 to 03/28/23 with PRN bathing (x11) when resident had not showered for 15 days in the month. <BR/>Record review of Resident #83's Survey Report for March 2023, for bathing revealed (x19) 8.8s which indicates Total Dependence - Activity itself did not occur. <BR/>Record review of facility shower list for the east wing for four different days which two are undated (other 03/22/23, 03/20/23, 03/19/23) revealed Resident #83 was not showered two times as there was no CNA initials. CNAs are to initial after showering the resident had been completed.<BR/>Observation on 03/26/2023 at 8:30 a.m., Resident #83 was lying in bed in a gown face shiny with oil, hair was uncombed. <BR/>Interview on 03/28/23 at 4:40 PM ADON F stated he looked at Resident #83's orders, progress notes, and the MDS Survey Report for bathing. ADON F stated it was marked with an 8 which indicates the bathing/showers did not occur. ADON F stated the risk to the Resident #83 would be false documentation, skin issues, hygiene, and infection. <BR/>Interview on 03/28/23 at 4:45 PM ADON B stated the facility uses the facility shower list were CNAs initial for accountability in the CNA Assignment Book. <BR/>Interview on 03/29/23 at 9:28 AM MDS B stated the Survey Report for March 2023 for Resident #83 reveals the dated and times resident was showered or not revealed Resident #83 was not showered. <BR/>Interview and record review on 03/29/23 at 9:30 AM with MDS A and MDS B both stated if the date was marked with an 8 on the survey report, then it indicated that the resident was not showered for the day. MDS A stated resident was not showered. MDS B stated the showering schedule needed to be put into the care plan for Resident #83 which it was not in his care plan. MDS B stated the care plan did not mention anything about the shower schedule. MDS B stated the risk to not showering would be their dignity and infection. <BR/>Resident #5 <BR/>Record review of Resident #5's Face Sheet admission date was 06/15/2005 and was readmitted on [DATE] at the facility. <BR/>Record review of Resident #5's History and Physical dated 08/19/2021 indicates Resident #5 was a [AGE] year-old female with a diagnosis dementia with behavioral disturbances and Alzheimer's with delusional psychotic features. <BR/>Record review of Resident #5's MDS Quarterly dated 03/14/2023 documented a BIMS score of 3 and was left unmarked on her cognitive impairment or independence. It also demonstrated Resident #5's ADLs was extensive assistance one person assistance with personal hygiene, dressing, and bathing (physical help). It also documents a diagnosis of schizophrenia, Alzheimer's disease, non-Alzheimer's dementia, is at risk for pressure ulcers. <BR/>Record review of Resident #5's Comprehensive Care Plan dated 02/24/2023 indicated ADLs self-care will maintain current level of function with one person assistance with dressing and personal hygiene/oral with one person participation with bathing in the care plan. <BR/>Record review of Resident #5's Schedule for March 2023 provided by the facility demonstrates Resident #5 as having Q-Shift bathing as T-TH-SAT with PRN bathing (x11) for showering/bathing. <BR/>Record review of facility shower list for the east wing for four different days which two are undated (other 03/22/23, 03/20/23, 03/19/23) revealed Resident #5 was not showered two times as there was no CNA initials. CNAs are to initial after showering the resident had been completed. <BR/>Interview on 03/28/23 at 4:45 PM ADON B stated the facility uses the facility shower list were CNAs initial for accountability in the CNA Assignment Book. <BR/>Interview on 03/29/23 at 9:28 AM MDS B stated the Survey Report for March 2023 for Resident #5 revealed the dates and times resident was showered or not revealed Resident #5 was not showered. <BR/>Observation on 03/29/23 at 9:29 AM MDS B review the MDS Survey Report for March 2023 for Resident #5. <BR/>Observation on 3/26/23 at 4:37 PM revealed Resident #5 hair was not combed and was disheveled. <BR/>Observation on 3/27/23 at 12:14 PM revealed Resident #5 hair was not combed and was disheveled. <BR/>Observation on 3/27/23 at 4:01 PM revealed Resident #5 hair was not combed and was disheveled. <BR/>Observation on 3/28/23 at 10:09 AM revealed Resident #5 hair was not combed and was disheveled. <BR/>Interview on 03/29/23 at 9:30 AM with MDS A and MDS B both stated if the date was marked with an 8 then it indicated that the resident was not showered for the day. MDS B stated he had not been showered. MDS B stated the showering schedule needed to be put into the care plan and on PCC for Resident #5. MDS B stated the care plan did not mention anything about the shower schedule in the care plan. MDS B stated the risk to not showering would be their dignity and infection. <BR/>Resident #66 <BR/>Record Review of Resident #66 Face Sheet dated 3/27/23 documented in part a [AGE] year-old male, admitted on [DATE]. <BR/>Record Review of Resident#66 Quarterly MDS dated [DATE] documented Resident #66 had a BIMS of 6 indicating he was severely cognitively impaired. Resident #66 required extensive assistance with one person assistance for personal hygiene, and dressing. Resident #66 is wheelchair-bound and requires total dependence for bathing with one person's assistance. Section I revealed active diagnosis of abnormalities of gait and mobility and lack of coordination. <BR/>Record Review of Care Plan dated 4/18/21 documented Resident #66 had an ADL self-care performance deficit. Resident #66 required assistance with personal hygiene, and bathing and did not indicate a shower schedule. <BR/>Record Review of Resident #66 March bathing task scheduled record indicated Resident #66 only received 6 baths and all other days were marked as this activity did not occur indicating Resident #66 was not showered. <BR/>Interview with Resident #66 on 3/26/23 at 02:59 PM revealed he was not getting his showers as scheduled. Resident #66 stated, they are times when I get maybe 2 showers a week and I know I am scheduled to receive 3 baths per week. <BR/>Resident #18 <BR/>Record review of Resident #18's admission MDS dated [DATE] documented that she was [AGE] years old and was admitted to the facility on [DATE]. Her diagnoses included a broken lower left leg (displaced comminuted fracture of shaft of left tibia). Her BIMS was 13 (cognitively intact). She needed extensive assistance from one person to dress and perform personal hygiene. She did not walk and did not move around the facility during the lookback period. She was totally dependent on one staff member for baths. She required extensive assistance from two people to move around in bed, to transfer between surfaces, and to use the toilet. She was always incontinent of bowel and bladder. She was at risk of developing pressure ulcers. <BR/>In an interview on 03/26/23 at 10:15 AM Resident #18 stated that when she turned on her call light because she had urinated and needed a brief change, staff members did not come for a long time. She was unable to specify how long it took. She said that most of the time it took them too long. She also said she had diarrhea a few weeks back and she had to wait a long time for staff to change her soiled brief. <BR/>In an interview on 03/27/23 at 10:28 AM Resident #18 stated that she had to wait a long time to get changed. She was not able to remember any particular dates or times. She stated that the only time NAs came to check on her was when she turned on the light and that the only times they turned her was when they changed the wound dressing on her back, which was every other day. <BR/>Record review of Resident #18's Point of Care Response History for 02/28/2023 - 03/28/2023 documented that she was not turned on any shift on two days and turned only once on four days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, 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 food and nutrition services, in that: <BR/>1. <BR/>Food products in dry storage, freezer, and in refrigerator were not correctly labeled, wrapped, or were expired. <BR/>2. <BR/>Staff were not wearing hairnets properly. <BR/>3. <BR/>Freezer was dirty. <BR/>4. <BR/>Food temperatures were not taken prior to serving meals. <BR/>5. <BR/>Staff did not wash hands after touching hair on the serving line. <BR/>These failures could affect residents by placing them at risk of food borne illness. <BR/>Findings include: <BR/>Observation and interview on 3/26/23 at 8:03 AM initial tour was conducted with Kitchen Aide P. Kitchen Aide P stated dessert in plastic containers (total of 11) were not labeled and should have been labeled with date they were prepared and chicken wings in freezer and sausages did not have date of when it was opened and should have been dated with date it was opened. The Kitchen Aide P stated the freezer was dirty with some spillage of unknown kind and stated the freezer was supposed to be cleaned weekly and stated it did not appear it had been cleaned recently, she stated there was spillage of some kind and dirt under the frozen goods. Kitchen Aide P stated the bins of flour (1 bin) and rice (1 bin) did not have labels with dates should be dated when they were filled. Kitchen Aide P stated she received training upon hire on food storage and labeling and sanitary conditions. Kitchen Aide P stated all kitchen staff were in charge of ensuring all goods were properly labeled and dated and kitchen supervisors were in charge of conducting checks as well. Kitchen Aide P stated kitchen managers were the ones in charge of taking food temperatures before meals and stated they did not keep a food temperature log. Kitchen Aide P stated she had not seen a temperature log for several days or seen the kitchen managers write down food temperatures anywhere. <BR/>Interview on 3/26/23 at 8:10 AM the Kitchen Supervisor stated they have not had a food temperature log for several days and they have been writing food temperatures down on scratch sheet of paper. The Kitchen Supervisor stated she did not have today's food temperatures for breakfast meals because they were running behind in the morning and did not have a chance to take the food temperatures. The Kitchen Supervisor stated by not taking food temperature could place residents at risk of acquiring food borne illness by not ensuring foods were served at appropriate food temperatures. <BR/>Observation and interview on 3/26/23 at 11:25 AM Dietary Manager stated all foods were required to be dated and labeled, he stated the items in the refrigerator were labeled on the food tray to not have to write on all items item by item (picture submitted to evidence shows 11 desserts in plastic containers not labeled [NAME] food tray that does not have a label with date).The Dietary Manager stated the staff should be cleaning the freezer at least weekly to not expose frozen goods to cross contamination. The Dietary Manager stated the flour and rice bins should have been dated and would get to it soon, stated he should have dated them when they were filled. The Dietary Manager obtained a copy of March ' s food temperature log with breakfast temperature for today recorded. The Dietary Manager stated she had filled out the form after State Surveyor left the kitchen and the information documented was not accurate for today ' s breakfast temperatures, The Dietary Manager stated food temperatures should be recorded before serving meals and not after they had served for accuracy in documentation and accuracy in temperatures. <BR/>Observation on 3/26/23 at 11:56 AM Kitchen Aide was on the serving line preparing meal trays to be distributed, her bangs were not covered with the hair net. The Kitchen Aide touched her bangs to fix them off her face 4 times and continued to serve food using kitchen utensils every time. The Kitchen Aide did not wash hands, use hand sanitizer, and was not wearing gloves each time she touched her hair and continued to serve food. <BR/>Interview on 3/26/23 at 12:50 PM Dietary Manager stated all staff who assisted with meal service were required to wash hands before assisting and could use hand sanitizer few times before having to wash again. The Dietary Manager stated hair nets were required to cover all hair and if staff were to touch hair while serving food on serving line they should be stepping aside to wash hands. The Dietary Manager stated the DON had conducted several hand hygiene in-services in the past addressing when they should be washing their hands. The Dietary Manager stated by not wearing hairnets appropriately and not washing hands after touching hair while at serving line was a cross contamination issue. <BR/>Interview on 3/26/23 at 1:13 PM Kitchen Aide Q stated she should have been wearing her hair net correctly which included bangs being covered. The Kitchen Aide Q stated she should have stepped away to wash hands or use hand sanitizer each time she fixed her hair, and her failure could place residents at risk of cross contamination leading to some type of infection. The Kitchen Aide Q stated she received training of hand washing and hair nets upon hire. <BR/>Record review of Daily Food Temperature Control Policy dated 2012 revealed We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges. 2- Prior to meal service, the cook shall take the temperature of all hot and cold foods. 3- Temperatures are recorded on the Temperature Log Form. <BR/>Record review of Dietary Food Service Personnel Policy and Procedures dated 2012 revealed Sanitation and Food Handling: 2- hair nets or hats covering the hairline are worn at all times. 3- wash your hands before starting work, touching something that is not clean and then handling food can cause food poisoning. <BR/>Record review of Storage Refrigerators policy dated 2012 revealed All storage refrigerators shall be maintained clean and have proper temperature for food storage and to ensure a proper environment and temperature for food storage. 4- storage refrigerators shall be kept cleaned and organized. Spills are to be wiped up immediately. 5- food must be covered when stored, with date label identifying what is in the container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 (Resident #2) of 5 residents reviewed for medical records. <BR/>The facility failed to ensure Resident #2's medical record accurately documented Resident #2's sexual abuse/expiation allegation. <BR/>This failure could place residents at risk of having incomplete and inaccurate medical records possibly resulting inadequate treatment/care. <BR/>Findings include: <BR/>Record review of Resident #2's face sheet dated 02/13/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #2's most recent facility history and physical in the system dated 12/21/20 revealed a [AGE] year-old female diagnosed with Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), Vascular Dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage, and cachexia (a complicated metabolic syndrome related to underlying illness and characterized by muscle mass loss with or without fat mass loss). <BR/>Record review of Resident #2's quarterly MDS dated [DATE] revealed a cognitively intact BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 11 to be able to make daily decision and recall information. Resident #2 needed partial/moderate (half the help) assistance from nursing staff to help in showering/bathing. Resident #2 was diagnosed with Non-Alzheimer's Dementia, muscle wasting, lack of coordination, and muscle weakness (no muscle strength). <BR/>Record review of Resident #2's shower report dated 02/02/24 at 8:16 PM and 02/09/24 at 5:57 PM revealed CNA H had showered/bathed Resident #2. <BR/>Record review of CNA H's time sheet dated 02/02/24 and 02/09/24 revealed he had been working on Resident #2's shower days (02/02/24, 02/09/24 (Resident #2 was to be showered Monday, Wednesday, Friday). <BR/>Record review of Resident #2's Weekly Assessments, Event Note Assessments, all other Assessments dated 02/12/24 revealed, from 02/02/24 to 02/13/24 did not indicate any assessments were conducted for the sexual abuse/exploitation allegation of Resident #2. <BR/>Record review of Resident #2's Progress Notes dated 02/12/24 revealed, from 02/02/24 to 02/13/24 did not indicate any assessments were conducted or any information regarding the sexual abuse/exploitation allegation of Resident #2. <BR/>Record review of Resident #2's care plan dated 12/19/20, revealed for bathing she required two staff for assistances. Care plan dated 12/19/20 revealed impaired cognitive function or impaired thought processes due to Dementia. Engage the resident in simple, structed activities that avoid overly demanding tasks. Monitor/document/report to medical doctor any changes in cognitive function, specially changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding other, level of consciousness, mental status. <BR/>Record review of Resident #2's [NAME] (documentation on the facility system that CNAs use to view resident care) dated 02/17/24, revealed bathing: requires staff x2 for assistance. <BR/>Record review of Resident #2's shower report dated 02/02/24 at 8:16 PM and 02/09/24 at 5:57 PM, revealed CNA H had showered/bathed Resident #2. <BR/>Record review of CNA H's time sheet dated 02/02/24 and 02/09/24, revealed he had been working on Resident #2's shower days on Friday 02/02/24 and 02/09/24. Resident #2 showers on Mondays, Wednesdays and Fridays of every week. <BR/>Record review of Resident #2's Weekly Assessments, Event Note Assessments, all other Assessments dated 02/12/24, revealed, from 02/02/24 to 02/13/24 did not indicate any assessments were conducted for the sexual abuse/exploitation allegation of Resident #2. <BR/>Record review of Resident #2's Progress Notes dated 02/12/24 revealed, from 02/02/24 to 02/13/24, did not indicate any assessments were conducted or any information regarding the sexual abuse/exploitation allegation of Resident #2. <BR/>Record review and observation of text message provided to surveyor between LVN F, LVN E, and DON 02/02/24 at 5:17 PM read as follows: LVN F when you get a chance can you go talk to Resident #2, she told the Business Office Assistant that when CNA H or CNA O bath her they do something to her. <BR/>At 5:25 PM - LVN F stated, Yes I will.<BR/>At 5:28 PM - DON stated, thank you, let me know what she says. <BR/>At 6:08 PM - LVN F stated, Resident #2 says she feels CNA H touches her inappropriately when he's bathing her. <BR/>At 6:13 PM - DON stated, OMG (oh my god). <BR/>LVN F stated, Shouldn't the Social Worker and Administrator have interviewed Resident #2. I feel like that's serious allegations.<BR/>LVN E stated, Resident #2 says that when CNA H's washing her he washes her Parts and she feels him put his fingers inside of her. <BR/>DON - stated she would talk to her on Monday (unknown which Monday). <BR/>LVN F stated, No one came to help out. <BR/>Nothing else follows in the text message in regard to the sexual abuse/exploitation outcry from Resident #2. During an interview on 02/12/24 at 4:42 PM with LVN F, he stated that he had received a message from the DON revealing that Resident #2 was stating CNA H was touching her in her private parts during shower/bathe time. LVN F stated he and LVN E went to go speak with Resident #2 in which she told them that CNA H was touching her and would stick his fingers inside of her when he showered her and did not want CNA H to shower her anymore. LVN F stated he thought it was a serious allegation and though the Administrator and Social Worker would be the ones to go interview Resident #2 regarding her allegation. <BR/>During an interview on 02/12/24 at 5:12 PM with LVN E, she stated the DON had sent LVN F a text message wanting for LVN F to go speak to Resident #2 about her allegation. LVN E stated that she went with LVN F to go talk to Resident #2 in which she stated that CNA H had touched her in her private parts. LVN E stated the DON and Administrator should have been the ones to go and interview Resident #2. LVN E stated Resident #2 claimed that CNA H would penetrate her through the shower chair and would go underneath the bottom of the shower chair. <BR/>During an interview on 02/13/24 at 1:00 PM with Resident #2, she stated she had reported to LVN F that Resident #2 had been touching her down there when CNA H showers her. Resident #2 stated CNA H will put on his music and dance while he showers her. Resident #2 stated she did not have strength and was weak to fight back against CNA H. Resident #2 stated she did not want CNA H around her and did not feel safe around him. Resident #2 stated she had not reported it due to feeling embarrassed. <BR/>During an interview on 02/13/24 at 1:35 PM, with the DON, she stated that Resident #2 had made an outcry of sexual abuse/exploitation to the Business Office Assistant. The DON stated the Business Office Assistant was told by Resident #2 that CNA H had touched Resident #2 in her private area. The DON stated she had instructed LVN F to go and speak with Resident #2 regarding the sexual abuse/exploitation outcry and report back to her what she had said. The DON stated she was still working on the investigation. The DON stated she had not done any assessments on Resident #2. The DON stated LVN E had done a body assessment for Resident #2 but was not documented. The DON stated if it was not documented it did not happen. The DON stated she could not recall the exact date of Resident #2's sexual abuse/exploitation outcry. The DON stated she had not imputed anything into the computer. The DON stated there was no reason for the delay for not documenting and doing an assessment on Resident #2. <BR/>During an interview on 02/13/24 at 2:55 PM with the Administrator, she stated she was unaware of the alleged allegation from Resident #2 of sexual abuse/exploitation. The Administrator stated she was just notified right now of the sexual abuse/exploitation outcry for Resident #2 from LVN F. The Administrator stated she was told by LVN F that Resident #2 had alleged CNA H had touched her incorrectly. The Administrator stated LVN F told the DON about what Resident #2 had alleged. The Administrator stated she was not told by the DON what Resident #2 had alleged. The Administrator stated once an outcry of an allegation has been made it needed to be reported to the Abuse Coordinator which was her. The Administrator started she would take measures to talk to the resident and see what had happened as well as suspend the staff to ensure the safety of the Resident #2 until the conclusion of the investigation. The Administrator stated there could be a risk if the outcome was proven correct in that CNA H did do the sexual abuse/exploitation. The Administrator stated she had sent CNA H immediately as soon as she found out. The Administrator stated she still needed to go speak to Resident #2. The Administrator stated she did not know if a body assessment was conducted for Resident #2. The Administrator stated she did not report it to state survey agency as she not notified of the sexual abuse/exploitation allegation. The Administrator stated it would have been protocol for the nurses to do a body assessment. <BR/>During an interview on 02/15/24 at 10:28 AM with ADON G, she stated when an incident happens it needs to be documented right away. ADON G stated not documenting or documenting right away could be a risk to the residents. ADON G stated the risk could be the resident having an injury and the facility not doing anything about it. ADON G stated facility staff were trained on documenting. <BR/>During an interview on 02/16/24 at 2:08 PM with the Administrator, she stated that both LVN F and LVN E did not document the assessment nor the sexual abuse/exploitation outcry for resident #2. The Administrator stated it should have been documented and could have been a risk to the resident but did not indicate what the risk was. <BR/>During an interview on 02/16/24 at 2:26 PM with LVN F, he stated he was not told do an assessment on Resident #2 nor was it documented. LVN F stated it should have been documented but did not indicate why it was not documented. <BR/>During an interview on 02/16/24 at 2:26 PM with LVN E, she stated she was not asked to do a head-to-toe assessment on Resident #2. LVN E stated it should have been documented but did not indicate why it was not documented. <BR/>Record review of the facility Documentation policy and procedure manual dated 2003 revealed, Documentation was the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has a legal requirement regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessments, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets weekly, daily, monthly, discharge).<BR/>Goal- The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. <BR/>The facility will ensure that information was comprehensive and timely and properly signed. <BR/>Document completed assessments in a timely manner and per policy. <BR/>Complete documentation in narrative nursing notes as needed in a timely manner.<BR/>Daily documentation x72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 (Resident #11) of 3 residents reviewed for urinary catheter care. <BR/>Resident #11's catheter bag did not have a catheter bag cover exposing the catheter bag filled with urine<BR/>This failure could have compromised residents' dignity for those who require urinary catheter care. <BR/>Findings include: <BR/>Record review of Resident #11's face sheet dated 02/14/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #11's facility history and physical dated 11/06/23 revealed a [AGE] year-old male diagnosed with schizophrenia (a serious mental disorder in which people interpret reality abnormally) and bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode)). <BR/>Record review of Resident #11's quarterly MDS dated [DATE] revealed an intact cognition to be able to recall and make daily decisions BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 13. Resident #11 was dependent on nursing staff for toileting. Resident #11 had an indwelling catheter. <BR/>Record review of Resident #11's care plan dated 01/13/24 revealed indwelling catheter - check for kinks and maintain the drainage bag off the floor, ensure tubing is anchored to the resident's leg or linens so that tubing was not pulling on the urethra, monitor and document intake and output as per facility policy, and for signs of discomfort on urination and frequency. <BR/>Observation on 02/15/24 at 9:47 AM revealed Resident #11 was lying down in the bed with an indwelling catheter. The indwelling catheter was hanging from the bed and did not have a cover. <BR/>Observation and interview on 02/15/24 at 9:54 AM with LVN J, she stated Resident #11's indwelling catheter bag needed to have a cover for Resident #11's dignity, his privacy, and infection control. LVN J stated it was everyone's responsibility for ensuring the indwelling catheter bag had a covers. <BR/>During an interview on 02/15/24 at 10:28 AM with the ADON G, she stated indwelling catheters were to be placed on the edge of the bed hanging with a cover for privacy. ADON G stated not having a cover could result in a negative outcome for the resident's dignity. ADON G stated it was the nurses and CNAs responsibility to ensure there was a privacy cover on the indwelling catheter bag. <BR/>During an interview on 02/15/24 at 11:00 AM with the Area Director of operations, stated DON was suspended, so no interview regarding the indwelling catheter was conducted with DON. <BR/>Record review of the facility's Catheter Insertion, Male/Female policy and procedure manual dated 2003 revealed, An indwelling catheter provides continuous bladder drainage in residents with a neurogenic bladder or urinary disfunction.<BR/>Catheter Change/Replacement - Catheters that are encrusted so that urinary outflow was blocked should be changed. <BR/>Record review of the facility's Resident Rights policy manual dated 11/28/16 revealed, Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.<BR/>Respect and Dignity - The resident has a right to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #14) of 16 residents reviewed for call light placement.<BR/>The facility failed to ensure that Residents #14's call light was within her reach.<BR/>This failure placed residents at risk of not being able to call for assistance when needed.<BR/>Findings included: <BR/>Record review of Resident #14's face sheet dated 02/17/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #14's facility history and physical dated 01/06/23 revealed a [AGE] year-old female diagnosed with severe intellectual disability (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills) and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). <BR/>Record review of Resident #14's annual MDS dated [DATE], revealed positive for Intellectual Disability. No score was documented for BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements). Activities of Daily Living noted Resident #14 was dependent on nursing staff for eating, oral/personal hygiene, toileting, showering, and dressing. Resident #14 was diagnosed with Cerebral Palsy, Seizure Disorder (a disorder of the brain), lack of coordination, and severe intellectual disabilities. <BR/>Record review of Resident #14's care plan dated 03/16/23, revealed she has a communication problem due to Intellectual Disability. Ensure/provide a safe environment: Call light within reach.<BR/>Observation and interview on 02/17/24 at 2:42 PM with Admissions Marketing Director K and Admissions Marketing Director L, revealed the call light was clipped on to the call light cord on the wall away from Resident #14 who was lying down on her bed. The Admissions Marketing Director K stated the call light had to be within reach of the resident. Admissions Marketing Director K stated it was so Resident #14 could call for assistance. Admissions Marketing Director L stated the risk of not having the call light within reach could result injury or a fall. Admissions Marketing Director L stated all staff were trained in call light placement with residents. <BR/>During an attempted interview on 02/17/24 at 2:50 PM with Resident #14, when interviewed Resident #14 just looked and smiled at investigator. <BR/>During an interview on 02/17/24 at 3:17 PM with CNA M, she stated call lights had to be within reach of a resident to be able to call facility staff for assistance. CNA M stated not having the call light within could result in the resident not being able to call for help or assistance if they needed. CNA M stated it was everyone's responsibility to ensure resident call lights were within reach. <BR/>During an interview on 02/17/24 at 3:02 PM with CNA O stated everyone was responsible for ensuring call lights were within reach of the residents. CNA O stated there could be a risk if it was not within reach in which the resident would not be able to call for assistance or help. <BR/>During an interview on 02/17/24 at 3:28 PM with NCNA N, he stated residents needed to have call lights within so residents would be able to call nursing staff for anything or in an emergency. NCNA N stated there could be a risk to the resident like falling or like someone was in their room that should not be in there . <BR/>During an interview on 02/17/24 at 3:39 PM with the Administrator, she stated call lights have to be within the reach of the residents for assistance or an in emergency. The Administrator stated there was a risk if there was an emergency. The Administrator stated that all facility staff were trained on call lights. <BR/>During an interview on 02/17/24 at 3:05 PM with the Regional Nurse, she stated the facility had no call light policy.<BR/>Record review of the facility's Resident Rights policy manual dated 11/28/16 revealed, Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.<BR/>Respect and Dignity - The resident has a right to be treated with respect and dignity, including:<BR/>The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to communicate with hospice representatives for 1 of 7 (Resident #1) residents reviewed for hospice services. <BR/>The facility failed to notify Hospice of Resident #1's acute glucose level increase on 05/04/24. <BR/>This deficient practice could place residents who receive hospice services at risk of receiving substandard care due to miscommunication between their hospice and facility care givers. <BR/>The findings included: <BR/>Record review of Resident #1's face sheet dated 5/16/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of DM II (long-term condition in which the body has trouble controlling blood sugar and using it for energy), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and anxiety. <BR/>Record review of Resident #1's physician order dated 09/27/23 revealed an order for accucheck daily for DM II, notify MD if blood glucose levels less than 70 or over 400, and symptomatic she was a full code. <BR/>Record review of Resident #1's physician order dated 10/07/22 revealed order for admitted to hospice with diagnosis of hypertensive heart disease with heart failure. <BR/>Record review of Resident #1's care plan dated 05/15/24 revealed focus area for DM II with hyperglycemia and interventions that included Monitor/document/report to MD PRN signs and symptoms of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. <BR/>Record review of Resident #1's vital signs for May 2024 revealed a blood glucose level of 349 on 05/04/24 at 5:31 am. <BR/>In an interview on 5/11/24 at 12:07 pm, LVN C stated she had worked a double shift (6am-10pm) on 05/24/24 and was the nurse responsible for Resident #1. LVN C stated she had not received a report from the night shift nurse regarding Resident #1's blood glucose level 349. LVN C stated she had not checked Resident #1's vital signs therefore she was not aware of Resident #1's glucose level that morning. LVN C stated Resident #1 had been fatigued throughout the day and had an increase in thirst. LVN C stated when an acute change was noted, like an increase in glucose levels, she had been trained to report it to the Hospice nurses and document actions taken to address the increase in glucose level . <BR/>In an interview on 5/11/24 at 12:56 pm, the Hospice Nurse stated he was on call the weekend of Friday 05/03/24 through Sunday 05/05/24. The Hospice nurse stated the facility was required to report any acute changes in condition to them. The Hospice nurse stated an increase of blood glucose level out of the resident's normal range would have been something the facility should have reported. The Hospice Nurse stated they would review the residents file and either adjust medication and/or insulin and reach out to the MD and the family to see what aggressive treatment they wanted for the resident . <BR/>In an interview on 5/13/24 at 9:31 am, the DON stated it was expected for the charge nurses to report an acute change in blood glucose levels. The DON stated the charge nurses should have followed up on the glucose levels with another Accu-Chek, monitor symptoms, and report to MD if glucose levels and/or symptoms kept increasing. The DON stated the nurses received training upon hire and the risks included lack of blood glucose monitoring . <BR/>In an interview on 5/14/24 at 11:56 am, the Hospice NP stated the facility should report glucose levels depending on their order parameters. The NP stated if the order read to report the glucose level if lower than 70 or higher than 400 and if the resident started showing some symptoms the facility should not wait until resident's blood glucose levels were over 400. The NP stated a blood glucose level of 349 with some symptoms should have been reported for medication adjustment or insulin to be adjusted . <BR/>In an interview on 05/16/24 at 1:58 pm, the Compliance Nurse stated the facility was only to report a blood glucose level to hospice if over 400. The Compliance Nurse stated that hospice would not do anything for a blood glucose level of 349. <BR/>Record review of Hospice Services policy dated 02/13/2007 read in part as an end-of-life measure, the resident or responsible family member may choose to use hospice services within the facility. The resident and/or responsible party will receive comfort care. The DON or designee will be responsible for immediately notifying the hospice of any significant change in condition. Notification will be documented in the medical record.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and locked in compartments 1 of 3 medication carts (medication cart A) reviewed for the storage of drugs and biologicals.<BR/>- The facility failed to secure medications located in medication cart A when unattended.<BR/>This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. <BR/>Findings included: <BR/>An observation on 02/21/2023 at 09:12 AM, revealed the facility's medication cart A was unlocked and unattended. The medication cart was in the hallway of zone 6. The drawers were unlocked and able to be opened by the surveyor. No employees were noted in hallway. MA A was in a resident's room and LVN B was down the hall of zone 4 in bedroom of RES #5. <BR/>An observation on 02/21/2023 at 08:55 AM, revealed RES #2 resided on zone 6 and was in the hallway. She used a wheelchair to transfer herself from one area to another. The unlocked medication cart A was in her hallway. <BR/>An interview and observation on 02/21/2023 at 09:19 AM with MA A, she said the resident that she was administering medications to was talking with her inside the resident's bedroom. She said she did not have the medication cart A within view. She said she normally did not stay in the room that long. She was asked if she usually left her cart unlocked, and she said her cart is usually facing the door. She demonstrated by moving her medication cart and placing it in front of the door with the drawers facing the inside of the bedroom. She was aware her cart was unlocked. She said she had been doing this for a long time and she does not leave her cart unlocked when the cart is not in use. She said nothing has ever happened and she knows the cart to be locked. <BR/>An interview on 02/21/2023 at 09:28 AM with LVN B, LVN B said each person was responsible for their cart. LVN B was asked if there was a risk for residents if a medication cart was to be left unlocked and shook her head no with her shoulder's raised. <BR/>An interview on 02/21/2023 at 3:30 PM with MA B revealed that her cart was locked. She showed the surveyor her keys and said she does not share her keys with anyone. She said the cart being open is dangerous because anyone can have access to the medications. <BR/>An interview on 02/21/2023 at 3:50 PM with RN A revealed each medication cart has it own set of keys. RN A keys are passed on at shift change. RN A said each nurse or medication aide was responsible for their cart during their shift. RN A said there could be a risk to the residents if they entered an unlocked medication cart. <BR/>An interview on 02/21/2023 at 4:05 PM with the ADM revealed employees should be aware of their medication carts remaining locked. The ADM Revealed that an unlocked medication cart could cause harm to a resident. <BR/>An interview on 02/21/2023 at 4:30 PM with ADON A, revealed employees have been educated to have their carts locked when not in view or in use. ADON A revealed that an unlocked cart could allow access to the cart. <BR/>Record review of the facility's policy on Medication Administration Procedures (PA 03-4.02) Pharmacy Policy & Procedure Manual 2003 (undated), reflected in part . 5 . During the medication administration process, the unlocked side of the cart must always be in full view of the nurse . 8. After the medication administration process is complete, the medication cart must be completely locked, or otherwise secured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 employees (SNA A) reviewed for infection control.<BR/>-The facility failed to ensure SNA A followed infection control procedures on performing hand hygiene after providing perineal care to Res #1.<BR/>The failure could place residents at risk for infection.<BR/>Findings include:<BR/>Record review of RES #1's face sheet with admission date of 01/02/2020 revealed an [AGE] year-old female with diagnoses of dementia (impairment of memory), repeated falls, muscle wasting and atrophy (loss of muscle tissue) abnormalities of gait and mobility (change in walking pattern), diabetes (high blood sugar) and abnormal posture.<BR/>Record review of RES #1's Minimum Data Set Resident Assessment and Care Screening dated 01/26/2023 revealed a Brief interview for Mental Status summary score of 03 indicating a severe cognitive impairment. <BR/>Record review of RES #1's care plan focus included bladder incontinence related to cognitive impairment and decrease mobility (revision on 01/10/2020), intervention/task reflected in part . Monitor/document for s/sx UTI (Urinary Tract Infection) . monitor/document/report . bladder infection <BR/>Observation on 02/16/2023 at 3:11 PM revealed SNA A performing perineal care (cleaning the private area to include vaginal and rectum area of resident) on RES #1 in her bedroom. SNA A had the resident on her back with a clean adult brief and wipes on the side of bed. The resident had her adult brief open. SNA A placed her gloves on and proceeded to provide perineal care to resident. She took the wipe and wiped the resident's vaginal area from front to back. The adult brief appeared to be soiled with urine. SNA A completed the task of perineal care on RES #1. She transferred the resident to her side to remove the soiled adult brief and placed the new adult brief. She repositioned the resident on her back and took the soiled adult brief and wipes and placed them in the trash. She then continued to place the clean adult brief on resident and cover her. The bed was placed in the lowest position using the control. The head of the bed was slightly elevated using the control. SNA A took the floor mats located next to the wall and placed them on the floor next to RES #1's bed. She proceeded to place the call bell within reach. SNA A did not change gloves at any time after providing perineal care, changing the adult soiled brief, placing the clean brief on the resident, repositioning the resident, placing the floor mats, or placing the call bell. SNA A was observed to have also touched her own face while wearing contaminated gloves after repositioning the resident and lowering her bed.<BR/>Interview on 02/16/2023 at 3:16 PM, SNA A said she forgot to change her gloves when she was done providing perineal care to RES #1. SNA A did contaminate other areas by not changing gloves. She said she was aware the correct technique was to change gloves after perineal care was provided. She said she was not aware she had not changed her gloves. washed her hands or used antibacterial hand gel prior to continuing care. Which included the placement of the mats and call bell with contaminated gloves on. She proceeded to remove her gloves and wash her hands after interview. <BR/>Interview on 02/16/2023 at 4:30 PM, C. RN said that SNA were Student Nurse Aides who had received training from the facility. C. RN said the training is based on phases. C. RN said the initial phase is 16 hours of classroom training prior to going on the floor with residents. C. RN said then there are two phases based on task afterwards. C. RN said SNA A had completed the initial and both phases of the program and is waiting for a test date for her Certified Nurse Aide Certificate. <BR/>Interview on 02/21/2023 at 1625, ADON A said the nurse aides go through training prior to working with residents. ADON A revealed she checked off on SNA A, Phase I and Phase II training and stated she had met competency. ADON A said student nurse aides are trained to preform competencies correctly to prevent injury or infection to residents. ADON A did stress the importance of hand hygiene to prevent cross contaminate of the residents. <BR/>Record review of SNA A's training record dated from 01/16/2023 to 01/19/2023 reflected she demonstrated competency in Hand Hygiene on 01/16/2023. The record included training on perineal care/incontinent care female on 01/18/2023. The record reflected in part . after disposing of used linen, and placing used equipment in designated storage area, remove and dispose of gloves (without contaminating self) into waste container and wash hands. <BR/>Record review of Hand Hygiene Phase 1 Competencies for Aides reflected in part . Procedural Guidelines: Turn on warm water. Wet hands and wrists. Apply soap or skin cleanser to hands to produce lather. Vigorously rub hands together in a circular motion producing lather for at least 20 seconds, washing all surfaces of the fingers and hands (including the wrists). Clean under nails by rubbing fingertips on palm of hand. Rinse hands thoroughly from wrist to fingertips, keeping fingertips down. Dry hands on clean paper towel and discard. Obtain a clean paper towel and turn off faucet with clean paper towel. Discard towel appropriately without contaminating hands .

Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care <BR/>equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment; failed to maintain 1 of 6 linen carts in safe operating condition. <BR/>The facility failed to maintain the oven in operational condition. <BR/>The facility failed to maintain a working trash can next to the hand washing sink in the kitchen. <BR/>The facility failed to correctly wash cookware using the three-compartment sink. <BR/>The facility failed to maintain 1 of 6 clean linen carts in safe operating conditions. <BR/>This failure could place residents at risk of foodborne illnesses; and potential for injury to residents and staff by not maintaining essential equipment in safe operating condition. <BR/>Findings include: <BR/>Observation and interview on 05/28/24 at 8:31 AM, the Dietary Manager revealed 3 of 5 stove knobs were missing. The oven door was being held closed by a bungie cord. The Dietary Manager stated that the hinges to the oven door were not working, and the oven would not stay closed. <BR/>Interview with the Dietary Manager on 5/28/24 at 4:05 p.m., revealed that the oven in the kitchen had not been working for over a month and that the knobs of the stove had been missing for about 3 months. The Dietary Manager said, We turn on the stove with our fingers or with a towel. <BR/>Observation and interview on 05/30/24 8:48 a.m., revealed the foot pedal of the trash can next to the handwashing sink in the kitchen was not working. Dietary Staff #1 assigned to dish washing stated, The trash can broke this morning. <BR/>Observation 05/30/24 8:49 AM, with Dietary Staff #1 revealed she was assigned to dish washing. Dietary Staff #1 stated In the first sink we scrape the food from the pans and cookie sheets, rinse them off with water, place them in the second sink to wash the pans, then we place the pans in the third sink that contains the chlorine. After that we place the pans/cookie sheets in dish rack and run them through the dish washing machine to sanitize them. She stated she was not aware and did not know why they needed to check the chemical levels in the Three-Compartment sink. She stated, We only check the chlorine in the dish washing machine and document the results in the log that is kept on the wall by the dishwashing machine. She stated, she was not aware of the Three-Compartment Sink Procedures posted directly above the 3-compartment written in English and Spanish. Dietary Staff #1 could not recall if she had been trained in how to wash the pots and pans in the Three-Compartment-Sink. <BR/>Observation and interview 05/30/24 8:54 AM, the Corporate Traveling Certified Dietary Manager and Dietary Staff #1, revealed that facility did not have logs to show that they were checking the chemical levels in the Three-Compartment Sink. The Consultant stated the facility only kept logs of the chemical checks done on the dish washing machine. Surveyor requested Policy & Procedure on using the Three-Compartment. <BR/>Observation and interview 05/30/24 8:55 AM, the Traveling Certified Dietary Manager and Dietary Staff #1 revealed that staff will check the chemical levels after the washing cycle is completed. The test strip level was dark orange color 150 ppm. <BR/>Interview 05/30/24 at 9:00 AM, with the Dietary Manager in the presence of the Corporate Traveling Certified Dietary Manager revealed that he had started working at the facility 4 days ago. He reported that he was aware that the kitchen staff were following the correct procedure on using the 3-compartment sink and had not had the opportunity to provide in-service training. He stated, I need to try to fix all identified concerns in the kitchen little by little. <BR/>Interview on 05/30/24 at 9:03 AM, with Dietary Staff #2 assigned to wash dishes, in the presence of the Corporate Traveling Certified Dietary Manager and the Dietary Manager, reported that she had been employed at the facility for 16 years. She reported that she washes pots and pans in the Three-Compartment sink. She reported that in the first sink staff scraped the food from the pans and cookie sheets and rinsed them off with water, then we put them in the second sink to wash the pans, then we put them in the third sink that contains the chlorine. After that we put them on plastic rack and run them through the dish washing machine to sanitize them. She reported that they only checked the chemical level for the dish washer and kept a log when chemical levels were checked when they started to wash dishes. She could not remember when she was trained in how to use the 3-compartment sink. <BR/>Review of poster posted directly above the Three-Compartment Sink revealed, Three-Compartment Sink Procedures. Dispenser to wash and sanitizer. 1. Wash Hot 110 degrees Fahrenheit. Fill the wash compartment with detergent solution. Wash lightly soiled items first-heavily soiled items last. Refill wash sink when suds dissipate. 2. Rinse all items in clean, hot water until all soap is removed. Change water often to prevent soap residue. 3. Fill sanitizer compartment with proper sanitizer solution. Completely immerse cleaned items in the sanitizer solution for at least one minute. Remove and place on clean surface to air dry. Check sanitizer solution frequently. Sanitizer Test Procedure: 1. Tear about 2 of test paper Hydrion QT-10. 2. Dip test paper in sanitizing solution for 10 seconds. Do not shake. 3. Compare strip to color chart on test paper dispenser at once. Test paper must read 150-400 ppm. <BR/>Interview on 05/30/24 at 9:45 AM, with Corporate Traveling Certified Dietary Manager revealed that 1 of 2 ovens in the kitchen was not working. <BR/>Interview on 05/29/24 at 4:07 p.m., the Maintenance Supervisor revealed that the facility staff completed electronic work orders and send to him. He stated that one of the ovens in the kitchen had hinges that are not working properly, and the oven door does not close. The stove's temperature control valve was not working properly and does not regulate the temperature in the oven. He also reported the stove was missing the knobs to turn on the burners. He stated that the oven and stove issues have been going on for 2-3 months because the vendor had been having problems finding the parts. He stated that the parts for the oven and stove were ordered on Friday 05/24/24 and delivery were pending. I reported the issues with the oven and the stove to the administrator and she told me to fix them as soon as possible. Surveyor requested copy of Purchase Order and/or Invoice from Vendor. <BR/>Interview on 05/30/24 at 9:32 AM, the Administrator revealed that she was aware that the hinges on the oven door had not been working for over a month. She stated that the oven door would not stay closed due to the hinges not working properly. She said she was not aware of any other issues with essential kitchen equipment. Administrator reported that the new Dietary Manager had started working May 23, 2024. She stated that the Dietary Supervisor had not reported any concerns to her. The administrator stated that she goes to the kitchen to check that Dietary staff are labeling foods and taking food temperatures. The administrator reported that they have an electronic system to submit work orders to the Maintenance Department. The staff will also verbally notify the Maintenance Director of any issues with equipment to ensure that work orders are promptly completed. The administrator reported that the area director had contacted a vendor to obtain the replacement parts for the oven door and that they are still pending delivery. The administrator stated that she was not aware that the oven hinges had not been working for several months. The Administrator was not aware that the stove knobs were missing from the stove. <BR/>In a telephone interview on 05/30/24 at 9:52 a.m. the Dietitian revealed she started working at the facility on March 01, 2024. She said it was not part of her regular duties to conduct inspections of the kitchen during her monthly visits. She stated that she was not aware of any problems with equipment in the kitchen. She stated that if the dietary staff voiced any concerns during her visit, she would follow up on their concerns and conduct in-service training as needed. <BR/>Record Review of Dietitian Consulting Contract dated March 01, 2024, revealed, Purpose: The purpose of this agreement is to arrange for dietetic consultation by the RD for the facility. Responsibilities of the Consultant: The RD's sole responsibility shall be to provide consultation to the facility. As such a consultant, the therapeutic dietitian shall give guidance and counsel the dietary department's food service program as follows: Oversees kitchen operation and provides consultation as necessary according to facility's policy. Participation of consultant on any survey for licensure or certification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure respiratory care was provided in a manner consistent with professional standards of practice for 1 (Resident#10) of 2 residents reviewed for respiratory care in that: <BR/>The facility failed to place Resident #10 ' s nasal cannula in a clear labeled bag while not in use. <BR/>These deficient practices could place residents at risk for infection due to improper care practices. <BR/>Findings Include: <BR/>Record review of Resident #10 ' s face sheet dated 01/22/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #10 ' s facility history and physical dated 08/03/23 revealed an [AGE] year-old female diagnosed with Type 2 Diabetes Mellitus, Asthma, Alzheimer ' s Disease, multiple of falls, and Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). <BR/>Record review of Resident #10 ' s quarterly MDS dated [DATE] revealed a severe cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 2. Resident #10 does have a behavior of delusions and wandering. Resident #10 needs partial/moderate assistance for nursing staff to sit to stand, chair/bed to chair transfer, toilet transfer. Resident #10 was total dependent on showers. Resident #10 was diagnosed with Alzheimer ' s, asthma, and muscle weakness (no muscle strength), and lack of coordination (Uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements). Resident was not marked for oxygen therapy as the MDS was done on 10/12/23 before Resident #10 needed oxygen. <BR/>Record review of Resident #10 ' s order recap dated 01/05/24 revealed change nasal cannula as needed. Check oxygen saturation every shift and as needed and every shift. May use oxygen at 2 liter per minute via nasal cannula every shift. <BR/>Record review of Resident #10 ' s Care Plan dated 08/22/22 revealed Resident #10 has asthma and was at risk for respiratory distress. Give medications as ordered. Give nebulizer treatments and oxygen therapy as ordered. <BR/>Observation on 01/13/24 at 1:13 PM revealed Resident #10 ' s nasal cannula to be placed on top of the concentrator unbagged. The nasal cannula part where it goes into your nose had a slight tint color as well as some parts of the oxygen tubing. <BR/>During an interview on 01/13/24 at 1:20 PM with the family member, she stated the nursing staff always just placed Resident #10 ' s nasal cannula on the concentrator unbagged. <BR/>During an interview on 01/13/24 at 1:25 PM with MDS Coordinator C, she stated nasal cannulas are to be bagged if not in use. MDS Coordinator C stated the risk of not bagging the nasal cannula could be infection to the resident. <BR/>Observation and interview on 01/22/24 at 10:25 AM with the DON, she stated Resident #10 ' s nasal cannula should be changed as needed or once a week. The DON stated Resident #10 ' s nasal cannula being unbagged and placed on the concentrator was unacceptable. The DON stated Resident #10 ' s nasal cannula should have been placed in a clear baggy that was labeled with the date. The DON stated that was so the nursing staff would know when to change the nasal cannula. The DON stated Resident #10 ' s nasal cannula had been used. The DON stated not bagging the nasal cannula was a risk to Resident #10 with an infection. <BR/>Record review of the facility Infection Control Plan: Overview policy dated 2019 revealed, The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. <BR/>On 01/22/24 at 9:00 AM with the Administrator, she stated the facility did not have an oxygen policy specifically about nasal cannulas being bagged. <BR/>Record review of the facility Oxygen Administration policy dated 02/13/07 revealed, Oxygen therapy includes the administration of oxygen in liters per minute by cannula or face mask to treat hypoxemia conditions caused by pulmonary or cardiac diseases. <BR/>The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. <BR/>The resident will be free from infection. <BR/>Changing the tubing (including any nasal prongs or mask) that was in use on one patient when it malfunctions or becomes visibly contaminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 employees (SNA A) reviewed for infection control.<BR/>-The facility failed to ensure SNA A followed infection control procedures on performing hand hygiene after providing perineal care to Res #1.<BR/>The failure could place residents at risk for infection.<BR/>Findings include:<BR/>Record review of RES #1's face sheet with admission date of 01/02/2020 revealed an [AGE] year-old female with diagnoses of dementia (impairment of memory), repeated falls, muscle wasting and atrophy (loss of muscle tissue) abnormalities of gait and mobility (change in walking pattern), diabetes (high blood sugar) and abnormal posture.<BR/>Record review of RES #1's Minimum Data Set Resident Assessment and Care Screening dated 01/26/2023 revealed a Brief interview for Mental Status summary score of 03 indicating a severe cognitive impairment. <BR/>Record review of RES #1's care plan focus included bladder incontinence related to cognitive impairment and decrease mobility (revision on 01/10/2020), intervention/task reflected in part . Monitor/document for s/sx UTI (Urinary Tract Infection) . monitor/document/report . bladder infection <BR/>Observation on 02/16/2023 at 3:11 PM revealed SNA A performing perineal care (cleaning the private area to include vaginal and rectum area of resident) on RES #1 in her bedroom. SNA A had the resident on her back with a clean adult brief and wipes on the side of bed. The resident had her adult brief open. SNA A placed her gloves on and proceeded to provide perineal care to resident. She took the wipe and wiped the resident's vaginal area from front to back. The adult brief appeared to be soiled with urine. SNA A completed the task of perineal care on RES #1. She transferred the resident to her side to remove the soiled adult brief and placed the new adult brief. She repositioned the resident on her back and took the soiled adult brief and wipes and placed them in the trash. She then continued to place the clean adult brief on resident and cover her. The bed was placed in the lowest position using the control. The head of the bed was slightly elevated using the control. SNA A took the floor mats located next to the wall and placed them on the floor next to RES #1's bed. She proceeded to place the call bell within reach. SNA A did not change gloves at any time after providing perineal care, changing the adult soiled brief, placing the clean brief on the resident, repositioning the resident, placing the floor mats, or placing the call bell. SNA A was observed to have also touched her own face while wearing contaminated gloves after repositioning the resident and lowering her bed.<BR/>Interview on 02/16/2023 at 3:16 PM, SNA A said she forgot to change her gloves when she was done providing perineal care to RES #1. SNA A did contaminate other areas by not changing gloves. She said she was aware the correct technique was to change gloves after perineal care was provided. She said she was not aware she had not changed her gloves. washed her hands or used antibacterial hand gel prior to continuing care. Which included the placement of the mats and call bell with contaminated gloves on. She proceeded to remove her gloves and wash her hands after interview. <BR/>Interview on 02/16/2023 at 4:30 PM, C. RN said that SNA were Student Nurse Aides who had received training from the facility. C. RN said the training is based on phases. C. RN said the initial phase is 16 hours of classroom training prior to going on the floor with residents. C. RN said then there are two phases based on task afterwards. C. RN said SNA A had completed the initial and both phases of the program and is waiting for a test date for her Certified Nurse Aide Certificate. <BR/>Interview on 02/21/2023 at 1625, ADON A said the nurse aides go through training prior to working with residents. ADON A revealed she checked off on SNA A, Phase I and Phase II training and stated she had met competency. ADON A said student nurse aides are trained to preform competencies correctly to prevent injury or infection to residents. ADON A did stress the importance of hand hygiene to prevent cross contaminate of the residents. <BR/>Record review of SNA A's training record dated from 01/16/2023 to 01/19/2023 reflected she demonstrated competency in Hand Hygiene on 01/16/2023. The record included training on perineal care/incontinent care female on 01/18/2023. The record reflected in part . after disposing of used linen, and placing used equipment in designated storage area, remove and dispose of gloves (without contaminating self) into waste container and wash hands. <BR/>Record review of Hand Hygiene Phase 1 Competencies for Aides reflected in part . Procedural Guidelines: Turn on warm water. Wet hands and wrists. Apply soap or skin cleanser to hands to produce lather. Vigorously rub hands together in a circular motion producing lather for at least 20 seconds, washing all surfaces of the fingers and hands (including the wrists). Clean under nails by rubbing fingertips on palm of hand. Rinse hands thoroughly from wrist to fingertips, keeping fingertips down. Dry hands on clean paper towel and discard. Obtain a clean paper towel and turn off faucet with clean paper towel. Discard towel appropriately without contaminating hands .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to communicate with hospice representatives for 1 of 7 (Resident #1) residents reviewed for hospice services. <BR/>The facility failed to notify Hospice of Resident #1's acute glucose level increase on 05/04/24. <BR/>This deficient practice could place residents who receive hospice services at risk of receiving substandard care due to miscommunication between their hospice and facility care givers. <BR/>The findings included: <BR/>Record review of Resident #1's face sheet dated 5/16/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of DM II (long-term condition in which the body has trouble controlling blood sugar and using it for energy), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and anxiety. <BR/>Record review of Resident #1's physician order dated 09/27/23 revealed an order for accucheck daily for DM II, notify MD if blood glucose levels less than 70 or over 400, and symptomatic she was a full code. <BR/>Record review of Resident #1's physician order dated 10/07/22 revealed order for admitted to hospice with diagnosis of hypertensive heart disease with heart failure. <BR/>Record review of Resident #1's care plan dated 05/15/24 revealed focus area for DM II with hyperglycemia and interventions that included Monitor/document/report to MD PRN signs and symptoms of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. <BR/>Record review of Resident #1's vital signs for May 2024 revealed a blood glucose level of 349 on 05/04/24 at 5:31 am. <BR/>In an interview on 5/11/24 at 12:07 pm, LVN C stated she had worked a double shift (6am-10pm) on 05/24/24 and was the nurse responsible for Resident #1. LVN C stated she had not received a report from the night shift nurse regarding Resident #1's blood glucose level 349. LVN C stated she had not checked Resident #1's vital signs therefore she was not aware of Resident #1's glucose level that morning. LVN C stated Resident #1 had been fatigued throughout the day and had an increase in thirst. LVN C stated when an acute change was noted, like an increase in glucose levels, she had been trained to report it to the Hospice nurses and document actions taken to address the increase in glucose level . <BR/>In an interview on 5/11/24 at 12:56 pm, the Hospice Nurse stated he was on call the weekend of Friday 05/03/24 through Sunday 05/05/24. The Hospice nurse stated the facility was required to report any acute changes in condition to them. The Hospice nurse stated an increase of blood glucose level out of the resident's normal range would have been something the facility should have reported. The Hospice Nurse stated they would review the residents file and either adjust medication and/or insulin and reach out to the MD and the family to see what aggressive treatment they wanted for the resident . <BR/>In an interview on 5/13/24 at 9:31 am, the DON stated it was expected for the charge nurses to report an acute change in blood glucose levels. The DON stated the charge nurses should have followed up on the glucose levels with another Accu-Chek, monitor symptoms, and report to MD if glucose levels and/or symptoms kept increasing. The DON stated the nurses received training upon hire and the risks included lack of blood glucose monitoring . <BR/>In an interview on 5/14/24 at 11:56 am, the Hospice NP stated the facility should report glucose levels depending on their order parameters. The NP stated if the order read to report the glucose level if lower than 70 or higher than 400 and if the resident started showing some symptoms the facility should not wait until resident's blood glucose levels were over 400. The NP stated a blood glucose level of 349 with some symptoms should have been reported for medication adjustment or insulin to be adjusted . <BR/>In an interview on 05/16/24 at 1:58 pm, the Compliance Nurse stated the facility was only to report a blood glucose level to hospice if over 400. The Compliance Nurse stated that hospice would not do anything for a blood glucose level of 349. <BR/>Record review of Hospice Services policy dated 02/13/2007 read in part as an end-of-life measure, the resident or responsible family member may choose to use hospice services within the facility. The resident and/or responsible party will receive comfort care. The DON or designee will be responsible for immediately notifying the hospice of any significant change in condition. Notification will be documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #14) of 16 residents reviewed for call light placement.<BR/>The facility failed to ensure that Residents #14's call light was within her reach.<BR/>This failure placed residents at risk of not being able to call for assistance when needed.<BR/>Findings included: <BR/>Record review of Resident #14's face sheet dated 02/17/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #14's facility history and physical dated 01/06/23 revealed a [AGE] year-old female diagnosed with severe intellectual disability (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills) and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). <BR/>Record review of Resident #14's annual MDS dated [DATE], revealed positive for Intellectual Disability. No score was documented for BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements). Activities of Daily Living noted Resident #14 was dependent on nursing staff for eating, oral/personal hygiene, toileting, showering, and dressing. Resident #14 was diagnosed with Cerebral Palsy, Seizure Disorder (a disorder of the brain), lack of coordination, and severe intellectual disabilities. <BR/>Record review of Resident #14's care plan dated 03/16/23, revealed she has a communication problem due to Intellectual Disability. Ensure/provide a safe environment: Call light within reach.<BR/>Observation and interview on 02/17/24 at 2:42 PM with Admissions Marketing Director K and Admissions Marketing Director L, revealed the call light was clipped on to the call light cord on the wall away from Resident #14 who was lying down on her bed. The Admissions Marketing Director K stated the call light had to be within reach of the resident. Admissions Marketing Director K stated it was so Resident #14 could call for assistance. Admissions Marketing Director L stated the risk of not having the call light within reach could result injury or a fall. Admissions Marketing Director L stated all staff were trained in call light placement with residents. <BR/>During an attempted interview on 02/17/24 at 2:50 PM with Resident #14, when interviewed Resident #14 just looked and smiled at investigator. <BR/>During an interview on 02/17/24 at 3:17 PM with CNA M, she stated call lights had to be within reach of a resident to be able to call facility staff for assistance. CNA M stated not having the call light within could result in the resident not being able to call for help or assistance if they needed. CNA M stated it was everyone's responsibility to ensure resident call lights were within reach. <BR/>During an interview on 02/17/24 at 3:02 PM with CNA O stated everyone was responsible for ensuring call lights were within reach of the residents. CNA O stated there could be a risk if it was not within reach in which the resident would not be able to call for assistance or help. <BR/>During an interview on 02/17/24 at 3:28 PM with NCNA N, he stated residents needed to have call lights within so residents would be able to call nursing staff for anything or in an emergency. NCNA N stated there could be a risk to the resident like falling or like someone was in their room that should not be in there . <BR/>During an interview on 02/17/24 at 3:39 PM with the Administrator, she stated call lights have to be within the reach of the residents for assistance or an in emergency. The Administrator stated there was a risk if there was an emergency. The Administrator stated that all facility staff were trained on call lights. <BR/>During an interview on 02/17/24 at 3:05 PM with the Regional Nurse, she stated the facility had no call light policy.<BR/>Record review of the facility's Resident Rights policy manual dated 11/28/16 revealed, Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.<BR/>Respect and Dignity - The resident has a right to be treated with respect and dignity, including:<BR/>The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and locked in compartments 1 of 3 medication carts (medication cart A) reviewed for the storage of drugs and biologicals.<BR/>- The facility failed to secure medications located in medication cart A when unattended.<BR/>This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. <BR/>Findings included: <BR/>An observation on 02/21/2023 at 09:12 AM, revealed the facility's medication cart A was unlocked and unattended. The medication cart was in the hallway of zone 6. The drawers were unlocked and able to be opened by the surveyor. No employees were noted in hallway. MA A was in a resident's room and LVN B was down the hall of zone 4 in bedroom of RES #5. <BR/>An observation on 02/21/2023 at 08:55 AM, revealed RES #2 resided on zone 6 and was in the hallway. She used a wheelchair to transfer herself from one area to another. The unlocked medication cart A was in her hallway. <BR/>An interview and observation on 02/21/2023 at 09:19 AM with MA A, she said the resident that she was administering medications to was talking with her inside the resident's bedroom. She said she did not have the medication cart A within view. She said she normally did not stay in the room that long. She was asked if she usually left her cart unlocked, and she said her cart is usually facing the door. She demonstrated by moving her medication cart and placing it in front of the door with the drawers facing the inside of the bedroom. She was aware her cart was unlocked. She said she had been doing this for a long time and she does not leave her cart unlocked when the cart is not in use. She said nothing has ever happened and she knows the cart to be locked. <BR/>An interview on 02/21/2023 at 09:28 AM with LVN B, LVN B said each person was responsible for their cart. LVN B was asked if there was a risk for residents if a medication cart was to be left unlocked and shook her head no with her shoulder's raised. <BR/>An interview on 02/21/2023 at 3:30 PM with MA B revealed that her cart was locked. She showed the surveyor her keys and said she does not share her keys with anyone. She said the cart being open is dangerous because anyone can have access to the medications. <BR/>An interview on 02/21/2023 at 3:50 PM with RN A revealed each medication cart has it own set of keys. RN A keys are passed on at shift change. RN A said each nurse or medication aide was responsible for their cart during their shift. RN A said there could be a risk to the residents if they entered an unlocked medication cart. <BR/>An interview on 02/21/2023 at 4:05 PM with the ADM revealed employees should be aware of their medication carts remaining locked. The ADM Revealed that an unlocked medication cart could cause harm to a resident. <BR/>An interview on 02/21/2023 at 4:30 PM with ADON A, revealed employees have been educated to have their carts locked when not in view or in use. ADON A revealed that an unlocked cart could allow access to the cart. <BR/>Record review of the facility's policy on Medication Administration Procedures (PA 03-4.02) Pharmacy Policy & Procedure Manual 2003 (undated), reflected in part . 5 . During the medication administration process, the unlocked side of the cart must always be in full view of the nurse . 8. After the medication administration process is complete, the medication cart must be completely locked, or otherwise secured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 employees (SNA A) reviewed for infection control.<BR/>-The facility failed to ensure SNA A followed infection control procedures on performing hand hygiene after providing perineal care to Res #1.<BR/>The failure could place residents at risk for infection.<BR/>Findings include:<BR/>Record review of RES #1's face sheet with admission date of 01/02/2020 revealed an [AGE] year-old female with diagnoses of dementia (impairment of memory), repeated falls, muscle wasting and atrophy (loss of muscle tissue) abnormalities of gait and mobility (change in walking pattern), diabetes (high blood sugar) and abnormal posture.<BR/>Record review of RES #1's Minimum Data Set Resident Assessment and Care Screening dated 01/26/2023 revealed a Brief interview for Mental Status summary score of 03 indicating a severe cognitive impairment. <BR/>Record review of RES #1's care plan focus included bladder incontinence related to cognitive impairment and decrease mobility (revision on 01/10/2020), intervention/task reflected in part . Monitor/document for s/sx UTI (Urinary Tract Infection) . monitor/document/report . bladder infection <BR/>Observation on 02/16/2023 at 3:11 PM revealed SNA A performing perineal care (cleaning the private area to include vaginal and rectum area of resident) on RES #1 in her bedroom. SNA A had the resident on her back with a clean adult brief and wipes on the side of bed. The resident had her adult brief open. SNA A placed her gloves on and proceeded to provide perineal care to resident. She took the wipe and wiped the resident's vaginal area from front to back. The adult brief appeared to be soiled with urine. SNA A completed the task of perineal care on RES #1. She transferred the resident to her side to remove the soiled adult brief and placed the new adult brief. She repositioned the resident on her back and took the soiled adult brief and wipes and placed them in the trash. She then continued to place the clean adult brief on resident and cover her. The bed was placed in the lowest position using the control. The head of the bed was slightly elevated using the control. SNA A took the floor mats located next to the wall and placed them on the floor next to RES #1's bed. She proceeded to place the call bell within reach. SNA A did not change gloves at any time after providing perineal care, changing the adult soiled brief, placing the clean brief on the resident, repositioning the resident, placing the floor mats, or placing the call bell. SNA A was observed to have also touched her own face while wearing contaminated gloves after repositioning the resident and lowering her bed.<BR/>Interview on 02/16/2023 at 3:16 PM, SNA A said she forgot to change her gloves when she was done providing perineal care to RES #1. SNA A did contaminate other areas by not changing gloves. She said she was aware the correct technique was to change gloves after perineal care was provided. She said she was not aware she had not changed her gloves. washed her hands or used antibacterial hand gel prior to continuing care. Which included the placement of the mats and call bell with contaminated gloves on. She proceeded to remove her gloves and wash her hands after interview. <BR/>Interview on 02/16/2023 at 4:30 PM, C. RN said that SNA were Student Nurse Aides who had received training from the facility. C. RN said the training is based on phases. C. RN said the initial phase is 16 hours of classroom training prior to going on the floor with residents. C. RN said then there are two phases based on task afterwards. C. RN said SNA A had completed the initial and both phases of the program and is waiting for a test date for her Certified Nurse Aide Certificate. <BR/>Interview on 02/21/2023 at 1625, ADON A said the nurse aides go through training prior to working with residents. ADON A revealed she checked off on SNA A, Phase I and Phase II training and stated she had met competency. ADON A said student nurse aides are trained to preform competencies correctly to prevent injury or infection to residents. ADON A did stress the importance of hand hygiene to prevent cross contaminate of the residents. <BR/>Record review of SNA A's training record dated from 01/16/2023 to 01/19/2023 reflected she demonstrated competency in Hand Hygiene on 01/16/2023. The record included training on perineal care/incontinent care female on 01/18/2023. The record reflected in part . after disposing of used linen, and placing used equipment in designated storage area, remove and dispose of gloves (without contaminating self) into waste container and wash hands. <BR/>Record review of Hand Hygiene Phase 1 Competencies for Aides reflected in part . Procedural Guidelines: Turn on warm water. Wet hands and wrists. Apply soap or skin cleanser to hands to produce lather. Vigorously rub hands together in a circular motion producing lather for at least 20 seconds, washing all surfaces of the fingers and hands (including the wrists). Clean under nails by rubbing fingertips on palm of hand. Rinse hands thoroughly from wrist to fingertips, keeping fingertips down. Dry hands on clean paper towel and discard. Obtain a clean paper towel and turn off faucet with clean paper towel. Discard towel appropriately without contaminating hands .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 (Resident #11) of 3 residents reviewed for urinary catheter care. <BR/>Resident #11's catheter bag did not have a catheter bag cover exposing the catheter bag filled with urine<BR/>This failure could have compromised residents' dignity for those who require urinary catheter care. <BR/>Findings include: <BR/>Record review of Resident #11's face sheet dated 02/14/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #11's facility history and physical dated 11/06/23 revealed a [AGE] year-old male diagnosed with schizophrenia (a serious mental disorder in which people interpret reality abnormally) and bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode)). <BR/>Record review of Resident #11's quarterly MDS dated [DATE] revealed an intact cognition to be able to recall and make daily decisions BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 13. Resident #11 was dependent on nursing staff for toileting. Resident #11 had an indwelling catheter. <BR/>Record review of Resident #11's care plan dated 01/13/24 revealed indwelling catheter - check for kinks and maintain the drainage bag off the floor, ensure tubing is anchored to the resident's leg or linens so that tubing was not pulling on the urethra, monitor and document intake and output as per facility policy, and for signs of discomfort on urination and frequency. <BR/>Observation on 02/15/24 at 9:47 AM revealed Resident #11 was lying down in the bed with an indwelling catheter. The indwelling catheter was hanging from the bed and did not have a cover. <BR/>Observation and interview on 02/15/24 at 9:54 AM with LVN J, she stated Resident #11's indwelling catheter bag needed to have a cover for Resident #11's dignity, his privacy, and infection control. LVN J stated it was everyone's responsibility for ensuring the indwelling catheter bag had a covers. <BR/>During an interview on 02/15/24 at 10:28 AM with the ADON G, she stated indwelling catheters were to be placed on the edge of the bed hanging with a cover for privacy. ADON G stated not having a cover could result in a negative outcome for the resident's dignity. ADON G stated it was the nurses and CNAs responsibility to ensure there was a privacy cover on the indwelling catheter bag. <BR/>During an interview on 02/15/24 at 11:00 AM with the Area Director of operations, stated DON was suspended, so no interview regarding the indwelling catheter was conducted with DON. <BR/>Record review of the facility's Catheter Insertion, Male/Female policy and procedure manual dated 2003 revealed, An indwelling catheter provides continuous bladder drainage in residents with a neurogenic bladder or urinary disfunction.<BR/>Catheter Change/Replacement - Catheters that are encrusted so that urinary outflow was blocked should be changed. <BR/>Record review of the facility's Resident Rights policy manual dated 11/28/16 revealed, Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.<BR/>Respect and Dignity - The resident has a right to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 (Resident #26) of 5 resident reviewed for accuracy of MDS assessment, in that: <BR/>Resident #26's quarterly MDS did not accurately reflect the residents' significant changes in pressure ulcers and in bathing in the quarterly MDS. <BR/>This deficient practice could affect residents at the facility who had been assessed for pressure ulcers and bathing and could contribute to inadequate care. <BR/>Findings included: <BR/>Record review of Resident #26's Face Sheet admission date was 06/10/21 and readmission was 01/25/2022 to the facility. <BR/>Record review of Resident #26's History and Physical dated 09/20/2022 indicates Resident #26 was a [AGE] year-old male was a diagnosis with a stroke, hemiplegia (paralysis of one side of the body), and Atrial fibrillation is an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart). <BR/>Record review of Resident #26's MDS significant change for 08/22/22, Quarterly MDS assessments for 09/18/22, 12/19/22, and 03/21/23 revealed that the 09/18/22 assessment was a significant change assessment and should not have been a quarterly assessment. <BR/>Interview on 03/28/23 at 11:14 PM with MDS A and MDS B stated the care plans and MDS are completed by them. MDS A stated they complete the MDS assessments upon admission, annually, quarterly, and upon a significant change of condition. MDS A stated a significant change was a resident going into hospice, weight loss, or a significant physical change. <BR/>Interview on 03/28/23 at 3:18 PM MDS A stated that when a resident had a significant change in condition that should have triggered a significant change of condition MDS. Once the significant change of condition MDS was completed it would have reset the time frame for the next quarterly MDS assessment. MDS A stated the MDS quarterly for 09/18/22 showed a significant change in condition with Stage III Pressure Ulcer from the amount being 0 in 08/22/22 to an increase of 3 in 09/18/22, Stage IV Pressure Ulcers from the amount in 08/22/23 to 2 in 09/18/22, and unstageable pressure ulcers from 0 in 08/22/22 to 1 in 09/18/22 and should have triggered MDS to generate a Significant Change MDS for Resident #26. MDS A stated she did not know why one was not triggered. MDS A stated the Quarterly MDS for 09/18/22 was incorrectly coded for Resident #26's bathing as total dependence with one person assist was inaccurate. MDS A stated in the Quarterly MDS 08/22/22 Resident #26 for bathing was two-person assistance. MDS A stated she does not assess the patient, only looks at the assessments. <BR/>Observation on 03/28/23 at 3:20 PM with MDS A reviewed the MDSs for Resident #26 on the computer and on a sheet of paper where MDS information such as functional status and skin condition were written on to formulate the changes in MDSs to see if an improvement or decline in the Resident #26 was made.<BR/>Interview on 03/28/23 at 3:21 PM with MDS A stated she did see the change from 08/22/23 to 09/18/22 and that a significant change in condition MDS was required because resident had an increase in pressure ulcers. <BR/>Interview on 03/28/23 at 3:30 PM ADON B stated that a significant change for Resident #26 should have been made according to Resident #26's pressure ulcers decline for 09/18/22. <BR/>Record review of facility policy CMS's RAI Version 3.0 Manual dated 04/2012 indicates a (SCSA) Significant Change in Status Assessment was appropriate when there was a determination that significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to most recent comprehensive assessment and any subsequent quarterly assessments; and the resident's condition is not expected to return to baseline within two weeks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 5 (Resident # 3, #4, #5, #7, and #8 ) of 12 residents reviewed for care plans. <BR/>The facility failed to implement a comprehensive person-centered care plan for Resident #7 ' s history of falls. <BR/>The facility failed to implement a comprehensive person-centered care plan to address elopement risk for Residents #3, #4, #5, #7, and #8. <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include: <BR/>Resident #7 <BR/>Record review of Resident #7 ' s face sheet dated 01/19/24 revealed admission on [DATE] and re-admission on [DATE] to the facility with diagnoses of unspecified lack of coordination, abnormalities of gait and mobility, disorganized schizophrenia, muscle wasting and atrophy, muscle weakness, unsteadiness on feet, and unspecified dementia. <BR/>Record review of Resident #7 ' s care plan dated 11/21/23 revealed at risk for wandering. Assess for fall risk. Care plan did not indicate anything regarding the focus area of falls. <BR/>Record review of Resident #7 ' s Event Note dated 11/20/23 revealed bruising to left knee, left lower leg, left ankle bruising. <BR/>Record review of Resident #7 ' s Fall Assessments dated 01/19/24 revealed from there were only fall assessments completed from 02/13/20-08/09/23. No fall assessment was conducted for the Event note that was completed on 11/20/23. <BR/>Resident #3 <BR/>Record review of Resident #3 ' s face sheet dated 01/18/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #3 ' s facility history and physical dated 07/25/23 revealed a [AGE] year-old female diagnosed with Dementia and Major Depression Disorder (affects how you feel, think and behave and can lead to a variety of emotional and physical problems). <BR/>Record review of Resident #3 ' s quarterly MDS dated [DATE] revealed a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 3. Resident #3 was diagnosed with Alzheimer Disease, Non-Alzheimer ' s Disease, and Depression. <BR/>Record review of Resident #3 ' s elopement risk assessment dated [DATE] revealed a score of 13, high risk of elopement. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident # 3 ' s care plan dated revealed no focus area and/or interventions to address elopement risk. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet dated 01/18/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #4's facility history and physical dated 05/18/23 revealed a [AGE] year-old female diagnosed with psychiatric behavior with aggression and paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly). <BR/>Record review of Resident #4's annual MDS dated [DATE] revealed a Preadmission Screening and Resident Review condition as serious mental illness. Resident #4 had a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 3. MDS indicated zero (no behavioral symptoms) for behaviors. Resident #4 was diagnosed with Non-Alzheimer's Disease, Psychotic Disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), Schizophrenia (a serious mental disorder in which people interpret reality abnormally), depression, and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). <BR/>Record review of facility assessment scoring report sheet dated 01/01/20-01/19/24 reviewed Resident #4 had a score of 13 for elopment risk. <BR/>Record review of Resident #4's care plan dated 12/17/21 revealed no focus area for elopement. <BR/>Resident #5 <BR/>Record review of Resident #5 ' s face sheet dated 01/18/24 revealed admission on [DATE] to the facility. Resident #5 was a [AGE] year-old female diagnosed with Dementia and Psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). <BR/>Record review of Resident #5 ' quarterly MDS dated [DATE] revealed a moderately cognition to be able to recall and make daily decision BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score which was not taken for whatever reason. Resident #5 was diagnosed with Cerebrovascular Accident (an interruption in the flow of blood to cells in the brain), Non-Alzheimer ' s Dementia, Depression, Psychotic Disorder (affect brain function by altering thoughts, beliefs or perceptions) and Adjustment Disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior) with Depressed Mood (Feelings of sadness, hopelessness, crying and lack of joy from things that used to bring you pleasure). <BR/>Record review of Resident #5 ' s Elopement assessment dated [DATE] revealed a elopement risk score of 18. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident #5 ' care plan dated 01/22/24 revealed no focus area for elopement. <BR/>Resident #8 <BR/>Record review of Resident #8 ' s face sheet dated 01/19/23 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #8 ' s facility history and physical dated 04/06/23 revealed a [AGE] year-old male diagnosed with severe intellectual disability, anxiety, and Major depressive Disorder (it affects how you feel, think and behave and can lead to a variety of emotional and physical problems). <BR/>Record review of Resident #8 ' s annual MDS dated [DATE] revealed a Preadmission Screening and Resident Review condition as intellectual disability. Resident #4 had a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score that was not taken for whatever reason. Behaviors was marked zero revealing Resident #8 had no behaviors when Resident #8 really did have behaviors. Resident #8 was diagnosed with Seizure Disorder (abnormal electrical brain activity), Depression, and Serve Intellectual Disabilities (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills). <BR/>Record review of Resident #8 ' s elopement risk assessment dated [DATE] revealed a score of 14, high risk. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident #8 ' s care plan dated 01/15/24 revealed no focus area for elopement. <BR/>During an interview on 01/19/24 at 6:17 PM with MDS Coordinator C and MDS Coordinator D, MDS Coordinator C, she stated the comprehensive care plans should have had falls and elopement care planned for Resident #7, #3, #4, #5, #8. MDS Coordinator D stated there could be a risk of not care planning falls and elopement. MDS Coordinator stated the risk could be a resident elopement from the facility. MDS Coordinator C stated anytime there was an elopement assessment completed for a resident that meant it would need to be care planned for the resident. MDS Coordinator C stated the DON, ADON, and the MDS department were responsible for overseeing that the comprehensive care plans are accurate. <BR/>During an interview on 01/22/24 at 10:46 AM with the DON, she stated residents with elopement risk should have elopement as a focus area in their care plans. The DON stated the charge nurse will update the care plans and the DON and ADONs will oversee to make sure it was done. The DON stated that Resident #7 had no focus area for falls and had overlooked the fall for the comprehensive care plan. The DON stated Residents #3, #4, #5, and #8 had no focus for elopement because she did not look for it on the comprehensive care plan as she did not know it needed to be care planned. The DON stated the risk of not including the elopement in the comprehensive care plan could be identifying resident elopement risk and monitoring of the resident. <BR/>During an interview on 01/22/24 at 12:44 PM with the Administrator, she stated she was not too familiar with comprehensive care plans and asked to refer to the DON regarding care plans. <BR/>Record review of the facility Elopement Assessment Scoring Report dated 01/01/20-01/19/24 was review revealed there were 30 residents on it to include Residents #3, #4, #5, #8. <BR/>Record review of the facility Preventive Strategies to Reduce Fall Risk dated 10/05/16 revealed, Policy: The goal of fall prevention strategies was to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident ' s mobility. <BR/>Residents at risk will be care planned for fall prevention. <BR/>After risk was assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will educate on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. <BR/>Record review of the facility comprehensive care plan policy not dated revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. <BR/>The comprehensive care plan will describe the following: <BR/>The services that are to be furnished to attain and maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. <BR/>Record review of the facility Elopement Prevention policy 01/2023 revealed, Every effort will be made to prevent elopement episode while maintaining the least restrictive environment for residents who are at risk for elopement. <BR/>All residents who area at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. <BR/>The resident ' s care plan will be modified to indicate the resident was at risk for elopement episodes. <BR/>Interventions into elopement episodes will be entered onto the resident ' s care plan and medical record. <BR/>Record review of the facility Elopement Response policy dated 10/27/10 revealed, After an elopement the care plan coordinator will reevaluate the resident ' s care plan. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to provide the necessary services to maintain good grooming and personal hygiene care for 4 (Resident #83, Resident #5, Resident #66 and Resident #18) of 5 residents reviewed for ADL care. <BR/>Resident #18 did not have her brief changed on a timely basis and was not turned as needed. <BR/>The facility failed to ensure facility staff provided showers, personal grooming for Resident #83, Resident #5, and Resident #14. <BR/>This failure could place residents at risk of not receiving assistance with personal care which could cause pain, skin breakdown, and low self-esteem. <BR/>Findings Included: <BR/>Resident #83 <BR/>Record review of Resident #83's Face Sheet admission date was 11/21/2022 at the facility. <BR/>Record review of Resident #83's History and Physical dated 11/22/2022 indicates Resident #83 was a [AGE] year-old female who had a diagnosis of End Stage Renal Disease, hypertension, Type 2 diabetes, and osteomyelitis. <BR/>Record review of Resident #83's MDS Quarterly dated 02/27/23 documented a BIMS score of 14 indicating no cognitive impairments. It also demonstrated she was extensive assistance with two-person assistance with ADLs including personal hygiene. It was also indicated bathing as total dependence with one person assistance. <BR/>Record review of Resident #83's Comprehensive Care Plan dated 03/17/2023 documented resident had ADL self-care in which she will maintain or improve current level of function with personal hygiene. Will need two-person assistance with bathing and did not indicate how often resident was to be showered/bathed. <BR/>Record review of Resident #83's Task Response History for bathing support provided - from 02/26/23 to 03/27/23, revealed 7 showers with one-person physical assist have only been conducted for that provided time period and the rest is marked as ADL activity itself did not occur. Task Response History for type of bath for 02/26/23 shown x15 did not occur. <BR/>Record review of Resident #83's Schedule for March 2023 provided by the facility demonstrates Resident #83 as having QShift bathing. It shows Resident #83 was showered every day from 03/01/23 to 03/28/23 with PRN bathing (x11) when resident had not showered for 15 days in the month. <BR/>Record review of Resident #83's Survey Report for March 2023, for bathing revealed (x19) 8.8s which indicates Total Dependence - Activity itself did not occur. <BR/>Record review of facility shower list for the east wing for four different days which two are undated (other 03/22/23, 03/20/23, 03/19/23) revealed Resident #83 was not showered two times as there was no CNA initials. CNAs are to initial after showering the resident had been completed.<BR/>Observation on 03/26/2023 at 8:30 a.m., Resident #83 was lying in bed in a gown face shiny with oil, hair was uncombed. <BR/>Interview on 03/28/23 at 4:40 PM ADON F stated he looked at Resident #83's orders, progress notes, and the MDS Survey Report for bathing. ADON F stated it was marked with an 8 which indicates the bathing/showers did not occur. ADON F stated the risk to the Resident #83 would be false documentation, skin issues, hygiene, and infection. <BR/>Interview on 03/28/23 at 4:45 PM ADON B stated the facility uses the facility shower list were CNAs initial for accountability in the CNA Assignment Book. <BR/>Interview on 03/29/23 at 9:28 AM MDS B stated the Survey Report for March 2023 for Resident #83 reveals the dated and times resident was showered or not revealed Resident #83 was not showered. <BR/>Interview and record review on 03/29/23 at 9:30 AM with MDS A and MDS B both stated if the date was marked with an 8 on the survey report, then it indicated that the resident was not showered for the day. MDS A stated resident was not showered. MDS B stated the showering schedule needed to be put into the care plan for Resident #83 which it was not in his care plan. MDS B stated the care plan did not mention anything about the shower schedule. MDS B stated the risk to not showering would be their dignity and infection. <BR/>Resident #5 <BR/>Record review of Resident #5's Face Sheet admission date was 06/15/2005 and was readmitted on [DATE] at the facility. <BR/>Record review of Resident #5's History and Physical dated 08/19/2021 indicates Resident #5 was a [AGE] year-old female with a diagnosis dementia with behavioral disturbances and Alzheimer's with delusional psychotic features. <BR/>Record review of Resident #5's MDS Quarterly dated 03/14/2023 documented a BIMS score of 3 and was left unmarked on her cognitive impairment or independence. It also demonstrated Resident #5's ADLs was extensive assistance one person assistance with personal hygiene, dressing, and bathing (physical help). It also documents a diagnosis of schizophrenia, Alzheimer's disease, non-Alzheimer's dementia, is at risk for pressure ulcers. <BR/>Record review of Resident #5's Comprehensive Care Plan dated 02/24/2023 indicated ADLs self-care will maintain current level of function with one person assistance with dressing and personal hygiene/oral with one person participation with bathing in the care plan. <BR/>Record review of Resident #5's Schedule for March 2023 provided by the facility demonstrates Resident #5 as having Q-Shift bathing as T-TH-SAT with PRN bathing (x11) for showering/bathing. <BR/>Record review of facility shower list for the east wing for four different days which two are undated (other 03/22/23, 03/20/23, 03/19/23) revealed Resident #5 was not showered two times as there was no CNA initials. CNAs are to initial after showering the resident had been completed. <BR/>Interview on 03/28/23 at 4:45 PM ADON B stated the facility uses the facility shower list were CNAs initial for accountability in the CNA Assignment Book. <BR/>Interview on 03/29/23 at 9:28 AM MDS B stated the Survey Report for March 2023 for Resident #5 revealed the dates and times resident was showered or not revealed Resident #5 was not showered. <BR/>Observation on 03/29/23 at 9:29 AM MDS B review the MDS Survey Report for March 2023 for Resident #5. <BR/>Observation on 3/26/23 at 4:37 PM revealed Resident #5 hair was not combed and was disheveled. <BR/>Observation on 3/27/23 at 12:14 PM revealed Resident #5 hair was not combed and was disheveled. <BR/>Observation on 3/27/23 at 4:01 PM revealed Resident #5 hair was not combed and was disheveled. <BR/>Observation on 3/28/23 at 10:09 AM revealed Resident #5 hair was not combed and was disheveled. <BR/>Interview on 03/29/23 at 9:30 AM with MDS A and MDS B both stated if the date was marked with an 8 then it indicated that the resident was not showered for the day. MDS B stated he had not been showered. MDS B stated the showering schedule needed to be put into the care plan and on PCC for Resident #5. MDS B stated the care plan did not mention anything about the shower schedule in the care plan. MDS B stated the risk to not showering would be their dignity and infection. <BR/>Resident #66 <BR/>Record Review of Resident #66 Face Sheet dated 3/27/23 documented in part a [AGE] year-old male, admitted on [DATE]. <BR/>Record Review of Resident#66 Quarterly MDS dated [DATE] documented Resident #66 had a BIMS of 6 indicating he was severely cognitively impaired. Resident #66 required extensive assistance with one person assistance for personal hygiene, and dressing. Resident #66 is wheelchair-bound and requires total dependence for bathing with one person's assistance. Section I revealed active diagnosis of abnormalities of gait and mobility and lack of coordination. <BR/>Record Review of Care Plan dated 4/18/21 documented Resident #66 had an ADL self-care performance deficit. Resident #66 required assistance with personal hygiene, and bathing and did not indicate a shower schedule. <BR/>Record Review of Resident #66 March bathing task scheduled record indicated Resident #66 only received 6 baths and all other days were marked as this activity did not occur indicating Resident #66 was not showered. <BR/>Interview with Resident #66 on 3/26/23 at 02:59 PM revealed he was not getting his showers as scheduled. Resident #66 stated, they are times when I get maybe 2 showers a week and I know I am scheduled to receive 3 baths per week. <BR/>Resident #18 <BR/>Record review of Resident #18's admission MDS dated [DATE] documented that she was [AGE] years old and was admitted to the facility on [DATE]. Her diagnoses included a broken lower left leg (displaced comminuted fracture of shaft of left tibia). Her BIMS was 13 (cognitively intact). She needed extensive assistance from one person to dress and perform personal hygiene. She did not walk and did not move around the facility during the lookback period. She was totally dependent on one staff member for baths. She required extensive assistance from two people to move around in bed, to transfer between surfaces, and to use the toilet. She was always incontinent of bowel and bladder. She was at risk of developing pressure ulcers. <BR/>In an interview on 03/26/23 at 10:15 AM Resident #18 stated that when she turned on her call light because she had urinated and needed a brief change, staff members did not come for a long time. She was unable to specify how long it took. She said that most of the time it took them too long. She also said she had diarrhea a few weeks back and she had to wait a long time for staff to change her soiled brief. <BR/>In an interview on 03/27/23 at 10:28 AM Resident #18 stated that she had to wait a long time to get changed. She was not able to remember any particular dates or times. She stated that the only time NAs came to check on her was when she turned on the light and that the only times they turned her was when they changed the wound dressing on her back, which was every other day. <BR/>Record review of Resident #18's Point of Care Response History for 02/28/2023 - 03/28/2023 documented that she was not turned on any shift on two days and turned only once on four days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 1 (Resident #3) of 4 residents reviewed for wound care. <BR/>Resident #3 was not given wound care as prescribed to left and right heel to cleanse with normal saline cleanser, pat dry, apply foam heel protector or abdominal pad and wrap with roll gauze dressing every Monday, Wednesday, and Friday for protection as ordered as there was no wound care performed on 03/13/24. <BR/>This failure could affect residents by placing them at risk of deterioration of the wound. <BR/>Findings included: <BR/>Record review of Resident #3's face sheet dated 03/15/24, revealed, admission on [DATE] to the facility. <BR/>Record review of Resident #3's facility history and physical dated 10/26/23, revealed, a [AGE] year-old male diagnosed with Diabetes Mellitus .<BR/>Record review of Resident #3's care plan dated 01/15/24, revealed has a pressure ulcer or potential for pressure ulcer development. Administer medications as ordered. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Notify nurse immediately of any new areas of skin breakdown. Open area, redness, blisters, bruises, discoloration noted during bath or daily care. <BR/>Record review of Resident #3's physician orders dated 02/28/24, revealed, to trauma wound of the right 1st toe. Cleanse with normal saline wound cleanser, apply Medi-Honey (hastens the healing of wounds through its anti-inflammatory effects), then Hydrophera (treatment of wounds burns, ulcers, and yeast) blue foam, cover with abdominal dressing and wrap with roll gauze, secure with Med Fix tape, everyday shift. Wound care to evaluate and treat as warranted for wound of the right great toe. <BR/>Record review of Resident #3's Weekly Skin assessment dated [DATE], revealed, open area to the right great toe, discoloration, black, red, serosanguinous drainage. Scab to the right knee. <BR/>Record review of Resident #3's Weekly Skin assessment dated [DATE], revealed, open are to the right great toe, discoloration of black, red to affected area. Minimal serosanguinous drainage. No foul smell or purulent drainage present. No other signs and symptoms noted. Peri skin was dry. No Erythema or edema present. <BR/>Record review of Resident #3's Weekly Skin assessment dated [DATE], revealed, Physician who was medical director of facility present and was asked to assess the patients wound. At this time order was given to floor nurse to transfer the Resident #3 to emergency room. At this time Physician F also notified.<BR/>Wound care for Resident #3 was not observed due to Resident #3 being in the hospital. <BR/>During an interview on 03/15/24 at 3:27 PM, with LVN C, he stated that the DON and him would be responsible for wound care during the weekdays. LVN C stated Resident #3 had hit his right big toe on the wall during shower time. LVN C stated Resident #3 had bleeding underneath his right big toenail. LVN C stated on 03/13/24, LVN D did not perform wound care as Resident #3 was notify him that it had not been done. LVN C stated Resident #3's dressing still had his initials from 03/12/24. LVN C stated Resident #3 had recorded LVN D, where Resident #3 had asked LVN D if he was going to do wound care and LVN D replied that he was going to go do it later and never did. <BR/>During an interview on 03/15/24 at 4:48 PM, with NP, he stated he was informed of Resident #3 hitting his toe and having a discoloration. NP stated that wound care was ordered. NP stated on 03/13/24, Resident #3 had not had wound care done. NP stated it would have affected Resident #3 if wound care was not preformed. <BR/>During an interview on 03/15/24 at 4:12 PM, with Physician, he stated it was reported to him that Resident #3 had bumped his foot on the wall and had a scab on the injury site. The Physician stated wound care was started last week. The Physician stated the nurses are to provide wound care. The Physician stated Resident #3 was diabetic. The Physician stated there could have been a risk to Resident #3 if physician orders were not followed. The Physician stated the wound could get worse if wound care was not provided.<BR/>During an interview on 03/18/24 at 2:38 PM, with LVN D, he stated the nurses and LVN C needed to be providing wound care as per physician orders. LVN D stated not providing wound care as order could be a risk to the resident of the wound worsening or infection. LVN D stated he was aware on 03/13/24, that LVN C was suspended and did not provide wound care for Resident #3. LVN D stated not doing wound care would be a risk of wounds worsening. <BR/>During an interview on 03/18/24 at 4:17 PM, with the Administrator, she stated anytime LVN C was not in the facility the nurses were expected to do wound care. The Administrator stated the DON, ADON, and nurse to nurse report was how the nurses will know to do their own wound care. The Administrator stated wound care not being done as per physician orders for the residents with wounds would be out compliance. The Administrator stated she was not clinical but said missing a day of wound care she thought would be bad. The Administrator stated Resident #3 had hit his toe in the shower wall and had a cut. The Administrator stated LVN C knew Resident #3 had a diagnoses of Diabetes Mellitus. The Administrator stated it was reported to the physician and wound care orders were given to conduct wound care. <BR/>During an interview on 03/19/24 at 11:20 AM, with the ADON, she stated the facility does have a wound care nurse which was LVN C. The ADON stated the DON and ADON will tell the nurses that LVN C did not go into work and the nurses are expected once notified to doing the wound care. The ADON stated there could be a negative outcome if wound care was not provided which could result in the resident getting worse or sick. The ADON stated it was expected for the nurses to be following physician orders and not following physician orders could cause wounds to get worse. <BR/>During an interview on 03/19/24 at 1:56 PM, with the Regional Nurse, she stated wound care needs to be conducted as per physician orders. Regional Nurse stated not providing wound care as prescribed could result in the missing a change in the wound care. Regional Nurse stated the DON, ADON, and the floor nurses in the weekdays when LVN C was not at work are to be doing the wound care on residents. Regional Nurse stated management would let the nurses know LVN C would not be at work. <BR/>Record review of the facility Skin Integrity Management policy dated 10/05/16, revealed, Wound care should be performed as ordered by the physician.<BR/>Record review of the facility Skin Assessment policy dated 08/15/24, revealed, It was the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to allow of appropriate intervention be initiated in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, for 1 resident (Resident #64) of 21 residents reviewed for weight loss. <BR/>The facility failed to monitor, document, care plan, and implementplace interventionss for Resident #64 significant weight loss. <BR/>This failure could place all residents in the facility at risk for weight loss, and not maintaining their highest practicable level of health. <BR/>The findings included:<BR/>Record Review of Resident #64's Face Sheet dated 3/27/23 documented in part resident is a [AGE] year-old female admitted on [DATE] to the facility. <BR/>Record Review of Resident #64's History and Physical dated 07/06/22 established diagnoses of anemia, prediabetic, gastroesophageal reflux disease, and hyperlipidemia.<BR/>Record Review of Resident #64 Referral History and Physical dated 6/24/22 from doctor visit documented in part resident weight as 181 lbs. <BR/>Record Review of Resident#64 Annual MDS dated [DATE] documented Resident #64 had a BIMS of 14 indicating she was cognitively intact. Resident #64 required limited assistance with one person's physical assistance for eating. Resident #64 required set up or clean up assistance for eating. <BR/>Record Review of Care Plan dated 2/03/22 documented in part Resident #64 was is at risk for Malnutrition, with the goal to maintain stable weight and nutritional parameters. Interventions included monitor resident meal intake and resident weight.<BR/>Record Review of Resident #64 weights summary trend displayed her current weight for 03/01/23 was 130 lbs. Resident #64 initial weight upon arrival on 07/06/22 at 04:08 PM was 170 lbs. Documentation was crossed out and disputed by Dietitian on 10/10/22 at 08:40 AM. Dietitian left Resident #64 weight of 148lbs obtained on 9/6/22. Resident had a 5% weight loss from 12/7/22 to 1/4/23. <BR/>Record Review of Resident #64 Progress Notes dated 1/6/22 by the dietician indicated Resident #64 had 13% weight loss in 90 days, and 15.5% in 180 days. Dietician recommendations included adding fortified foods to all meals and the physician to consider appetite stimulants if medically feasible and plan to follow up as needed. Interventions were not implemented or acknowledged by nursing staff. <BR/>Record Review of Resident #64 diet order dated creation date is 07/13/22 and date of revisedsion onis 09/20/22 read regular diet, regular texture and consistency, health shakes and red glass (feeding assistance).<BR/>Record Review of Resident #64 Progress Notes dated 3/4/23 by the dietician, Resident #64 weight loss in 180 days was 18 lbs. Resident #64 diet was regular/texture/regular liquid and the supplement included health shakes three times a day. Documentation indicated Resident#64 average oral intake was 25-50% and the goal was being met. To continue with the current diet and support as ordered no recommendations at this time. <BR/>Record Review of Resident #64 Medication Administration note dated 3/3/23 at 12:04 PM stated Health Shake Refused resident does not like it. Resident #64 stated, she did not like the health shakes that was the reason reason she kept refusing. <BR/>Interview with Resident #64 on 3/26/23 at 3:50 PM, Resident disclosed she did not like the food in the facility, due to cultural preference. Resident #64 stated, I do not eat much because I just do not like it, I am not from this area, and in this facility, all they serve is Mexican food. Resident #64 stated, since I been in this facility, I have lost weight none of my clothes fit me, but they started giving medication. Resident #64 stated she had told several staff members. She stated, But the staff don't listen - they keep bringing me the same thing, I just try to eat whatever I can from my tray. <BR/>Interview with Dietician on 03/29/23 at 01:30 PM, Dietician stated, when reviewing weights and diets for the residents, I check the admission listing daily, wound care reports, weight's daily progress notes, and weight summary if there is a weight trigger for 30 and 90 days. The facility staff will also notify me if they have any issues that I needed to review. Dietician stated, I send recommendations to the facility as needed, and I check daily that interventions are being followed. I have several buildings I check daily from my computer. For Resident #64 never triggered there was no weight loss trend in September 2022. I noticed a weight loss on 09/15/22 and disputed the weight on 07/06/22 of 170 lbs., since there was too much weight loss difference. Resident #64 was not re-weighed, Dietician stated in a similar situation he would have reviewed the history and physical as a guide for a baseline, however, with Resident #64 he did did not review her history and physical. Dietician stated, If I would have noticed her weight was 180 lbs. on her history and physical, I would have implemented interventions. Resident #64 did not trigger for weight loss; however, no weight was entered until September. The Dietician confirmed the facility should have weighed Resident #64 monthly. Since this did not occur, he was not able to do a full assessment. Dietician stated, When residents do trigger significant weight loss, I speak with them about their diet preferences, and if they have any issues with their food. I would then recommend diet modification, an appetite stimulant with physician approval, and fortified food. With Resident #64 I did not go speak to her about her preferences. Failure to identify a resident nutritional status can affect the resident weight. <BR/>Interview on 03/29/23 at 02:00 PM with DON and Administrator revealed the CNAs responsibility was to weigh the residents however the nurse is responsible to ensure it is done. DON and Administrator stated, that weights are covered weekly in our meeting and Resident #64 did not trigger. If Resident #64 would have triggered the department head from dietary would be responsible to monitor recommendations are followed. Administrative staff confirmed Resident #64 had lost significant weight, and if this issue was not addressed it can lead to malnutrition. <BR/>Record Review of the facility policy Resident Weights for nursing policy and procedure manual 2003 revised 2/13/2007 documented the facility all residents will be weight monthly, weights will be documented correctly, and appropriate actions regarding signification weight change will be carried out. Weights shall be obtained and documented on admission, readmission, and monthly unless ordered otherwise or dictated more frequently by the resident's condition. All significant weight changes will be referred to a dietician to complete an assessment of all significant weight losses. The dietician will review all facility interventions and make appropriate recommendations which will be approved by the physician if necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 2 (Resident #2 and Resident #67) of 2 meals reviewed for residents with a diet order for nectar consistency reviewed for provision of food in a form designed to meet individual needs. <BR/>1. <BR/>Resident #2 and Resident #67 received liquids of the wrong consistency. <BR/>2. <BR/>Residents #2 and #67 had meal tickets that had not been updated and contained old information regarding dietary orders for liquid consistency. <BR/>3. <BR/>Resident #2 and Resident #67 meal tickets were not updated.<BR/>This failure could place residents who received liquid consistency diets at-risk of inadequate nutrition, choking, and aspiration. <BR/>Findings include: <BR/>Resident #2 <BR/>Record review of Resident #2's Face Sheet admission was on 03/28/2012 and readmitted on [DATE] at the facility. <BR/>Record review of Resident #2's History and Physical dated 05/26/2022 had a [AGE] year-old female with a diagnosis of dysphagia (difficult swallowing), malnutrition, and dementia. <BR/>Record review of Resident #2's MDS significant change in condition dated 01/18/2023 demonstrates a Brief Interview for Mental Score of 3 which cognition was not marked. It also indicated ADLs as extensive assistance with one person assistance for eating but did not indicate swallowing issues. Diagnosis was non-Alzheimer's dementia and malnutrition. It indicated mechanically altered diet. <BR/>Record review of Resident #2 Care Plan dated 02/07/2023 did not indicate any information regarding assisted feeding or swallowing problems. <BR/>Record review of Resident #2's Order Summary Report dated 01/25/23 revealed Regular Diet - Puree texture, Nectar consistency, d/c thin liquids. <BR/>Observation on 03/26/23 at 8:58 AM Resident #2 was in her room in bed being assisted with feeding by CNA L. It was noted on the meal tray that two cups were filled with thin liquids. The meal ticket next to the cups indicated nectar consistency and beverage. Beverage Texture to be regular. On the food tray itself was an open carton of regular unthicken milk.<BR/>Interview on 03/26/23 at 9:12 AM CNA L stated Resident #2 was one person assistance when feeding. CNA L stated she noticed that the liquids were thin and immediately asked for nectar as she noticed the drink was thin and not nectar as prescribed in the dietary ticket. CNA L stated the stationed nurse that checks the trays would have checked it and from there it was passed out to the resident. CNA L stated the risk to the Resident #2 would be choking or aspiration. <BR/>Observation on 03/27/23 at 12:20 PM Resident #2 was in her room in bed with CNA A who was assisting Resident #2 with feeding. It was noted on the meal tray that there was a cup with a thin liquid and a straw in it. The ticket read puree and nectar. It also demonstrated Thursday March 9, 2023, with the food and beverage textures not crossed off. <BR/>Interview on 03/27/23 at 12:20 PM CNA A stated they receive the trays and do not check the meal tickets. CNA A stated she does not check them because they are checked by the nurses and the kitchen before getting to the residents. CNA A stated she had not been trained to review the tickets. CNA A stated the kitchen, and the nurses check the tickets. CNA A stated if they see normal water and the resident needs nectar then they report it to the nurses. CNA A stated she does not check the ticket and that Resident #2's diet was being changed regularly. CNA A stated the importance of checking the tickets would be for the sake of the residents. CNA A stated the risk to the residents could be that they could choke or gasp. <BR/>Interview on 03/27/23 at 12:25 PM CNA B stated the charge nurse checks the tickets with the trays and from there they check the tray with the tickets to make sure everything is correct. CNA B stated the risk was residents could choke or aspirate. <BR/>Interview on 03/28/23 at 8:40 AM Dietary Manager stated the menu system went down on 03/09/23; where resident tickets were generated and now, he manual scratches and writes in the new orders on the meal ticket. Dietary Manager stated the system in place for the serving trays and checking tickets is the dietary staff who handles the food carts, and the cook will check the diet ticket. Dietary Manager stated he does not check every card every day to make sure that handwritten slips are correct according to doctor's orders. Dietary Manager stated the facility had a dispensary that gives nectar liquids already mixed and did not know the nectar would settle since they are proportioned the day before. Dietary Manager stated the dietary staff are not trained on thickening liquids due to having the dispensary. Dietary Manager stated if Resident #67 would have drunk the nectar with the settlement than it could have caused him aspiration problems. Dietary Manager stated staff not being trained serving could be a risk for residents if they do not read the tickets and know the consistencies and textures that are being given leading to residents aspirating. <BR/>Interview on 03/28/23 at 8:45 AM Assistant Interim Administrator stated the changes in diet orders are not communicated in the morning meetings. Assistant Administrator stated Dietary Manager is not present in the morning meetings. Assistant Administrator stated speech therapist are present in the morning meetings and if they change something then it is communicated. Assistant Administrator stated they called for administrative staff to come out to help serve the resident their meals during lunch time. Assistant Administrator stated since they are not feeding and only serving the administrative staff do not need to be trained. Assistant Administrator stated the staff are not trained to adding to liquids such as going form thin to nectar and so far. <BR/>Resident #67 <BR/>Record review of Resident #67's face sheet dated 3/29/2023 documented that he was [AGE] years old and was initially admitted to the facility on [DATE] and again on 10/19/2022. <BR/>Record review of Resident #67's History and Physical dated 09/15/2022 documented that he was confused and oriented only to person. <BR/>Record review of Resident #67's care plan dated 10/20/2021 documented no care plan related to food texture or liquid consistency. <BR/>Record review of Resident #67's electronic diagnoses listing accessed 03/29/2023 documented an admitting diagnosis of chronic obstructive pulmonary disease (a lung disease with coughing and shortness of breath). <BR/>Record review of Resident #67's Physician's order dated 03/20/2023 documented in part that he was to receive a regular pureed diet with nectar consistency liquids. <BR/>Record review of Resident #67's quarterly MDS dated [DATE] did not document any issues with swallowing. <BR/>In observation and record review on 03/27/2023 at 12:15 PM Resident #67 was observed eating in the dining room. He had three containers of liquid within his reach; a glass of thickened water, a glass of red liquid that was not thickened, and a cup of coffee that was not thickened. Record review of the dietary ticket next to the liquids had a hand-written note that Resident #67 was to have nectar-thick liquids. <BR/>In an observation and interview on 03/27/2023 at 12:18 PM ADON F said that based on Resident #67's dietary ticket he was to have nectar thick liquids. He said that the resident needed thickened liquids because the resident had problems swallowing. The ADON said that if Resident #67 did not have thickened liquids the resident was at risk of aspiration (breathing liquids into his lungs). ADON F was observed to examine the glass of water and said that it was nectar-thick water. He was observed to examine the glass of red liquid. He said that it was thickened cranberry juice but needed to be stirred because the thickener was at the bottom of the glass. He was observed to put a spoon in the glass of liquid and bring up a mass of pudding-thick juice from the bottom which he then stirred into the thin cranberry juice. He picked up the cup of coffee and said it had not been thickened. The ADON was observed removing the coffee from the table. <BR/>Observation on 03/29/23 at 2:13 PM of Resident #67's ticket for lunch revealed that it was not updated. It was dated Thursday March 9, 2023, but that date had been crossed out and no other date had been added. The ticket for lunch had a hand-written note indicating that he was to receive puree texture food and nectar thick liquids, but previous food and beverage textures had not been marked off. <BR/>Record review of facility policy Nursing Responsibilities at Meal Service revealed the use of properly trained and supervised volunteers. Family members, and other individuals can enhance the quality of life and the quality of care for residents. Assist in preparing food after the tray has been delivered to the resident, if necessary. This includes unwrapping food, cutting meat, buttering bread, opening condiments packages, seasoning food when desired by resident, preparing beverages and explaining location of food items. Food should be removed from the serving tray when placed in front of the resident. If the facility elects to use volunteers, family members, and other individuals to pass out trays the facility should provide training to those individuals. Individuals providing assistance should also receive hands on training regarding such topics as various feeding techniques, proper use of adaptive equipment, and providing/coordinating emergency services if a resident experiences a problem while eating. All feeding assistance programs should be closely monitored and supervised by appropriate facility staff, including nursing and dietary services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, for 1 resident (Resident #64) of 21 residents reviewed for weight loss. <BR/>The facility failed to monitor, document, care plan, and implementplace interventionss for Resident #64 significant weight loss. <BR/>This failure could place all residents in the facility at risk for weight loss, and not maintaining their highest practicable level of health. <BR/>The findings included:<BR/>Record Review of Resident #64's Face Sheet dated 3/27/23 documented in part resident is a [AGE] year-old female admitted on [DATE] to the facility. <BR/>Record Review of Resident #64's History and Physical dated 07/06/22 established diagnoses of anemia, prediabetic, gastroesophageal reflux disease, and hyperlipidemia.<BR/>Record Review of Resident #64 Referral History and Physical dated 6/24/22 from doctor visit documented in part resident weight as 181 lbs. <BR/>Record Review of Resident#64 Annual MDS dated [DATE] documented Resident #64 had a BIMS of 14 indicating she was cognitively intact. Resident #64 required limited assistance with one person's physical assistance for eating. Resident #64 required set up or clean up assistance for eating. <BR/>Record Review of Care Plan dated 2/03/22 documented in part Resident #64 was is at risk for Malnutrition, with the goal to maintain stable weight and nutritional parameters. Interventions included monitor resident meal intake and resident weight.<BR/>Record Review of Resident #64 weights summary trend displayed her current weight for 03/01/23 was 130 lbs. Resident #64 initial weight upon arrival on 07/06/22 at 04:08 PM was 170 lbs. Documentation was crossed out and disputed by Dietitian on 10/10/22 at 08:40 AM. Dietitian left Resident #64 weight of 148lbs obtained on 9/6/22. Resident had a 5% weight loss from 12/7/22 to 1/4/23. <BR/>Record Review of Resident #64 Progress Notes dated 1/6/22 by the dietician indicated Resident #64 had 13% weight loss in 90 days, and 15.5% in 180 days. Dietician recommendations included adding fortified foods to all meals and the physician to consider appetite stimulants if medically feasible and plan to follow up as needed. Interventions were not implemented or acknowledged by nursing staff. <BR/>Record Review of Resident #64 diet order dated creation date is 07/13/22 and date of revisedsion onis 09/20/22 read regular diet, regular texture and consistency, health shakes and red glass (feeding assistance).<BR/>Record Review of Resident #64 Progress Notes dated 3/4/23 by the dietician, Resident #64 weight loss in 180 days was 18 lbs. Resident #64 diet was regular/texture/regular liquid and the supplement included health shakes three times a day. Documentation indicated Resident#64 average oral intake was 25-50% and the goal was being met. To continue with the current diet and support as ordered no recommendations at this time. <BR/>Record Review of Resident #64 Medication Administration note dated 3/3/23 at 12:04 PM stated Health Shake Refused resident does not like it. Resident #64 stated, she did not like the health shakes that was the reason reason she kept refusing. <BR/>Interview with Resident #64 on 3/26/23 at 3:50 PM, Resident disclosed she did not like the food in the facility, due to cultural preference. Resident #64 stated, I do not eat much because I just do not like it, I am not from this area, and in this facility, all they serve is Mexican food. Resident #64 stated, since I been in this facility, I have lost weight none of my clothes fit me, but they started giving medication. Resident #64 stated she had told several staff members. She stated, But the staff don't listen - they keep bringing me the same thing, I just try to eat whatever I can from my tray. <BR/>Interview with Dietician on 03/29/23 at 01:30 PM, Dietician stated, when reviewing weights and diets for the residents, I check the admission listing daily, wound care reports, weight's daily progress notes, and weight summary if there is a weight trigger for 30 and 90 days. The facility staff will also notify me if they have any issues that I needed to review. Dietician stated, I send recommendations to the facility as needed, and I check daily that interventions are being followed. I have several buildings I check daily from my computer. For Resident #64 never triggered there was no weight loss trend in September 2022. I noticed a weight loss on 09/15/22 and disputed the weight on 07/06/22 of 170 lbs., since there was too much weight loss difference. Resident #64 was not re-weighed, Dietician stated in a similar situation he would have reviewed the history and physical as a guide for a baseline, however, with Resident #64 he did did not review her history and physical. Dietician stated, If I would have noticed her weight was 180 lbs. on her history and physical, I would have implemented interventions. Resident #64 did not trigger for weight loss; however, no weight was entered until September. The Dietician confirmed the facility should have weighed Resident #64 monthly. Since this did not occur, he was not able to do a full assessment. Dietician stated, When residents do trigger significant weight loss, I speak with them about their diet preferences, and if they have any issues with their food. I would then recommend diet modification, an appetite stimulant with physician approval, and fortified food. With Resident #64 I did not go speak to her about her preferences. Failure to identify a resident nutritional status can affect the resident weight. <BR/>Interview on 03/29/23 at 02:00 PM with DON and Administrator revealed the CNAs responsibility was to weigh the residents however the nurse is responsible to ensure it is done. DON and Administrator stated, that weights are covered weekly in our meeting and Resident #64 did not trigger. If Resident #64 would have triggered the department head from dietary would be responsible to monitor recommendations are followed. Administrative staff confirmed Resident #64 had lost significant weight, and if this issue was not addressed it can lead to malnutrition. <BR/>Record Review of the facility policy Resident Weights for nursing policy and procedure manual 2003 revised 2/13/2007 documented the facility all residents will be weight monthly, weights will be documented correctly, and appropriate actions regarding signification weight change will be carried out. Weights shall be obtained and documented on admission, readmission, and monthly unless ordered otherwise or dictated more frequently by the resident's condition. All significant weight changes will be referred to a dietician to complete an assessment of all significant weight losses. The dietician will review all facility interventions and make appropriate recommendations which will be approved by the physician if necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, 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 food and nutrition services, in that: <BR/>1. <BR/>Food products in dry storage, freezer, and in refrigerator were not correctly labeled, wrapped, or were expired. <BR/>2. <BR/>Staff were not wearing hairnets properly. <BR/>3. <BR/>Freezer was dirty. <BR/>4. <BR/>Food temperatures were not taken prior to serving meals. <BR/>5. <BR/>Staff did not wash hands after touching hair on the serving line. <BR/>These failures could affect residents by placing them at risk of food borne illness. <BR/>Findings include: <BR/>Observation and interview on 3/26/23 at 8:03 AM initial tour was conducted with Kitchen Aide P. Kitchen Aide P stated dessert in plastic containers (total of 11) were not labeled and should have been labeled with date they were prepared and chicken wings in freezer and sausages did not have date of when it was opened and should have been dated with date it was opened. The Kitchen Aide P stated the freezer was dirty with some spillage of unknown kind and stated the freezer was supposed to be cleaned weekly and stated it did not appear it had been cleaned recently, she stated there was spillage of some kind and dirt under the frozen goods. Kitchen Aide P stated the bins of flour (1 bin) and rice (1 bin) did not have labels with dates should be dated when they were filled. Kitchen Aide P stated she received training upon hire on food storage and labeling and sanitary conditions. Kitchen Aide P stated all kitchen staff were in charge of ensuring all goods were properly labeled and dated and kitchen supervisors were in charge of conducting checks as well. Kitchen Aide P stated kitchen managers were the ones in charge of taking food temperatures before meals and stated they did not keep a food temperature log. Kitchen Aide P stated she had not seen a temperature log for several days or seen the kitchen managers write down food temperatures anywhere. <BR/>Interview on 3/26/23 at 8:10 AM the Kitchen Supervisor stated they have not had a food temperature log for several days and they have been writing food temperatures down on scratch sheet of paper. The Kitchen Supervisor stated she did not have today's food temperatures for breakfast meals because they were running behind in the morning and did not have a chance to take the food temperatures. The Kitchen Supervisor stated by not taking food temperature could place residents at risk of acquiring food borne illness by not ensuring foods were served at appropriate food temperatures. <BR/>Observation and interview on 3/26/23 at 11:25 AM Dietary Manager stated all foods were required to be dated and labeled, he stated the items in the refrigerator were labeled on the food tray to not have to write on all items item by item (picture submitted to evidence shows 11 desserts in plastic containers not labeled [NAME] food tray that does not have a label with date).The Dietary Manager stated the staff should be cleaning the freezer at least weekly to not expose frozen goods to cross contamination. The Dietary Manager stated the flour and rice bins should have been dated and would get to it soon, stated he should have dated them when they were filled. The Dietary Manager obtained a copy of March ' s food temperature log with breakfast temperature for today recorded. The Dietary Manager stated she had filled out the form after State Surveyor left the kitchen and the information documented was not accurate for today ' s breakfast temperatures, The Dietary Manager stated food temperatures should be recorded before serving meals and not after they had served for accuracy in documentation and accuracy in temperatures. <BR/>Observation on 3/26/23 at 11:56 AM Kitchen Aide was on the serving line preparing meal trays to be distributed, her bangs were not covered with the hair net. The Kitchen Aide touched her bangs to fix them off her face 4 times and continued to serve food using kitchen utensils every time. The Kitchen Aide did not wash hands, use hand sanitizer, and was not wearing gloves each time she touched her hair and continued to serve food. <BR/>Interview on 3/26/23 at 12:50 PM Dietary Manager stated all staff who assisted with meal service were required to wash hands before assisting and could use hand sanitizer few times before having to wash again. The Dietary Manager stated hair nets were required to cover all hair and if staff were to touch hair while serving food on serving line they should be stepping aside to wash hands. The Dietary Manager stated the DON had conducted several hand hygiene in-services in the past addressing when they should be washing their hands. The Dietary Manager stated by not wearing hairnets appropriately and not washing hands after touching hair while at serving line was a cross contamination issue. <BR/>Interview on 3/26/23 at 1:13 PM Kitchen Aide Q stated she should have been wearing her hair net correctly which included bangs being covered. The Kitchen Aide Q stated she should have stepped away to wash hands or use hand sanitizer each time she fixed her hair, and her failure could place residents at risk of cross contamination leading to some type of infection. The Kitchen Aide Q stated she received training of hand washing and hair nets upon hire. <BR/>Record review of Daily Food Temperature Control Policy dated 2012 revealed We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges. 2- Prior to meal service, the cook shall take the temperature of all hot and cold foods. 3- Temperatures are recorded on the Temperature Log Form. <BR/>Record review of Dietary Food Service Personnel Policy and Procedures dated 2012 revealed Sanitation and Food Handling: 2- hair nets or hats covering the hairline are worn at all times. 3- wash your hands before starting work, touching something that is not clean and then handling food can cause food poisoning. <BR/>Record review of Storage Refrigerators policy dated 2012 revealed All storage refrigerators shall be maintained clean and have proper temperature for food storage and to ensure a proper environment and temperature for food storage. 4- storage refrigerators shall be kept cleaned and organized. Spills are to be wiped up immediately. 5- food must be covered when stored, with date label identifying what is in the container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 5 (Resident # 3, #4, #5, #7, and #8 ) of 12 residents reviewed for care plans. <BR/>The facility failed to implement a comprehensive person-centered care plan for Resident #7 ' s history of falls. <BR/>The facility failed to implement a comprehensive person-centered care plan to address elopement risk for Residents #3, #4, #5, #7, and #8. <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include: <BR/>Resident #7 <BR/>Record review of Resident #7 ' s face sheet dated 01/19/24 revealed admission on [DATE] and re-admission on [DATE] to the facility with diagnoses of unspecified lack of coordination, abnormalities of gait and mobility, disorganized schizophrenia, muscle wasting and atrophy, muscle weakness, unsteadiness on feet, and unspecified dementia. <BR/>Record review of Resident #7 ' s care plan dated 11/21/23 revealed at risk for wandering. Assess for fall risk. Care plan did not indicate anything regarding the focus area of falls. <BR/>Record review of Resident #7 ' s Event Note dated 11/20/23 revealed bruising to left knee, left lower leg, left ankle bruising. <BR/>Record review of Resident #7 ' s Fall Assessments dated 01/19/24 revealed from there were only fall assessments completed from 02/13/20-08/09/23. No fall assessment was conducted for the Event note that was completed on 11/20/23. <BR/>Resident #3 <BR/>Record review of Resident #3 ' s face sheet dated 01/18/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #3 ' s facility history and physical dated 07/25/23 revealed a [AGE] year-old female diagnosed with Dementia and Major Depression Disorder (affects how you feel, think and behave and can lead to a variety of emotional and physical problems). <BR/>Record review of Resident #3 ' s quarterly MDS dated [DATE] revealed a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 3. Resident #3 was diagnosed with Alzheimer Disease, Non-Alzheimer ' s Disease, and Depression. <BR/>Record review of Resident #3 ' s elopement risk assessment dated [DATE] revealed a score of 13, high risk of elopement. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident # 3 ' s care plan dated revealed no focus area and/or interventions to address elopement risk. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet dated 01/18/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #4's facility history and physical dated 05/18/23 revealed a [AGE] year-old female diagnosed with psychiatric behavior with aggression and paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly). <BR/>Record review of Resident #4's annual MDS dated [DATE] revealed a Preadmission Screening and Resident Review condition as serious mental illness. Resident #4 had a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 3. MDS indicated zero (no behavioral symptoms) for behaviors. Resident #4 was diagnosed with Non-Alzheimer's Disease, Psychotic Disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), Schizophrenia (a serious mental disorder in which people interpret reality abnormally), depression, and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). <BR/>Record review of facility assessment scoring report sheet dated 01/01/20-01/19/24 reviewed Resident #4 had a score of 13 for elopment risk. <BR/>Record review of Resident #4's care plan dated 12/17/21 revealed no focus area for elopement. <BR/>Resident #5 <BR/>Record review of Resident #5 ' s face sheet dated 01/18/24 revealed admission on [DATE] to the facility. Resident #5 was a [AGE] year-old female diagnosed with Dementia and Psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). <BR/>Record review of Resident #5 ' quarterly MDS dated [DATE] revealed a moderately cognition to be able to recall and make daily decision BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score which was not taken for whatever reason. Resident #5 was diagnosed with Cerebrovascular Accident (an interruption in the flow of blood to cells in the brain), Non-Alzheimer ' s Dementia, Depression, Psychotic Disorder (affect brain function by altering thoughts, beliefs or perceptions) and Adjustment Disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior) with Depressed Mood (Feelings of sadness, hopelessness, crying and lack of joy from things that used to bring you pleasure). <BR/>Record review of Resident #5 ' s Elopement assessment dated [DATE] revealed a elopement risk score of 18. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident #5 ' care plan dated 01/22/24 revealed no focus area for elopement. <BR/>Resident #8 <BR/>Record review of Resident #8 ' s face sheet dated 01/19/23 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #8 ' s facility history and physical dated 04/06/23 revealed a [AGE] year-old male diagnosed with severe intellectual disability, anxiety, and Major depressive Disorder (it affects how you feel, think and behave and can lead to a variety of emotional and physical problems). <BR/>Record review of Resident #8 ' s annual MDS dated [DATE] revealed a Preadmission Screening and Resident Review condition as intellectual disability. Resident #4 had a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score that was not taken for whatever reason. Behaviors was marked zero revealing Resident #8 had no behaviors when Resident #8 really did have behaviors. Resident #8 was diagnosed with Seizure Disorder (abnormal electrical brain activity), Depression, and Serve Intellectual Disabilities (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills). <BR/>Record review of Resident #8 ' s elopement risk assessment dated [DATE] revealed a score of 14, high risk. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident #8 ' s care plan dated 01/15/24 revealed no focus area for elopement. <BR/>During an interview on 01/19/24 at 6:17 PM with MDS Coordinator C and MDS Coordinator D, MDS Coordinator C, she stated the comprehensive care plans should have had falls and elopement care planned for Resident #7, #3, #4, #5, #8. MDS Coordinator D stated there could be a risk of not care planning falls and elopement. MDS Coordinator stated the risk could be a resident elopement from the facility. MDS Coordinator C stated anytime there was an elopement assessment completed for a resident that meant it would need to be care planned for the resident. MDS Coordinator C stated the DON, ADON, and the MDS department were responsible for overseeing that the comprehensive care plans are accurate. <BR/>During an interview on 01/22/24 at 10:46 AM with the DON, she stated residents with elopement risk should have elopement as a focus area in their care plans. The DON stated the charge nurse will update the care plans and the DON and ADONs will oversee to make sure it was done. The DON stated that Resident #7 had no focus area for falls and had overlooked the fall for the comprehensive care plan. The DON stated Residents #3, #4, #5, and #8 had no focus for elopement because she did not look for it on the comprehensive care plan as she did not know it needed to be care planned. The DON stated the risk of not including the elopement in the comprehensive care plan could be identifying resident elopement risk and monitoring of the resident. <BR/>During an interview on 01/22/24 at 12:44 PM with the Administrator, she stated she was not too familiar with comprehensive care plans and asked to refer to the DON regarding care plans. <BR/>Record review of the facility Elopement Assessment Scoring Report dated 01/01/20-01/19/24 was review revealed there were 30 residents on it to include Residents #3, #4, #5, #8. <BR/>Record review of the facility Preventive Strategies to Reduce Fall Risk dated 10/05/16 revealed, Policy: The goal of fall prevention strategies was to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident ' s mobility. <BR/>Residents at risk will be care planned for fall prevention. <BR/>After risk was assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will educate on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. <BR/>Record review of the facility comprehensive care plan policy not dated revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. <BR/>The comprehensive care plan will describe the following: <BR/>The services that are to be furnished to attain and maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. <BR/>Record review of the facility Elopement Prevention policy 01/2023 revealed, Every effort will be made to prevent elopement episode while maintaining the least restrictive environment for residents who are at risk for elopement. <BR/>All residents who area at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. <BR/>The resident ' s care plan will be modified to indicate the resident was at risk for elopement episodes. <BR/>Interventions into elopement episodes will be entered onto the resident ' s care plan and medical record. <BR/>Record review of the facility Elopement Response policy dated 10/27/10 revealed, After an elopement the care plan coordinator will reevaluate the resident ' s care plan. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure respiratory care was provided in a manner consistent with professional standards of practice for 1 (Resident#10) of 2 residents reviewed for respiratory care in that: <BR/>The facility failed to place Resident #10 ' s nasal cannula in a clear labeled bag while not in use. <BR/>These deficient practices could place residents at risk for infection due to improper care practices. <BR/>Findings Include: <BR/>Record review of Resident #10 ' s face sheet dated 01/22/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #10 ' s facility history and physical dated 08/03/23 revealed an [AGE] year-old female diagnosed with Type 2 Diabetes Mellitus, Asthma, Alzheimer ' s Disease, multiple of falls, and Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). <BR/>Record review of Resident #10 ' s quarterly MDS dated [DATE] revealed a severe cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 2. Resident #10 does have a behavior of delusions and wandering. Resident #10 needs partial/moderate assistance for nursing staff to sit to stand, chair/bed to chair transfer, toilet transfer. Resident #10 was total dependent on showers. Resident #10 was diagnosed with Alzheimer ' s, asthma, and muscle weakness (no muscle strength), and lack of coordination (Uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements). Resident was not marked for oxygen therapy as the MDS was done on 10/12/23 before Resident #10 needed oxygen. <BR/>Record review of Resident #10 ' s order recap dated 01/05/24 revealed change nasal cannula as needed. Check oxygen saturation every shift and as needed and every shift. May use oxygen at 2 liter per minute via nasal cannula every shift. <BR/>Record review of Resident #10 ' s Care Plan dated 08/22/22 revealed Resident #10 has asthma and was at risk for respiratory distress. Give medications as ordered. Give nebulizer treatments and oxygen therapy as ordered. <BR/>Observation on 01/13/24 at 1:13 PM revealed Resident #10 ' s nasal cannula to be placed on top of the concentrator unbagged. The nasal cannula part where it goes into your nose had a slight tint color as well as some parts of the oxygen tubing. <BR/>During an interview on 01/13/24 at 1:20 PM with the family member, she stated the nursing staff always just placed Resident #10 ' s nasal cannula on the concentrator unbagged. <BR/>During an interview on 01/13/24 at 1:25 PM with MDS Coordinator C, she stated nasal cannulas are to be bagged if not in use. MDS Coordinator C stated the risk of not bagging the nasal cannula could be infection to the resident. <BR/>Observation and interview on 01/22/24 at 10:25 AM with the DON, she stated Resident #10 ' s nasal cannula should be changed as needed or once a week. The DON stated Resident #10 ' s nasal cannula being unbagged and placed on the concentrator was unacceptable. The DON stated Resident #10 ' s nasal cannula should have been placed in a clear baggy that was labeled with the date. The DON stated that was so the nursing staff would know when to change the nasal cannula. The DON stated Resident #10 ' s nasal cannula had been used. The DON stated not bagging the nasal cannula was a risk to Resident #10 with an infection. <BR/>Record review of the facility Infection Control Plan: Overview policy dated 2019 revealed, The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. <BR/>On 01/22/24 at 9:00 AM with the Administrator, she stated the facility did not have an oxygen policy specifically about nasal cannulas being bagged. <BR/>Record review of the facility Oxygen Administration policy dated 02/13/07 revealed, Oxygen therapy includes the administration of oxygen in liters per minute by cannula or face mask to treat hypoxemia conditions caused by pulmonary or cardiac diseases. <BR/>The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. <BR/>The resident will be free from infection. <BR/>Changing the tubing (including any nasal prongs or mask) that was in use on one patient when it malfunctions or becomes visibly contaminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure that residents received the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible for 1 (Resident #11) of 5 residents reviewed for indwelling catheters in that:<BR/>Resident #11's indwelling catheter tubing was full and cloudy and evaluated on a wedge not being able to drain downwards properly. <BR/>These failures placed residents at risk of collection tube becoming full and allowing urine to flow back into the bladder that could result in a urinary tract infection.<BR/>Findings include: <BR/>Record review of Resident #11's face sheet dated 02/14/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #11's facility history and physical dated 11/06/23 revealed a [AGE] year-old male diagnosed with schizophrenia (a serious mental disorder in which people interpret reality abnormally) and bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode)). <BR/>Record review of Resident #11's quarterly MDS dated [DATE] revealed an intact cognition to be able to recall and make daily decisions BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 13. Resident #11 was dependent on nursing staff for toileting. Resident #11 had an indwelling catheter. <BR/>Record review of Resident #11's care plan dated 01/13/24 revealed indwelling catheter - check for kinks and maintain the drainage bag off the floor, ensure tubing is anchored to the resident's leg or linens so that tubing was not pulling on the urethra, monitor and document intake and output as per facility policy, and for signs of discomfort on urination and frequency. <BR/>Observation on 02/15/24 at 9:47 AM revealed Resident #11 was lying down in the bed with an indwelling catheter. The indwelling catheter tubing was cloudy. The catheter tubing was all the way full. The indwelling catheter tubing was hanging off a wedge creating a back flow to the resident. <BR/>Observation and interview on 02/15/24 at 9:54 AM with LVN J, she stated Resident #11's indwelling catheter was full and looked cloudy. LVN J stated the way the indwelling catheter tubing was positioned could create blockage and back flow resulting in a risk of urinary tract infection. LVN J stated it was everyone's responsibility for ensuring the indwelling catheter tubing was positioned properly. <BR/>During an interview on 02/15/24 at 10:28 AM with the ADON G, she stated tubing should be straight and not kinked allowing flow downwards to the catheter bag. ADON G stated the indwelling catheter tubing being kinked or elevated could cause back flow resulting in urinary retention and a urinary tract infection. ADON G stated it was the nurses and CNAs responsibility to ensure there the tubing was positioned correctly and not kinked. <BR/>During an interview on 02/15/24 at 11:00 AM with the Area Director of operations, stated DON was suspended, so no interview regarding the indwelling catheter was conducted with DON. <BR/>Record review of the facility's Catheter Insertion, Male/Female policy and procedure manual dated 2003 revealed, An indwelling catheter provides continuous bladder drainage in residents with a neurogenic bladder or urinary disfunction.<BR/>Catheter Change/Replacement - Catheters that are encrusted so that urinary outflow was blocked should be changed. <BR/>Record review of the facility's Resident Rights policy manual dated 11/28/16 revealed, Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.<BR/>Respect and Dignity - The resident has a right to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 5 (Resident # 3, #4, #5, #7, and #8 ) of 12 residents reviewed for care plans. <BR/>The facility failed to implement a comprehensive person-centered care plan for Resident #7 ' s history of falls. <BR/>The facility failed to implement a comprehensive person-centered care plan to address elopement risk for Residents #3, #4, #5, #7, and #8. <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include: <BR/>Resident #7 <BR/>Record review of Resident #7 ' s face sheet dated 01/19/24 revealed admission on [DATE] and re-admission on [DATE] to the facility with diagnoses of unspecified lack of coordination, abnormalities of gait and mobility, disorganized schizophrenia, muscle wasting and atrophy, muscle weakness, unsteadiness on feet, and unspecified dementia. <BR/>Record review of Resident #7 ' s care plan dated 11/21/23 revealed at risk for wandering. Assess for fall risk. Care plan did not indicate anything regarding the focus area of falls. <BR/>Record review of Resident #7 ' s Event Note dated 11/20/23 revealed bruising to left knee, left lower leg, left ankle bruising. <BR/>Record review of Resident #7 ' s Fall Assessments dated 01/19/24 revealed from there were only fall assessments completed from 02/13/20-08/09/23. No fall assessment was conducted for the Event note that was completed on 11/20/23. <BR/>Resident #3 <BR/>Record review of Resident #3 ' s face sheet dated 01/18/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #3 ' s facility history and physical dated 07/25/23 revealed a [AGE] year-old female diagnosed with Dementia and Major Depression Disorder (affects how you feel, think and behave and can lead to a variety of emotional and physical problems). <BR/>Record review of Resident #3 ' s quarterly MDS dated [DATE] revealed a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 3. Resident #3 was diagnosed with Alzheimer Disease, Non-Alzheimer ' s Disease, and Depression. <BR/>Record review of Resident #3 ' s elopement risk assessment dated [DATE] revealed a score of 13, high risk of elopement. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident # 3 ' s care plan dated revealed no focus area and/or interventions to address elopement risk. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet dated 01/18/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #4's facility history and physical dated 05/18/23 revealed a [AGE] year-old female diagnosed with psychiatric behavior with aggression and paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly). <BR/>Record review of Resident #4's annual MDS dated [DATE] revealed a Preadmission Screening and Resident Review condition as serious mental illness. Resident #4 had a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 3. MDS indicated zero (no behavioral symptoms) for behaviors. Resident #4 was diagnosed with Non-Alzheimer's Disease, Psychotic Disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), Schizophrenia (a serious mental disorder in which people interpret reality abnormally), depression, and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). <BR/>Record review of facility assessment scoring report sheet dated 01/01/20-01/19/24 reviewed Resident #4 had a score of 13 for elopment risk. <BR/>Record review of Resident #4's care plan dated 12/17/21 revealed no focus area for elopement. <BR/>Resident #5 <BR/>Record review of Resident #5 ' s face sheet dated 01/18/24 revealed admission on [DATE] to the facility. Resident #5 was a [AGE] year-old female diagnosed with Dementia and Psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). <BR/>Record review of Resident #5 ' quarterly MDS dated [DATE] revealed a moderately cognition to be able to recall and make daily decision BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score which was not taken for whatever reason. Resident #5 was diagnosed with Cerebrovascular Accident (an interruption in the flow of blood to cells in the brain), Non-Alzheimer ' s Dementia, Depression, Psychotic Disorder (affect brain function by altering thoughts, beliefs or perceptions) and Adjustment Disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior) with Depressed Mood (Feelings of sadness, hopelessness, crying and lack of joy from things that used to bring you pleasure). <BR/>Record review of Resident #5 ' s Elopement assessment dated [DATE] revealed a elopement risk score of 18. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident #5 ' care plan dated 01/22/24 revealed no focus area for elopement. <BR/>Resident #8 <BR/>Record review of Resident #8 ' s face sheet dated 01/19/23 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #8 ' s facility history and physical dated 04/06/23 revealed a [AGE] year-old male diagnosed with severe intellectual disability, anxiety, and Major depressive Disorder (it affects how you feel, think and behave and can lead to a variety of emotional and physical problems). <BR/>Record review of Resident #8 ' s annual MDS dated [DATE] revealed a Preadmission Screening and Resident Review condition as intellectual disability. Resident #4 had a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score that was not taken for whatever reason. Behaviors was marked zero revealing Resident #8 had no behaviors when Resident #8 really did have behaviors. Resident #8 was diagnosed with Seizure Disorder (abnormal electrical brain activity), Depression, and Serve Intellectual Disabilities (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills). <BR/>Record review of Resident #8 ' s elopement risk assessment dated [DATE] revealed a score of 14, high risk. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident #8 ' s care plan dated 01/15/24 revealed no focus area for elopement. <BR/>During an interview on 01/19/24 at 6:17 PM with MDS Coordinator C and MDS Coordinator D, MDS Coordinator C, she stated the comprehensive care plans should have had falls and elopement care planned for Resident #7, #3, #4, #5, #8. MDS Coordinator D stated there could be a risk of not care planning falls and elopement. MDS Coordinator stated the risk could be a resident elopement from the facility. MDS Coordinator C stated anytime there was an elopement assessment completed for a resident that meant it would need to be care planned for the resident. MDS Coordinator C stated the DON, ADON, and the MDS department were responsible for overseeing that the comprehensive care plans are accurate. <BR/>During an interview on 01/22/24 at 10:46 AM with the DON, she stated residents with elopement risk should have elopement as a focus area in their care plans. The DON stated the charge nurse will update the care plans and the DON and ADONs will oversee to make sure it was done. The DON stated that Resident #7 had no focus area for falls and had overlooked the fall for the comprehensive care plan. The DON stated Residents #3, #4, #5, and #8 had no focus for elopement because she did not look for it on the comprehensive care plan as she did not know it needed to be care planned. The DON stated the risk of not including the elopement in the comprehensive care plan could be identifying resident elopement risk and monitoring of the resident. <BR/>During an interview on 01/22/24 at 12:44 PM with the Administrator, she stated she was not too familiar with comprehensive care plans and asked to refer to the DON regarding care plans. <BR/>Record review of the facility Elopement Assessment Scoring Report dated 01/01/20-01/19/24 was review revealed there were 30 residents on it to include Residents #3, #4, #5, #8. <BR/>Record review of the facility Preventive Strategies to Reduce Fall Risk dated 10/05/16 revealed, Policy: The goal of fall prevention strategies was to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident ' s mobility. <BR/>Residents at risk will be care planned for fall prevention. <BR/>After risk was assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will educate on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. <BR/>Record review of the facility comprehensive care plan policy not dated revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. <BR/>The comprehensive care plan will describe the following: <BR/>The services that are to be furnished to attain and maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. <BR/>Record review of the facility Elopement Prevention policy 01/2023 revealed, Every effort will be made to prevent elopement episode while maintaining the least restrictive environment for residents who are at risk for elopement. <BR/>All residents who area at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. <BR/>The resident ' s care plan will be modified to indicate the resident was at risk for elopement episodes. <BR/>Interventions into elopement episodes will be entered onto the resident ' s care plan and medical record. <BR/>Record review of the facility Elopement Response policy dated 10/27/10 revealed, After an elopement the care plan coordinator will reevaluate the resident ' s care plan. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #14) of 16 residents reviewed for call light placement.<BR/>The facility failed to ensure that Residents #14's call light was within her reach.<BR/>This failure placed residents at risk of not being able to call for assistance when needed.<BR/>Findings included: <BR/>Record review of Resident #14's face sheet dated 02/17/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #14's facility history and physical dated 01/06/23 revealed a [AGE] year-old female diagnosed with severe intellectual disability (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills) and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). <BR/>Record review of Resident #14's annual MDS dated [DATE], revealed positive for Intellectual Disability. No score was documented for BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements). Activities of Daily Living noted Resident #14 was dependent on nursing staff for eating, oral/personal hygiene, toileting, showering, and dressing. Resident #14 was diagnosed with Cerebral Palsy, Seizure Disorder (a disorder of the brain), lack of coordination, and severe intellectual disabilities. <BR/>Record review of Resident #14's care plan dated 03/16/23, revealed she has a communication problem due to Intellectual Disability. Ensure/provide a safe environment: Call light within reach.<BR/>Observation and interview on 02/17/24 at 2:42 PM with Admissions Marketing Director K and Admissions Marketing Director L, revealed the call light was clipped on to the call light cord on the wall away from Resident #14 who was lying down on her bed. The Admissions Marketing Director K stated the call light had to be within reach of the resident. Admissions Marketing Director K stated it was so Resident #14 could call for assistance. Admissions Marketing Director L stated the risk of not having the call light within reach could result injury or a fall. Admissions Marketing Director L stated all staff were trained in call light placement with residents. <BR/>During an attempted interview on 02/17/24 at 2:50 PM with Resident #14, when interviewed Resident #14 just looked and smiled at investigator. <BR/>During an interview on 02/17/24 at 3:17 PM with CNA M, she stated call lights had to be within reach of a resident to be able to call facility staff for assistance. CNA M stated not having the call light within could result in the resident not being able to call for help or assistance if they needed. CNA M stated it was everyone's responsibility to ensure resident call lights were within reach. <BR/>During an interview on 02/17/24 at 3:02 PM with CNA O stated everyone was responsible for ensuring call lights were within reach of the residents. CNA O stated there could be a risk if it was not within reach in which the resident would not be able to call for assistance or help. <BR/>During an interview on 02/17/24 at 3:28 PM with NCNA N, he stated residents needed to have call lights within so residents would be able to call nursing staff for anything or in an emergency. NCNA N stated there could be a risk to the resident like falling or like someone was in their room that should not be in there . <BR/>During an interview on 02/17/24 at 3:39 PM with the Administrator, she stated call lights have to be within the reach of the residents for assistance or an in emergency. The Administrator stated there was a risk if there was an emergency. The Administrator stated that all facility staff were trained on call lights. <BR/>During an interview on 02/17/24 at 3:05 PM with the Regional Nurse, she stated the facility had no call light policy.<BR/>Record review of the facility's Resident Rights policy manual dated 11/28/16 revealed, Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.<BR/>Respect and Dignity - The resident has a right to be treated with respect and dignity, including:<BR/>The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 resident (Residents #83) of 8 reviewed for medication administration. <BR/>MA S administered Resident #83 medication prior to taking blood pressure. <BR/>This deficient practice could cause a decline in health of residents who receive medication that are not according to physician orders. <BR/>Findings included: <BR/>Review of Resident #83's face sheet dated 03/28/23 revealed a [AGE] year-old female with an admission date of 11/21/22. <BR/>Review of Resident #83's History and Physical dated 02/27/23 revealed she was diagnosed with hypertension (high blood pressure). <BR/>Review of physician orders dated 3/28/2023 revealed an order for Lisinopril Tablet 10 MG Give 1 tablet by mouth one time a day for hypertension hold if SBP &lt;110mm/Hg, pulse &lt;60. <BR/>Observations during medication pass on 03/28/23 at 8:40 AM, MA S was observed preparing medication and taking it to Resident #83 room. After MA S handed the medication to Resident #83 and Resident #83 took the medications. After the Resident #83 swallowed the medication MA S proceeded to take Resident #83 blood pressure which resulted in 181/85, and her heart rate was 93. <BR/>Interview with MA S on 03/28/23 at 08:45 AM revealed Resident #83 blood pressure had been running high lately. The doctor was aware and had been modifying her medications to address this issue. MA S stated, I am trained to notify the floor nurse of any blood pressure that is too high or low and if they refuse.<BR/>In an interview with LVN T on 03/18/23 at 9:00 AM, he stated Resident #83 usually had blood pressure readings that were high. LVN T stated, they are trained to take blood pressure prior to medication administration since it has parameters to hold if the parameter is out of range. LVN T stated Resident #83 blood pressure baseline is elevated and doctor is aware. <BR/>Interview with the DON on 3/28/23 at 03:00 PM revealed that nursing staff administering medication should be taking blood pressure prior since it can cause resident to become hypotensive (have blood pressure that is too low). The staff gets yearly training and as needed. <BR/>Policy not obtained.

Based on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for thirty-two of fifty-two days reviewed for nurse staffing information. <BR/>The facility failed to post the required staffing information for [NAME] & East Wings&ndash; <BR/>East Wing - 10/07/23, 10/21/23, 10/22/23. <BR/>West Wing - 10/07/23, 10/21/23, 10/22/23. <BR/>East Wing - 11/04/23, 11/18/23, 11/25/23, 11/26/23. <BR/>West Wing - 11/04/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23 <BR/>East Wing - 12/01/23, 12/02/23, 12/09/23, 12/10/23, 12/23/23, 12/24/23, 12/30/23, 12/31/23. <BR/>West Wing - 12/02/23, 12/03/23, 12/09/23, 12/10/23, 12/23/23, 12/24/23, 12/30/23, 12/31/23. <BR/>This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census. <BR/>Findings include: <BR/>Observation on 05/31/24 at 9:26 AM, of staffing posting revealed, missing information of number of RNs and LVNs scheduled to work and RN and LVN hours worked for both facility wings (West and East Wing). They are as following: <BR/> East Wing - 10/07/23, 10/21/23, 10/22/23. <BR/>West Wing - 10/07/23, 10/21/23, 10/22/23. <BR/>East Wing - 11/04/23, 11/18/23, 11/25/23, 11/26/23. <BR/>West Wing - 11/04/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23 <BR/>East Wing - 12/01/23, 12/02/23, 12/09/23, 12/10/23, 12/23/23, 12/24/23, 12/30/23, 12/31/23. <BR/>West Wing - 12/02/23, 12/03/23, 12/09/23, 12/10/23, 12/23/23, 12/24/23, 12/30/23, 12/31/23. <BR/>During an interview on 05/31/24 at 1:13 PM, with the DON, she stated the nurses were responsible for filling out the posted staffing. The DON stated not filling out the staffing postings the family, residents, and visitors would not know if there were staff to provide service to the residents. The DON stated the nurses were responsible for filling out the staffing postings. <BR/>Review of the facility document Mandatory Postings dated 5/16/2019 documented in part that the posting named Daily Staffing by shift of Licensed and Unlicensed Nursing Staff was listed as mandatory.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 5 (Resident # 3, #4, #5, #7, and #8 ) of 12 residents reviewed for care plans. <BR/>The facility failed to implement a comprehensive person-centered care plan for Resident #7 ' s history of falls. <BR/>The facility failed to implement a comprehensive person-centered care plan to address elopement risk for Residents #3, #4, #5, #7, and #8. <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include: <BR/>Resident #7 <BR/>Record review of Resident #7 ' s face sheet dated 01/19/24 revealed admission on [DATE] and re-admission on [DATE] to the facility with diagnoses of unspecified lack of coordination, abnormalities of gait and mobility, disorganized schizophrenia, muscle wasting and atrophy, muscle weakness, unsteadiness on feet, and unspecified dementia. <BR/>Record review of Resident #7 ' s care plan dated 11/21/23 revealed at risk for wandering. Assess for fall risk. Care plan did not indicate anything regarding the focus area of falls. <BR/>Record review of Resident #7 ' s Event Note dated 11/20/23 revealed bruising to left knee, left lower leg, left ankle bruising. <BR/>Record review of Resident #7 ' s Fall Assessments dated 01/19/24 revealed from there were only fall assessments completed from 02/13/20-08/09/23. No fall assessment was conducted for the Event note that was completed on 11/20/23. <BR/>Resident #3 <BR/>Record review of Resident #3 ' s face sheet dated 01/18/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #3 ' s facility history and physical dated 07/25/23 revealed a [AGE] year-old female diagnosed with Dementia and Major Depression Disorder (affects how you feel, think and behave and can lead to a variety of emotional and physical problems). <BR/>Record review of Resident #3 ' s quarterly MDS dated [DATE] revealed a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 3. Resident #3 was diagnosed with Alzheimer Disease, Non-Alzheimer ' s Disease, and Depression. <BR/>Record review of Resident #3 ' s elopement risk assessment dated [DATE] revealed a score of 13, high risk of elopement. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident # 3 ' s care plan dated revealed no focus area and/or interventions to address elopement risk. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet dated 01/18/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #4's facility history and physical dated 05/18/23 revealed a [AGE] year-old female diagnosed with psychiatric behavior with aggression and paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly). <BR/>Record review of Resident #4's annual MDS dated [DATE] revealed a Preadmission Screening and Resident Review condition as serious mental illness. Resident #4 had a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 3. MDS indicated zero (no behavioral symptoms) for behaviors. Resident #4 was diagnosed with Non-Alzheimer's Disease, Psychotic Disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), Schizophrenia (a serious mental disorder in which people interpret reality abnormally), depression, and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). <BR/>Record review of facility assessment scoring report sheet dated 01/01/20-01/19/24 reviewed Resident #4 had a score of 13 for elopment risk. <BR/>Record review of Resident #4's care plan dated 12/17/21 revealed no focus area for elopement. <BR/>Resident #5 <BR/>Record review of Resident #5 ' s face sheet dated 01/18/24 revealed admission on [DATE] to the facility. Resident #5 was a [AGE] year-old female diagnosed with Dementia and Psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). <BR/>Record review of Resident #5 ' quarterly MDS dated [DATE] revealed a moderately cognition to be able to recall and make daily decision BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score which was not taken for whatever reason. Resident #5 was diagnosed with Cerebrovascular Accident (an interruption in the flow of blood to cells in the brain), Non-Alzheimer ' s Dementia, Depression, Psychotic Disorder (affect brain function by altering thoughts, beliefs or perceptions) and Adjustment Disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior) with Depressed Mood (Feelings of sadness, hopelessness, crying and lack of joy from things that used to bring you pleasure). <BR/>Record review of Resident #5 ' s Elopement assessment dated [DATE] revealed a elopement risk score of 18. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident #5 ' care plan dated 01/22/24 revealed no focus area for elopement. <BR/>Resident #8 <BR/>Record review of Resident #8 ' s face sheet dated 01/19/23 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #8 ' s facility history and physical dated 04/06/23 revealed a [AGE] year-old male diagnosed with severe intellectual disability, anxiety, and Major depressive Disorder (it affects how you feel, think and behave and can lead to a variety of emotional and physical problems). <BR/>Record review of Resident #8 ' s annual MDS dated [DATE] revealed a Preadmission Screening and Resident Review condition as intellectual disability. Resident #4 had a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score that was not taken for whatever reason. Behaviors was marked zero revealing Resident #8 had no behaviors when Resident #8 really did have behaviors. Resident #8 was diagnosed with Seizure Disorder (abnormal electrical brain activity), Depression, and Serve Intellectual Disabilities (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills). <BR/>Record review of Resident #8 ' s elopement risk assessment dated [DATE] revealed a score of 14, high risk. Statements and or threats to leave the facility - Resident #5 verbalizes anger and frustration with the facility. <BR/>Record review of Resident #8 ' s care plan dated 01/15/24 revealed no focus area for elopement. <BR/>During an interview on 01/19/24 at 6:17 PM with MDS Coordinator C and MDS Coordinator D, MDS Coordinator C, she stated the comprehensive care plans should have had falls and elopement care planned for Resident #7, #3, #4, #5, #8. MDS Coordinator D stated there could be a risk of not care planning falls and elopement. MDS Coordinator stated the risk could be a resident elopement from the facility. MDS Coordinator C stated anytime there was an elopement assessment completed for a resident that meant it would need to be care planned for the resident. MDS Coordinator C stated the DON, ADON, and the MDS department were responsible for overseeing that the comprehensive care plans are accurate. <BR/>During an interview on 01/22/24 at 10:46 AM with the DON, she stated residents with elopement risk should have elopement as a focus area in their care plans. The DON stated the charge nurse will update the care plans and the DON and ADONs will oversee to make sure it was done. The DON stated that Resident #7 had no focus area for falls and had overlooked the fall for the comprehensive care plan. The DON stated Residents #3, #4, #5, and #8 had no focus for elopement because she did not look for it on the comprehensive care plan as she did not know it needed to be care planned. The DON stated the risk of not including the elopement in the comprehensive care plan could be identifying resident elopement risk and monitoring of the resident. <BR/>During an interview on 01/22/24 at 12:44 PM with the Administrator, she stated she was not too familiar with comprehensive care plans and asked to refer to the DON regarding care plans. <BR/>Record review of the facility Elopement Assessment Scoring Report dated 01/01/20-01/19/24 was review revealed there were 30 residents on it to include Residents #3, #4, #5, #8. <BR/>Record review of the facility Preventive Strategies to Reduce Fall Risk dated 10/05/16 revealed, Policy: The goal of fall prevention strategies was to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident ' s mobility. <BR/>Residents at risk will be care planned for fall prevention. <BR/>After risk was assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will educate on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. <BR/>Record review of the facility comprehensive care plan policy not dated revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. <BR/>The comprehensive care plan will describe the following: <BR/>The services that are to be furnished to attain and maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. <BR/>Record review of the facility Elopement Prevention policy 01/2023 revealed, Every effort will be made to prevent elopement episode while maintaining the least restrictive environment for residents who are at risk for elopement. <BR/>All residents who area at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. <BR/>The resident ' s care plan will be modified to indicate the resident was at risk for elopement episodes. <BR/>Interventions into elopement episodes will be entered onto the resident ' s care plan and medical record. <BR/>Record review of the facility Elopement Response policy dated 10/27/10 revealed, After an elopement the care plan coordinator will reevaluate the resident ' s care plan. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents in one of six zones (Zone 1 Rooms 1 -12) reviewed for effective pest control.<BR/>The facility failed to ensure that two live cockroaches were not found in Zone 1 (Rooms 1 -12) of the facility.<BR/>This failure put residents at increased risk of transmission of vermin-borne illness.<BR/>Findings include:<BR/>Observation on 05/29/2024 at 11:09 AM, in room [ROOM NUMBER] revealed two large cockroaches (1.5 to 2 inches long) crawling on the floor. Surveyor R stepped on one of the roaches that was running quickly out of room [ROOM NUMBER] and into the hallway. <BR/>In an interview and observation on 05/29/2024 at 11:12 AM, the Administrator came to room [ROOM NUMBER] and observed the live roach in room [ROOM NUMBER] and the dead roach in the hallway. She said that there should not be roaches in the facility because they were a contamination risk. She said the facility had a pest control program and would provide a copy of the contract and invoices showing when treatments were provided. <BR/>In an interview on 5/29/24 at 11:19 AM, CNA S revealed that in a normal week she saw roaches every other day or two. She said she would go into the main shower and bathroom and sometimes would see them, dead or alive. She said if roaches were seen housekeeping would be called. She said she had seen people spraying for pests. <BR/>Record review of the facility policy Insect and Rodent Control dated 2012 revealed that the facility would maintain an effective pest control program to provide an insect and vermin free food service department. Record review revealed the facility did have a contract with a local pest control provider and monthly invoices showed services were provided regularly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 2 residents (Resident #10 and Resident #11) reviewed for environment. <BR/>The facility did not ensure the foot boards of Resident #10 and Resident #11 were not broken. <BR/>These failures placed residents and staff at risk of living, working and visiting in an unsafe, unsanitary, and uncomfortable environment. <BR/>Findings include: <BR/>Resident #10 <BR/>Record review of Resident #10 ' s face sheet dated 01/22/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #10 ' s history and physical dated 08/03/23 revealed an [AGE] year-old female diagnosed with Type 2 Diabetes Mellitus, Asthma, Alzheimer ' s Disease, multiple of falls, and Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). <BR/>Record review of Resident #10 ' s quarterly MDS dated [DATE] revealed a severely cognitive impairment to recall or make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 2. Resident #10 does have a behavior of delusions and wandering. Resident #10 needs partial/moderate assistance for nursing staff to sit to stand, chair/bed to chair transfer, toilet transfer. Resident #10 was total dependent on showers. Resident #10 was diagnosed with Alzheimer ' s, asthma, and muscle weakness (no muscle strength), and lack of coordination (Uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements). <BR/>Record review of Resident #10 ' s Care Plan dated 08/22/22 revealed Resident #10 has impaired cognitive function or impaired thought process. Provide the resident with a homelike environment. <BR/>Observation on 01/22/24 at 10:20 AM revealed Resident #10 ' s foot board to be broken up to the two black screws, screw from the foot board to the bed were. The edges of the foot board were jagged. <BR/>Observation and interview on 01/22/24 at 10:25 AM with the DON, she stated Resident #10 ' s footboard should have been fixed. The DON stated the nursing staff and the maintenance department are responsible for ensuring the footboard was fixed. The DON stated the risk to Resident #10 could be a skin tear or a laceration. The DON stated she did not know if there was a work order placed for the broken foot board. <BR/>During an interview on 01/22/24 at 12:37 PM with the Maintenance Director, he stated he was not informed of Resident #10 ' s broken footboard nor was there a work order specifically for the broken footboard. The Maintenance Director stated it was expected for the facility staff to be placing work orders in the facility system. The Maintenance Director stated there was a risk to Resident #10 in which she could get her feet caught or a cut. <BR/>Resident #11 <BR/>Record review of Resident # 11 ' s face sheet dated 01/18/24 revealed, admission on [DATE] and re-admission on [DATE] to the facility. Resident #11 was a [AGE] year-old female diagnosed with Cerebral Palsy (weakness or problems with using the muscles), muscle weakness (no muscle strength), contracture of muscle to right hand, insomnia (a sleep disorder in which you have trouble falling and/or staying asleep), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), paraplegia (paralysis that affects your legs, but not your arms), and mild intellectual disabilities. <BR/>Record review of Resident # 11 ' s history and physical, MDS, and care plan were not obtained. <BR/>Observation on 01/18/24 at 4:40 PM revealed Resident #11 ' s foot board hanging off towards the ground from the left side of the foot board. Resident #11 ' s was using an air pressure mattress that was hanging on the middle of the foot board. The beige cords were seen in front of the foot board. They were not secured traveling to the side of the foot board caught between the footboard and wall. Pump black cord were seen in front of the footboard on the floor curled. <BR/>Observation and interview on 01/18/24 at 4:45 PM with ADON B, she stated Resident #11 ' s footboard was not to be hanging of the bed. ADON B stated Resident #11 was transferred recently to the new room but did not know when it occurred. ADON B stated there was a risk of the footboard hanging of the bed to Resident #11. ADON B stated it could result in injury. ADON B stated it was the responsibility of the maintenance department to ensure the footboards were not hanging. <BR/>Observation and interview on 01/18/24 at 4:50 PM with the Maintenance Director, he stated that Resident #11 was recently moved on 01/17/24 but did not know what had happened to the footboard. The Maintenance Director stated he was not notified by the nursing staff nor was a work order placed for the damaged footboard. The Maintenance Director stated it was important the nursing staff report to him any broken or damaged footboards. The Maintenance Director stated there was no risk to Resident #11 but to other resident that have their footboards hanging or broken it would be a risk of injury. <BR/>On 01/22/24 at 9:24 AM via text message a request of a facility Physical Environment policy was sent to the Administrator. One was not provided to the surveyors. <BR/>Record review of the facility Drive Medical Med-Aire alternating pressure mattress (low air loss system 14027) manual dated 2012 revealed, Hang the pump over the frame or board at the foot end of the bed using the hangers on the back of the pump. Make sure the pump was secured. Note! - Make sure the air hoses are not kinked or tucked under the mattress. Connect the inflation tubes from the mattress to the pump ' s inflation nozzles. Makes sure they are properly attached.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 (Resident #2) of 5 residents reviewed for medical records. <BR/>The facility failed to ensure Resident #2's medical record accurately documented Resident #2's sexual abuse/expiation allegation. <BR/>This failure could place residents at risk of having incomplete and inaccurate medical records possibly resulting inadequate treatment/care. <BR/>Findings include: <BR/>Record review of Resident #2's face sheet dated 02/13/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #2's most recent facility history and physical in the system dated 12/21/20 revealed a [AGE] year-old female diagnosed with Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), Vascular Dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage, and cachexia (a complicated metabolic syndrome related to underlying illness and characterized by muscle mass loss with or without fat mass loss). <BR/>Record review of Resident #2's quarterly MDS dated [DATE] revealed a cognitively intact BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 11 to be able to make daily decision and recall information. Resident #2 needed partial/moderate (half the help) assistance from nursing staff to help in showering/bathing. Resident #2 was diagnosed with Non-Alzheimer's Dementia, muscle wasting, lack of coordination, and muscle weakness (no muscle strength). <BR/>Record review of Resident #2's shower report dated 02/02/24 at 8:16 PM and 02/09/24 at 5:57 PM revealed CNA H had showered/bathed Resident #2. <BR/>Record review of CNA H's time sheet dated 02/02/24 and 02/09/24 revealed he had been working on Resident #2's shower days (02/02/24, 02/09/24 (Resident #2 was to be showered Monday, Wednesday, Friday). <BR/>Record review of Resident #2's Weekly Assessments, Event Note Assessments, all other Assessments dated 02/12/24 revealed, from 02/02/24 to 02/13/24 did not indicate any assessments were conducted for the sexual abuse/exploitation allegation of Resident #2. <BR/>Record review of Resident #2's Progress Notes dated 02/12/24 revealed, from 02/02/24 to 02/13/24 did not indicate any assessments were conducted or any information regarding the sexual abuse/exploitation allegation of Resident #2. <BR/>Record review of Resident #2's care plan dated 12/19/20, revealed for bathing she required two staff for assistances. Care plan dated 12/19/20 revealed impaired cognitive function or impaired thought processes due to Dementia. Engage the resident in simple, structed activities that avoid overly demanding tasks. Monitor/document/report to medical doctor any changes in cognitive function, specially changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding other, level of consciousness, mental status. <BR/>Record review of Resident #2's [NAME] (documentation on the facility system that CNAs use to view resident care) dated 02/17/24, revealed bathing: requires staff x2 for assistance. <BR/>Record review of Resident #2's shower report dated 02/02/24 at 8:16 PM and 02/09/24 at 5:57 PM, revealed CNA H had showered/bathed Resident #2. <BR/>Record review of CNA H's time sheet dated 02/02/24 and 02/09/24, revealed he had been working on Resident #2's shower days on Friday 02/02/24 and 02/09/24. Resident #2 showers on Mondays, Wednesdays and Fridays of every week. <BR/>Record review of Resident #2's Weekly Assessments, Event Note Assessments, all other Assessments dated 02/12/24, revealed, from 02/02/24 to 02/13/24 did not indicate any assessments were conducted for the sexual abuse/exploitation allegation of Resident #2. <BR/>Record review of Resident #2's Progress Notes dated 02/12/24 revealed, from 02/02/24 to 02/13/24, did not indicate any assessments were conducted or any information regarding the sexual abuse/exploitation allegation of Resident #2. <BR/>Record review and observation of text message provided to surveyor between LVN F, LVN E, and DON 02/02/24 at 5:17 PM read as follows: LVN F when you get a chance can you go talk to Resident #2, she told the Business Office Assistant that when CNA H or CNA O bath her they do something to her. <BR/>At 5:25 PM - LVN F stated, Yes I will.<BR/>At 5:28 PM - DON stated, thank you, let me know what she says. <BR/>At 6:08 PM - LVN F stated, Resident #2 says she feels CNA H touches her inappropriately when he's bathing her. <BR/>At 6:13 PM - DON stated, OMG (oh my god). <BR/>LVN F stated, Shouldn't the Social Worker and Administrator have interviewed Resident #2. I feel like that's serious allegations.<BR/>LVN E stated, Resident #2 says that when CNA H's washing her he washes her Parts and she feels him put his fingers inside of her. <BR/>DON - stated she would talk to her on Monday (unknown which Monday). <BR/>LVN F stated, No one came to help out. <BR/>Nothing else follows in the text message in regard to the sexual abuse/exploitation outcry from Resident #2. During an interview on 02/12/24 at 4:42 PM with LVN F, he stated that he had received a message from the DON revealing that Resident #2 was stating CNA H was touching her in her private parts during shower/bathe time. LVN F stated he and LVN E went to go speak with Resident #2 in which she told them that CNA H was touching her and would stick his fingers inside of her when he showered her and did not want CNA H to shower her anymore. LVN F stated he thought it was a serious allegation and though the Administrator and Social Worker would be the ones to go interview Resident #2 regarding her allegation. <BR/>During an interview on 02/12/24 at 5:12 PM with LVN E, she stated the DON had sent LVN F a text message wanting for LVN F to go speak to Resident #2 about her allegation. LVN E stated that she went with LVN F to go talk to Resident #2 in which she stated that CNA H had touched her in her private parts. LVN E stated the DON and Administrator should have been the ones to go and interview Resident #2. LVN E stated Resident #2 claimed that CNA H would penetrate her through the shower chair and would go underneath the bottom of the shower chair. <BR/>During an interview on 02/13/24 at 1:00 PM with Resident #2, she stated she had reported to LVN F that Resident #2 had been touching her down there when CNA H showers her. Resident #2 stated CNA H will put on his music and dance while he showers her. Resident #2 stated she did not have strength and was weak to fight back against CNA H. Resident #2 stated she did not want CNA H around her and did not feel safe around him. Resident #2 stated she had not reported it due to feeling embarrassed. <BR/>During an interview on 02/13/24 at 1:35 PM, with the DON, she stated that Resident #2 had made an outcry of sexual abuse/exploitation to the Business Office Assistant. The DON stated the Business Office Assistant was told by Resident #2 that CNA H had touched Resident #2 in her private area. The DON stated she had instructed LVN F to go and speak with Resident #2 regarding the sexual abuse/exploitation outcry and report back to her what she had said. The DON stated she was still working on the investigation. The DON stated she had not done any assessments on Resident #2. The DON stated LVN E had done a body assessment for Resident #2 but was not documented. The DON stated if it was not documented it did not happen. The DON stated she could not recall the exact date of Resident #2's sexual abuse/exploitation outcry. The DON stated she had not imputed anything into the computer. The DON stated there was no reason for the delay for not documenting and doing an assessment on Resident #2. <BR/>During an interview on 02/13/24 at 2:55 PM with the Administrator, she stated she was unaware of the alleged allegation from Resident #2 of sexual abuse/exploitation. The Administrator stated she was just notified right now of the sexual abuse/exploitation outcry for Resident #2 from LVN F. The Administrator stated she was told by LVN F that Resident #2 had alleged CNA H had touched her incorrectly. The Administrator stated LVN F told the DON about what Resident #2 had alleged. The Administrator stated she was not told by the DON what Resident #2 had alleged. The Administrator stated once an outcry of an allegation has been made it needed to be reported to the Abuse Coordinator which was her. The Administrator started she would take measures to talk to the resident and see what had happened as well as suspend the staff to ensure the safety of the Resident #2 until the conclusion of the investigation. The Administrator stated there could be a risk if the outcome was proven correct in that CNA H did do the sexual abuse/exploitation. The Administrator stated she had sent CNA H immediately as soon as she found out. The Administrator stated she still needed to go speak to Resident #2. The Administrator stated she did not know if a body assessment was conducted for Resident #2. The Administrator stated she did not report it to state survey agency as she not notified of the sexual abuse/exploitation allegation. The Administrator stated it would have been protocol for the nurses to do a body assessment. <BR/>During an interview on 02/15/24 at 10:28 AM with ADON G, she stated when an incident happens it needs to be documented right away. ADON G stated not documenting or documenting right away could be a risk to the residents. ADON G stated the risk could be the resident having an injury and the facility not doing anything about it. ADON G stated facility staff were trained on documenting. <BR/>During an interview on 02/16/24 at 2:08 PM with the Administrator, she stated that both LVN F and LVN E did not document the assessment nor the sexual abuse/exploitation outcry for resident #2. The Administrator stated it should have been documented and could have been a risk to the resident but did not indicate what the risk was. <BR/>During an interview on 02/16/24 at 2:26 PM with LVN F, he stated he was not told do an assessment on Resident #2 nor was it documented. LVN F stated it should have been documented but did not indicate why it was not documented. <BR/>During an interview on 02/16/24 at 2:26 PM with LVN E, she stated she was not asked to do a head-to-toe assessment on Resident #2. LVN E stated it should have been documented but did not indicate why it was not documented. <BR/>Record review of the facility Documentation policy and procedure manual dated 2003 revealed, Documentation was the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has a legal requirement regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessments, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets weekly, daily, monthly, discharge).<BR/>Goal- The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. <BR/>The facility will ensure that information was comprehensive and timely and properly signed. <BR/>Document completed assessments in a timely manner and per policy. <BR/>Complete documentation in narrative nursing notes as needed in a timely manner.<BR/>Daily documentation x72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 resident (Residents #83) of 8 reviewed for medication administration. <BR/>MA S administered Resident #83 medication prior to taking blood pressure. <BR/>This deficient practice could cause a decline in health of residents who receive medication that are not according to physician orders. <BR/>Findings included: <BR/>Review of Resident #83's face sheet dated 03/28/23 revealed a [AGE] year-old female with an admission date of 11/21/22. <BR/>Review of Resident #83's History and Physical dated 02/27/23 revealed she was diagnosed with hypertension (high blood pressure). <BR/>Review of physician orders dated 3/28/2023 revealed an order for Lisinopril Tablet 10 MG Give 1 tablet by mouth one time a day for hypertension hold if SBP &lt;110mm/Hg, pulse &lt;60. <BR/>Observations during medication pass on 03/28/23 at 8:40 AM, MA S was observed preparing medication and taking it to Resident #83 room. After MA S handed the medication to Resident #83 and Resident #83 took the medications. After the Resident #83 swallowed the medication MA S proceeded to take Resident #83 blood pressure which resulted in 181/85, and her heart rate was 93. <BR/>Interview with MA S on 03/28/23 at 08:45 AM revealed Resident #83 blood pressure had been running high lately. The doctor was aware and had been modifying her medications to address this issue. MA S stated, I am trained to notify the floor nurse of any blood pressure that is too high or low and if they refuse.<BR/>In an interview with LVN T on 03/18/23 at 9:00 AM, he stated Resident #83 usually had blood pressure readings that were high. LVN T stated, they are trained to take blood pressure prior to medication administration since it has parameters to hold if the parameter is out of range. LVN T stated Resident #83 blood pressure baseline is elevated and doctor is aware. <BR/>Interview with the DON on 3/28/23 at 03:00 PM revealed that nursing staff administering medication should be taking blood pressure prior since it can cause resident to become hypotensive (have blood pressure that is too low). The staff gets yearly training and as needed. <BR/>Policy not obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents in one of six zones (Zone 1 Rooms 1 -12) reviewed for effective pest control.<BR/>The facility failed to ensure that two live cockroaches were not found in Zone 1 (Rooms 1 -12) of the facility.<BR/>This failure put residents at increased risk of transmission of vermin-borne illness.<BR/>Findings include:<BR/>Observation on 05/29/2024 at 11:09 AM, in room [ROOM NUMBER] revealed two large cockroaches (1.5 to 2 inches long) crawling on the floor. Surveyor R stepped on one of the roaches that was running quickly out of room [ROOM NUMBER] and into the hallway. <BR/>In an interview and observation on 05/29/2024 at 11:12 AM, the Administrator came to room [ROOM NUMBER] and observed the live roach in room [ROOM NUMBER] and the dead roach in the hallway. She said that there should not be roaches in the facility because they were a contamination risk. She said the facility had a pest control program and would provide a copy of the contract and invoices showing when treatments were provided. <BR/>In an interview on 5/29/24 at 11:19 AM, CNA S revealed that in a normal week she saw roaches every other day or two. She said she would go into the main shower and bathroom and sometimes would see them, dead or alive. She said if roaches were seen housekeeping would be called. She said she had seen people spraying for pests. <BR/>Record review of the facility policy Insect and Rodent Control dated 2012 revealed that the facility would maintain an effective pest control program to provide an insect and vermin free food service department. Record review revealed the facility did have a contract with a local pest control provider and monthly invoices showed services were provided regularly.