MCKINNEY HEALTHCARE AND REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure medication was labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for one (Resident #81) of two residents reviewed for labelling of drugs and biologicals.<BR/>The facility failed to ensure MA L placed a change of instruction label for Resident #81's Sertraline blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) after the order was changed.<BR/>This failure could place residents at risk for wrong medication administration, mismanagement of care, adverse effects, and physical harm. <BR/>Findings included: <BR/>Review of Resident #81's Face Sheet dated 04/10/2024 reflected the resident was an [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses was depression.<BR/>Review of Resident #81's Quarterly MDS assessment dated [DATE] reflected resident had a moderately impaired cognition with a BIMS score of 07. The Quarterly MDS Assessment indicated the resident had depression.<BR/>Review of Resident #81's Comprehensive Care Plan dated 04/09/2023 reflected resident was taking antidepressant medication and one of the interventions was to administer antidepressant medications ordered by physician. <BR/>Review of Resident #81's Physician's order for Sertraline dated 04/09/2024 reflected Zoloft Oral Tablet 100 MG (Sertraline HCl). Give 1 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED.<BR/>Review of Resident #81's discontinued Physician's order for Sertraline on 04/09/2024 reflected Zoloft Oral Tablet 50 MG (Sertraline HCl). Give 1 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED.<BR/>Observation and interview on 04/10/2024 at 11:26 AM revealed MA L was checking Resident #81's blister pack for sertraline. It was noted that the blister pack's instruction was to give 50 mg (milligrams) once a day while the instruction in the eMAR (electronic medication administration record) was to give 100 mg once a day. MA L acknowledged that the instruction on the blister pack was different from the instruction in the system. MA L stated the dose for the sertraline was increased from 50 mg to 100 mg. MA L said the staff use a sticker that says change in instruction, check the eMAR or the staff could write a note on the blister pack to denote the change in order. MA L said since there was a change in instruction, she should had placed a change in instruction note or sticker on the sertraline 50 mg blister pack while waiting for the sertraline 100 mg blister pack. MA L opened her medication cart and looked for the sticker. She said she had no change of direction sticker so she would just write a note on the blister pack to ensure the right dosage of medication was administered and avoid medication error.<BR/>In an interview with MA J on 04/10/2024 at 1:04 PM, MA J stated the staff giving the medications should make sure they were reading the order and comparing the blister pack with the order in the system. She said the MAs and nurses were responsible in placing a change of direction sticker on blister pack if there was a change in direction. MA J said if there was change in order, the blister pack should have a note of change of direction to avoid medication error, undermedication, overmedication, or confusion among the staff.<BR/>In an interview with the DON on 04/10/2024 at 10:52 AM, the DON stated whoever staff that received the new order should have placed a change in order instruction on the blister pack to avoid confusion. The DON said the risk were overmedication or undermedication which could have an adverse effect for the residents. The DON said the expectation was to provide the right dosage of medication as per order and make sure the medications correlate with the eMAR and the order in the package.<BR/>In an interview with the Administrator on 04/11/2024 at 8:23 PM, the Administrator stated whatever the procedure was in giving the medications, it should have been followed to prevent any errors.<BR/>Record review of facility's policy Medication Orders revealed Procedures . g. orders . 2. The following steps are initiated . d). Transcribe newly prescribed medications on the MAR . When a new order changes the dosage of a previously prescribed medication, discontinue the previous entry by (writing DC'd [discontinued] .).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure medication was labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for one (Resident #81) of two residents reviewed for labelling of drugs and biologicals.<BR/>The facility failed to ensure MA L placed a change of instruction label for Resident #81's Sertraline blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) after the order was changed.<BR/>This failure could place residents at risk for wrong medication administration, mismanagement of care, adverse effects, and physical harm. <BR/>Findings included: <BR/>Review of Resident #81's Face Sheet dated 04/10/2024 reflected the resident was an [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses was depression.<BR/>Review of Resident #81's Quarterly MDS assessment dated [DATE] reflected resident had a moderately impaired cognition with a BIMS score of 07. The Quarterly MDS Assessment indicated the resident had depression.<BR/>Review of Resident #81's Comprehensive Care Plan dated 04/09/2023 reflected resident was taking antidepressant medication and one of the interventions was to administer antidepressant medications ordered by physician. <BR/>Review of Resident #81's Physician's order for Sertraline dated 04/09/2024 reflected Zoloft Oral Tablet 100 MG (Sertraline HCl). Give 1 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED.<BR/>Review of Resident #81's discontinued Physician's order for Sertraline on 04/09/2024 reflected Zoloft Oral Tablet 50 MG (Sertraline HCl). Give 1 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED.<BR/>Observation and interview on 04/10/2024 at 11:26 AM revealed MA L was checking Resident #81's blister pack for sertraline. It was noted that the blister pack's instruction was to give 50 mg (milligrams) once a day while the instruction in the eMAR (electronic medication administration record) was to give 100 mg once a day. MA L acknowledged that the instruction on the blister pack was different from the instruction in the system. MA L stated the dose for the sertraline was increased from 50 mg to 100 mg. MA L said the staff use a sticker that says change in instruction, check the eMAR or the staff could write a note on the blister pack to denote the change in order. MA L said since there was a change in instruction, she should had placed a change in instruction note or sticker on the sertraline 50 mg blister pack while waiting for the sertraline 100 mg blister pack. MA L opened her medication cart and looked for the sticker. She said she had no change of direction sticker so she would just write a note on the blister pack to ensure the right dosage of medication was administered and avoid medication error.<BR/>In an interview with MA J on 04/10/2024 at 1:04 PM, MA J stated the staff giving the medications should make sure they were reading the order and comparing the blister pack with the order in the system. She said the MAs and nurses were responsible in placing a change of direction sticker on blister pack if there was a change in direction. MA J said if there was change in order, the blister pack should have a note of change of direction to avoid medication error, undermedication, overmedication, or confusion among the staff.<BR/>In an interview with the DON on 04/10/2024 at 10:52 AM, the DON stated whoever staff that received the new order should have placed a change in order instruction on the blister pack to avoid confusion. The DON said the risk were overmedication or undermedication which could have an adverse effect for the residents. The DON said the expectation was to provide the right dosage of medication as per order and make sure the medications correlate with the eMAR and the order in the package.<BR/>In an interview with the Administrator on 04/11/2024 at 8:23 PM, the Administrator stated whatever the procedure was in giving the medications, it should have been followed to prevent any errors.<BR/>Record review of facility's policy Medication Orders revealed Procedures . g. orders . 2. The following steps are initiated . d). Transcribe newly prescribed medications on the MAR . When a new order changes the dosage of a previously prescribed medication, discontinue the previous entry by (writing DC'd [discontinued] .).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of six (Resident #5) residents reviewed for infection control.<BR/>1. <BR/>The facility failed to ensure CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #5 on 03/06/2025.<BR/>This failure could place residents at risk of cross-contamination and development of infections.<BR/>The findings included:<BR/>1. <BR/>Record review of Resident #5's Face Sheet, dated 03/06/2025, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included urinary tract infection (infection in any part of the urinary system) and the need for assistance with personal care. <BR/>Record review of Resident #5's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 03/02/2025, reflected a BIMS (screening tool used to assess cognitive status) assessment was not completed for the resident. Section H reflected Resident #5 was always incontinent of bowel and bladder. <BR/>Record review of Resident #5's Comprehensive Care Plan, dated 02/26/2025, reflected a potential for pressure ulcer development related to hypertension (high blood pressure), the use of pain medication, and the need for assistance with ADLs (collective term for all the basic skills needed in regular daily life) and personal care. One intervention was notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care.<BR/>On 03/06/2025 at 1:40 PM, CNA B was observed providing incontinence care for Resident #5. There were wipes, gloves, and a clean brief on Resident #5's bedside table. CNA B washed her hands in the resident's restroom. CNA B pulled the privacy curtain around Resident #5's bed and told the resident she was going to change her brief. CNA B put on clean gloves, pulled back the sheet and blanket to uncover Resident #5, and unfastened the tabs on the sides of the brief. CNA B used wipes to clean the front of the resident, wiping from the top down. CNA B dropped the wipes into the wastebasket next to her. CNA B removed the wet brief, dropped it into the wastebasket, and changed her gloves. CNA B did not use hand sanitizer or wash her hands when changing gloves. CNA wiped the residents bottom with a clean wipe and dropped it into the wastebasket. The CNA changed gloves, picked up a clean wipe, and wiped the resident's bottom again. CNA B kept the hand she used to wipe the resident's bottom to her side and did not touch anything with that hand. She used the other gloved hand to place the clean brief under Resident #5. The resident rolled to her back and CNA B secured the brief on each side. CNA B removed her gloves and used hand sanitizer from a pump on the wall near Resident #5's bathroom. CNA B took a pair of clean gloves from a box near the resident's door. CNA B put on the gloves and then put a pair of pants on Resident #5. CNA B removed her gloves and used hand sanitizer from the pump on the wall to clean her hands. CNA B carried the bag of trash out of Resident #5's room and disposed of it. <BR/>During an interview on 03/06/2025 at 1:55 PM, CNA B stated she should have used hand sanitizer or washed her hands each time she changed her gloves. CNA B stated it was important for infection control and she did not want to transmit urine to other surfaces. CNA B stated she usually had a small container of hand sanitizer on the bedside table with the other supplies. When asked about facility training, CNA B stated the facility provided in-services often about handwashing and the use of hand sanitizer when caring for residents. She stated it wasn't long ago staff was in-serviced about hand hygiene. CNA B stated she wasn't sure how often to change her gloves when a brief just had urine and not stool on it and ran out of gloves before she put the clean brief on. She stated she was nervous about being watched and missed steps. <BR/>During an interview on 03/06/2025 at 2:10 PM, the DON stated CNA B should have used hand sanitizer or washed her hands each time she changed gloves. The DON stated CNA B had worked in the facility for several years and knew how to provide incontinence care properly. The DON stated CNA B was nervous while being observed providing incontinence care. The DON stated CNA B probably changed gloves too frequently when cleaning the resident and used all her gloves before putting on the clean brief. The DON stated she would in-service staff immediately.<BR/>Review of the facility's policy Perineal Care, revised 05/2007, reflected steps to wash, rinse, and thoroughly dry the resident's skin. The policy did not reflect the use of gloves while providing perineal care. <BR/>Review of the facility's policy Infection Control, revised 10/2022, reflected Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #13) of 15 residents on 100 hall reviewed for resident rights.<BR/>1. <BR/>The Housekeeping Supervisor did not knock on Resident #13's room door and bathroom door before entering. <BR/>2. <BR/>The Housekeeping Supervisor did not inform Resident #13 that he was in her room or of the service he was to provide. <BR/>This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.<BR/>The findings include:<BR/>Review of Resident # 13's admission record revealed a [AGE] year-old female with a diagnosis which included Alzheimer's (a brain disease that slowly destroys memory and thinking skills, making it hard to do everyday tasks), aphasia (a condition that makes it hard to speak, understand, read, or write, usually after a stroke or brain injury), end stage renal disease (When the kidneys stop working well enough to keep you alive, often requiring dialysis or a kidney transplant), dysphagia (difficulty swallowing liquids and/or solid food and drink). <BR/>Review of Resident #13's quarterly Minimum Data Set, dated [DATE] revealed a brief interview for mental status (BIMS) summary score of 9 indicating moderate cognitive impairment. Section titled Functional Status documented the need for assistance with personal care. <BR/>Observation on 05/06/2025 at 9:50 a.m. During an interview with Resident #13 in her room, the Housekeeping Supervisor entered Resident #13's room without knocking or announcing himself. Once he entered the room, he opened the bathroom door without knocking or announcing himself. <BR/>During an interview on 05/06/2025 at 9:52 a.m. Resident #13 stated that staff will usually knock before entering and it bothered her that the Housekeeping Supervisor did not. <BR/>During an interview on 05/06/25 at 10:00 a.m. The Housekeeping Supervisor stated he usually knocks before entering resident's room. He stated he saw Resident #13's door open so he went in looking for the other housekeeper. He stated he just peeped in the bathroom.<BR/>During an interview with Director of Nursing (DON) on 05/07/25 at 2:05 p.m. DON reported prior to entering a resident's room, staff knock on the door, identify themselves, ask permission to enter, and explain the reason for entering. The DON stated that was the expectation for all staff who go into a resident's room. The DON stated that would include housekeeping staff. <BR/>Review of facility policy titled Resident Rights/Dignity and Respect, dated 02/2020 stated Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by. People not involved in the care of the Resident shall not be present without the resident's consent while they are being examined or treated. Staff members shall knock before entering the Resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of six (Resident #5) residents reviewed for infection control.<BR/>1. <BR/>The facility failed to ensure CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #5 on 03/06/2025.<BR/>This failure could place residents at risk of cross-contamination and development of infections.<BR/>The findings included:<BR/>1. <BR/>Record review of Resident #5's Face Sheet, dated 03/06/2025, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included urinary tract infection (infection in any part of the urinary system) and the need for assistance with personal care. <BR/>Record review of Resident #5's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 03/02/2025, reflected a BIMS (screening tool used to assess cognitive status) assessment was not completed for the resident. Section H reflected Resident #5 was always incontinent of bowel and bladder. <BR/>Record review of Resident #5's Comprehensive Care Plan, dated 02/26/2025, reflected a potential for pressure ulcer development related to hypertension (high blood pressure), the use of pain medication, and the need for assistance with ADLs (collective term for all the basic skills needed in regular daily life) and personal care. One intervention was notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care.<BR/>On 03/06/2025 at 1:40 PM, CNA B was observed providing incontinence care for Resident #5. There were wipes, gloves, and a clean brief on Resident #5's bedside table. CNA B washed her hands in the resident's restroom. CNA B pulled the privacy curtain around Resident #5's bed and told the resident she was going to change her brief. CNA B put on clean gloves, pulled back the sheet and blanket to uncover Resident #5, and unfastened the tabs on the sides of the brief. CNA B used wipes to clean the front of the resident, wiping from the top down. CNA B dropped the wipes into the wastebasket next to her. CNA B removed the wet brief, dropped it into the wastebasket, and changed her gloves. CNA B did not use hand sanitizer or wash her hands when changing gloves. CNA wiped the residents bottom with a clean wipe and dropped it into the wastebasket. The CNA changed gloves, picked up a clean wipe, and wiped the resident's bottom again. CNA B kept the hand she used to wipe the resident's bottom to her side and did not touch anything with that hand. She used the other gloved hand to place the clean brief under Resident #5. The resident rolled to her back and CNA B secured the brief on each side. CNA B removed her gloves and used hand sanitizer from a pump on the wall near Resident #5's bathroom. CNA B took a pair of clean gloves from a box near the resident's door. CNA B put on the gloves and then put a pair of pants on Resident #5. CNA B removed her gloves and used hand sanitizer from the pump on the wall to clean her hands. CNA B carried the bag of trash out of Resident #5's room and disposed of it. <BR/>During an interview on 03/06/2025 at 1:55 PM, CNA B stated she should have used hand sanitizer or washed her hands each time she changed her gloves. CNA B stated it was important for infection control and she did not want to transmit urine to other surfaces. CNA B stated she usually had a small container of hand sanitizer on the bedside table with the other supplies. When asked about facility training, CNA B stated the facility provided in-services often about handwashing and the use of hand sanitizer when caring for residents. She stated it wasn't long ago staff was in-serviced about hand hygiene. CNA B stated she wasn't sure how often to change her gloves when a brief just had urine and not stool on it and ran out of gloves before she put the clean brief on. She stated she was nervous about being watched and missed steps. <BR/>During an interview on 03/06/2025 at 2:10 PM, the DON stated CNA B should have used hand sanitizer or washed her hands each time she changed gloves. The DON stated CNA B had worked in the facility for several years and knew how to provide incontinence care properly. The DON stated CNA B was nervous while being observed providing incontinence care. The DON stated CNA B probably changed gloves too frequently when cleaning the resident and used all her gloves before putting on the clean brief. The DON stated she would in-service staff immediately.<BR/>Review of the facility's policy Perineal Care, revised 05/2007, reflected steps to wash, rinse, and thoroughly dry the resident's skin. The policy did not reflect the use of gloves while providing perineal care. <BR/>Review of the facility's policy Infection Control, revised 10/2022, reflected Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for one (Resident # 138) of six residents reviewed for misappropriation of property.<BR/>The Administrator failed to start thoroughly investigating a misappropriation of property on 01/11/2024, after the facility filed a report to the state regarding Resident # 138's [NAME] Of Attorney misappropriating her property.<BR/>Failure to timely investigate misappropriation of property placed residents at risk for unidentified misappropriation of property.<BR/>Findings included:<BR/>Review of Resident #138's face sheet reflected she was a [AGE] year-old female with an original admission date of 06/11/2022 and she was discharged to an assisted living facility on 02/15/2024. Resident was diagnosed with dementia (loss of cognitive functioning), schizophrenia (a chronic brain disorder), cognitive communication deficit (difficulty with thinking and use of language), end stage renal disease ( kidney failure). MDS assessment dated [DATE] reflected Resident had a BIMS score of 09 which indicated resident's cognition was moderately impaired. Resident required moderate assistance with toilet/shower transfers, and she was occasionally incontinent of bowel and urine.<BR/>Review of the Adult Protective Services report dated 01/09/2024 and facility self-reported incident dated 01/11/2024 reflected the facility staff had concerns of misappropriation of property by resident # 138's friend who obtained a [NAME] Of Attorney that included financial access. Further review revealed the facility failed to investigate this allegation of misappropriation of property to ensure her finances were safe.<BR/>Record review of progress note dated 01/09/2024 reflected the Social Services Staff made and Adult Protective Services report of suspicious activity against Resident 138's friend who was enquiring about finances and document being signed.<BR/>Interview with the facility Social Services staff on 04/10/2024 at 9:41 AM revealed resident's friend started asking Social Services staff about reimbursement for his visits to the facility and the Resident #138 had recently signed a Power Of Attorney over to the friend Social Services staff stated Resident's friend's had a sudden interest in resident's finances and his (Power Of Attorney-friend) access to her (Resident #138) finances made her suspicious of Power Of Attorney friend and she filed an Adult Protective Services report to investigate and find out what exactly was going on. Social Services Staff stated the facility received a copy of the Power Of Attorney document, she stated she did not read the Power Of Attorney document prior to making the Adult Protective Services report. <BR/>An attempted call to Resident #138 at her cell phone listed in the admission record was not answered on 04/10/24 at 9: 50 AM.<BR/>Interview with Business Office Manager on 04/10/24 at 10:52 AM revealed she was familiar with Resident #138 and resident's friend was the only point of contact at the time of her admission. She stated the friend was listed as the Resident #138's Medical Power Of Attorney and that document (Medical Power Of Attorney) was signed on 05/21/2022. She stated at the time of Resident #138's admission, the Power Of Attorney did not want to be involved in her financial matters, but he started showing interest in her finances by the end of December 2023. She stated the facility wanted to apply for Medicaid for the Resident # 138 and the friend was contacted for Resident's financial documents. The friend informed the Business Office Manager that resident received a lump sum amount from her brother who passed away and the friend obtained a guardianship of the resident. Business Office Manager stated the Power Of Attorney friend brought a guardianship document to her on 01/09/2024, he started showing interest in Resident #138's finances and asked about her social security income and status of resident's trust fund account. Business Office Manager stated the friend wanted reimbursement for his expenses towards the visit such as gas, food purchases for the resident, she reimbursed him from the resident's trust fund for food. Business Office Manager stated his sudden interest in resident's finances made her suspicious of his intentions. Business Office Manager stated she discussed her concerns about Resident #138's finances with the social services staff and the administrator. Business Office Manager stated the social services staff made an Adult Protective Services report against resident's friend/Power Of Attorney for financial exploitation, Business Office Manager stated she did not know the outcome of the Adult Protective Services report. Business Office Manager stated the resident was discharged on 02/15/2024. Business Office Manager stated she was able to identify misappropriation of property, the recent in-service training she received on misappropriation of property was 2 weeks ago. Business Office Manager stated if she came to know about a misappropriation of property, she would immediately report it to Adult Protective Services, also notify the social worker and the administrator, and the facility would investigate the allegation. Business Office Manager stated not investigating an allegation of misappropriation of property would place a resident at the risk of the continuation of misappropriation. Business Office Manager stated whoever made the report was responsible to follow up and ensure an investigation was completed and resident's assets were safe. <BR/>A second attempted telephone call on 04/10/2024 at 10:26 AM to Resident #138 was not answered. <BR/>A follow up interview with the Social Services staff on 04/10/2024 at 11:02 AM revealed she had received in services on misappropriation of property and the last in service she received was a year ago. She stated she would report to Adult Protective Services and administrator whenever she learned that an individual was taking advantage of a resident financially. She stated she made the report to make sure the Resident 138's finances were safe, and she was not taken advantage of by his friend/Power Of Attorney. She stated the risk for the resident for not investigating misappropriation of property was her safety, her stay at the facility and her finances. She stated in this case she was responsible to ensure an investigation was completed. She stated she was not aware of any other state agency report regarding exploitation other than the one she made to Adult Protective Services. <BR/>Interview with the administrator on 04/10/2024 at 12:55 PM revealed he was familiar with Resident #138 and her friend/Power Of Attorney. He stated the friend's sudden interest in her finances made the facility Business Office Manager and Social Services staff suspicious of his intention and the Inter Disciplinary Team meeting discussed and determined the issue was more appropriate for Adult Protective Services to investigate. Administrator stated he was not aware if the Adult Protective Services completed the investigation, the staff who reported was responsible to follow up and ensure an investigation was completed. Administrator stated the staff were provided training on misappropriation of property at least once a month and he expect his staff to immediately notify him and report to the state if there was a concern of misappropriation of property. He stated he was the only one who has access to Tulip to file a state report and he did not report it because he did not fell this case was appropriate for misappropriation. He stated not investigating a misappropriation of property could affect the finances of a resident. <BR/>An interview with DON on 04/11/2024 at 10:38 AM revealed she was familiar with Resident #138 and his friend. DON stated resident's friend did not have any responsibility at the time of her admission. DON stated his sudden interest in resident's finances and his demand for reimbursement for any visits and purchases towards resident made the facility staff suspicious of his intention. The friend brought a Power Of Attorney document on the resident and the facility staff made an Adult Protective Services report to investigate financial exploitation. DON stated she did not know the outcome of the investigation. DON stated she was not aware of the incident reported to any other state agency than Adult Protective Services. DON stated the business office was responsible to do the due diligence, she stated she could not say who was responsible to ensure an investigation was completed. DON sated she did not know the risk for the resident if a misappropriation of property report was not investigated. <BR/>Review of the hospital document from dated 05/21/2022 reflected Resident #138 appointed her friend as her Medical Power Of Attorney.<BR/>Review of the Probate Court document reflected Resident #138 did not need a guardian and Resident #138's friend was appointed as her durable Power Of Attorney on 12/14/2023 based on the Power Of Attorney Resident signed on 08/03/2023.<BR/>Review of the facility policy dated 10/1/2022 reflected It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment . Residents must not be subjected to abuse by anyone, including, but not limited to, Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. Misappropriation of resident property - means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.<BR/>PROCEDURES:<BR/>In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will:<BR/>o Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but:<BR/>o Not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury<BR/>o Not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury<BR/>o Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to:<BR/>o The Administrator of the Facility<BR/>o The State Survey Agency<BR/>o Adult Protective Services (as appropriate)<BR/>o Ensure that, after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident(s).<BR/>o Ensure that the results of all investigations are reported within five (5) working days of the incident to:<BR/>o The Administrator<BR/>o The State Survey Agency<BR/>o Ensure that, if the alleged violation is verified, appropriate corrective action is taken.<BR/>GUIDELINES FOR FACILITY COMPLIANCE<BR/>In order to comply with the Facility's obligations as set forth in 42 CFR Section 483.12, it will:<BR/>o Make all staff aware of the applicable reporting requirements.<BR/>o Educate all staff on the definitions of abuse, neglect, mistreatment, exploitation, and misappropriation of resident property.<BR/>Policy / Procedure - Nursing Administration<BR/>Revised 10/1/2022 Page 4<BR/>o Educate all staff on the types of conduct which might meet the definition of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property.<BR/>o Support an environment in which staff and others freely and without hesitation report situations which may be or are consistent with abuse, neglect, mistreatment, exploitation, or misappropriation of resident property.<BR/>o Conduct a prompt, thorough and complete investigation in response to reportable allegations of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property.<BR/>o Maintain evidence that all allegations of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property are thoroughly investigated.<BR/>o Depending on the nature of the allegation, immediately put effective measures in place to ensure that further potential abuse, neglect, mistreatment, exploitation, or misappropriation of resident property does not occur while the investigation is in process.<BR/>o Take corrective action as appropriate given the results of the investigation.<BR/>o Assess the corrective action taken, if any, in response to the results of the investigation to determine its effectiveness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that comprehensive person-centered care plans were developed and implemented 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 for 1 of 3 residents (Resident #175) reviewed for Care Plans. <BR/>The facility failed to ensure Resident #175's Care Plan included goals and interventions for her oxygen therapy.<BR/>This failure could place residents at risk of their needs not being met. <BR/>Findings Included:<BR/>Review of Resident #175's Face Sheet, dated 03/08/23, revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses (process of identifying a disease, condition or injury) included type 2 diabetes, digestive system diseases, chronic obstructive respiratory disease, generalized anxiety, dementia, and heart failure. <BR/>Review of Resident #175's re-entry MDS, dated [DATE] stated she was moderately cognitively intact with a BIMS score of 12. She required extensive assistance of one staff for bed mobility, toilet use, and personal hygiene. <BR/>Record review of Resident #175's physician orders revealed, Check & Record O2 Saturation . every shift . with a start date of 03/03/2023.Elevate HOB to promote lung expansion . every shift related to chronic obstructive pulmonary disease with (acute) exacerbation with a start date of 03/06/2023. No physician orders related to the administration of oxygen therapy were documented during review. <BR/>Record review of Resident #175's Comprehensive Care Plan, dated 12/15/2022 revealed that Resident #175 had no documentation of oxygen therapy, nor any interventions, or goals related to oxygen therapy.<BR/>In observation and interview with Resident #175 on 03/07/2023 at 11:53am revealed resident sitting in her wheelchair with her oxygen concentrator turned on and the end of the nasal cannula positioned appropriately in her nares. She stated she sometimes needed oxygen upon physical exertion, as she would become short of breath. <BR/>In observation and interview with Resident #175 on 03/08/2023 at 11:23am revealed resident in wheelchair with her oxygen concentrator turned off. Resident did not have a nasal cannula in her nares. She did not appear to be in any distress upon observation and denied any distress upon interview. <BR/>In observation and interview with RN A on 03/08/2023 at 1:06pm revealed RN A stated that Resident #175 was on oxygen yesterday but did not need oxygen today. RN A was observed referencing the electronic medical record and stated that Resident #175 did not currently have any physician orders for oxygen at this time. She stated she was not certain who applied oxygen to Resident #175 yesterday and that the resident was not capable of doing it herself. RN A stated it was required for residents on oxygen to have a physician order for safety purposes and that she would call the physician next to obtain an order. <BR/>In interview with the MDS Coordinator on 03/09/2023 at 10:33am, she stated that it was a shared responsibility to ensure care plans were updated and accurate to reflect the resident's care needs and requirements. She stated it was a team effort, as the DON was responsible for completing the initial or admission care plan and she was responsible to updating resident care plans. She stated the physician orders were what triggered her to update resident care plans and unless a physician order was obtained, it would not initiate her to re-evaluate or update resident care plans. She stated if resident care plans were not updated to reflect resident care needs and requirements, the facility cannot ensure that the best care was provided. <BR/>In interview with the DON on 03/09/2023 at 9:57am she stated oxygen therapy would not necessarily need to be included in Resident #175's care plan, but it would be best if it was on there. She stated that care plans were important as they guide the facility on the care needs and requirements of the resident. She stated it was the MDS nurse's responsibility to ensure updates were completed to resident care plans. <BR/>Record review of facility policy, Comprehensive Person-Centered Care Planning, rev. Jan. 2022, revealed Policy It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene to a resident who was unable to carry out activities of daily living for one of six residents (Resident #8) reviewed for ADL care.<BR/>The facility failed to provide Resident #8, who required extensive assistance, with timely incontinence care on 04/09/24 from 9:30 a.m. to 3:00 p.m. <BR/>This failure could place residents at risk of skin breakdown, urinary tract infections and loss of dignity.<BR/>Findings included:<BR/>Record review of Resident #8's quarterly MDS assessment, dated 01/22/24, reflected a [AGE] year-old female with an admission dated of 03/25/17. She had a BIMS of 14, indicating she was cognitively intact. She had no behaviors documented and not resisted care. Resident #8 required extensive assistance with toileting and personal hygiene and was always incontinent of urinary bladder and bowel. Resident #8 was at risk of pressure ulcers with no current skin issues. Her active diagnoses included atrial fibrillation (fast irregular heart rate), depression, and bipolar disorder (mental disorder that cause extreme mood swings). <BR/>Record review of Resident #8's Comprehensive Care Plan initiated on 09/06/22, reflected, . Has bowel/bladder incontinence r/t dementia, decrease/impaired mobility Interventions .Change as required for incontinence. Wash, rinse and dry perineum .Monitor/document for s/sx of UTI: pain, burning .urinary frequency .foul smelling urine .<BR/>In an interview with Resident #8 on 04/09/24 at 2:30 p.m. she stated she was not getting changed throughout the day. She stated she was gotten up around 9:30 a.m. so she can make the first smoke break. She stated she was not laid back down and changed until after the last smoke break which was at 6:30 p.m. She stated it may be close to 7:30 p.m. before she gets changed. She stated she cannot make staff understand that she wants to be gotten back up so she can have her smoke breaks, so they just leave her up the whole time. She stated by the time they laid her down at night she was soaked in urine. She stated she was wet right now and would like to be changed, but stated she wanted to make sure they knew she wanted to get back up.<BR/>On 04/09/24 at 2:35 p.m. LVN B was notified Resident #8 was wet and had requested to be changed. She stated she would let the CNAs know and they would be in to change her. <BR/>An observation on 04/09/24 at 2:40 p.m. reveled LVN B and CNA D entered Resident #8's room with a stand assist lift. Resident stated, after I get changed, I want to be gotten back up, LVN B attached the lift sling around the resident's waist and slowly lift her to a standing position which revealed the resident was soaked in urine with the front and back of her pants wet. Resident was transferred to the bed and both staff removed the residents' wet pants and opened the wet brief. LVN B wiped from front to back and down the middle and with assistance from CNA D rolled the resident onto her side, revealing she had also had a bowel movement. Resident #6 stated her butt was burning. Residents' buttocks was slightly red but no skin breakdown. LVN B removed the soiled brief and placed a clean brief under the resident before completion of incontinence care. LVN B wiped the resident's anal area and buttocks from front to back until all bowel movement had been removed. LVN B then opened a packet of barrier cream without removing her soiled gloves or performing hand hygiene and was about to apply to the resident buttocks, when the resident stated she needed to turn on her other side. LVN B handed the barrier cream to CNA D, and they assisted the resident onto her other side. CNA C applied the barrier cream to the resident's buttocks and the staff rolled the resident back onto her back and fastened the brief. LVN B and CNA D then removed their gloves and performed hand hygiene and redressed the resident, transferred her back into her wheelchair. <BR/>In an interview with LVN B on 04/09/24 at 3:15 p.m. she stated incontinent residents were supposed to be checked and changed every two hours. She stated she was not sure if the resident had been changed earlier in the shift or not. She stated she knew the resident wanted to be up before the first smoke break which was at 10:00 a.m. <BR/>In an interview with CNA D on 04/09/24 at 3:50 p.m. she stated she works the 2 p.m. to 10 p.m. shift. She stated they do not check Resident #8 for incontinences until after she goes to bed after the last smoke break. She stated the resident can let them know if she wants to be changed. She stated she was not sure if day shift changed her after she was gotten up in the morning. <BR/>In an interview with CNA E on 04/10/24 at 12:40 a.m. she stated she was not assigned to Resident #8 on 04/09/24 but does assist with getting her up and incontinent care when asked. She stated she does not recall getting asked on 04/09/24 to assist with providing any incontinence care to Resident #8. She stated she knows she likes to be up before 10:00 a.m. so she can go for the first smoke break. She stated Resident #8 was always incontinent. <BR/>In an interview with the DON on 04/10/24 at 2:00 p.m. she stated incontinent residents were to be checked and changed every two hours. She stated failing to do this could cause skin breakdown and puts them at risk of urinary tract infections. <BR/>Review of the facility's policy titled, Incontinent Care, dated May 2007, reflected, It is the policy of this facility to remove urine or feces from skin, cleanse and lubricate skin, provide dry, odor free perineal care system .Check for wetness at least every two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of six residents (Resident #47) reviewed for incontinence care. <BR/>The facility failed to ensure NA C provided appropriate perineal care for Resident # 47 after an incontinent episode when he failed to clean the resident's scrotum, and penis on 04/09/24.<BR/>This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. <BR/>Findings included:<BR/>Record review of resident #47's quarterly MDS assessment, dated 02/25/24, reflected a [AGE] year-old male with an admission date of 06/15/22. Staff assessed residents' cognition as severely impaired. He required extensive assistance with personal hygiene and toileting and was frequently incontinent of urine and always incontinent of bowel. Active diagnoses included diabetes, cerebral vascular accident (stroke) and dementia. <BR/>Review of Resident #47's care plan, initiated on 10/03/23, reflected .Has bowel/bladder incontinence r/t impaired mobility, post CVA, hemiplegia .Interventions .use disposable briefs. Change as needed .<BR/>An observation on 04/09/24 at 1:30 p.m. revealed NA C with assistance from therapy staff transferring Resident #47 from his wheelchair to the bed so he could provide incontinence care. Resident #47 was observed to have wet pants from front to back. NA C performed hand hygiene and put on gloves and removed the resident wet pants and unfasted the wet brief and took a peri wipe and wiped up and down residents' groin without changing the surface of the wipe with each stroke. NA C did not clean the resident's penis or scrotum or pull back the foreskin to clean the tip of the penis. NA C rolled the resident over onto his side and wiped the back of the resident's thighs and wiped the anal area from front to back with a clean peri-wipe. NA C placed a clean brief under the resident without changing his gloves and performing hand hygiene. NA C fastened the brief and repositioned the resident and then removed his gloves and gathered the trash and dirty linens and left the room without performing hand hygiene and walked across the hall and entered the soiled linen closet to deposit the trash and linens, and then performed hand hygiene. <BR/>In an interview with NA C on 04/09/24 at 01:55 p.m. he was unsure about the proper steps of peri-care for a male resident and was not sure what steps he had missed. After a few minutes he stated he should have cleaned the penis and scrotum. He stated the foreskin needed to be pulled back to clean the tip of the penis. He stated failing to do this could cause skin breakdown and infections. <BR/>Review of NA C's skill check off for Male Perineal care dated 03/09/24 reflected he was competent in providing this care. <BR/>In an interview on 04/10/24 at 02:00 p.m., the DON stated when providing incontinent care staff were to clean the peri area including penis and scrotum for male residents then moving toward the buttocks. She stated by not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. She stated NA C was very nervous and stated she knew he knew how to provide proper care.<BR/>Record review of the facility's procedure check off titled, Male Perineal Care, dated 2019, reflected, .Wash hands .Put on disposable gloves .Use a different section of the washcloth or disposable wipe for each stroke .Hold penis upright .pull back the foreskin of the uncircumcised penis. Wash the urinary meatus (tip of penis) in a circular motion .Return the foreskin to the natural position .wet and sop a new washcloth. With downward strokes(away from the urinary meatus), wash down the shaft of the penis, then scrotum, perineum, and thigh creases .Wash the perineum and the anal area .Wash from front to back .Change gloves and perform hand hygiene if apply peri cream .Apply incontinent brief .Remove gloves and wash hands .Tie up bags of soiled linen and trash .Wash hands .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to ensure that five (Resident #289, Resident #290, Resident #61, Resident # 79, and Resident #16) of ten residents were provided medications and/or biologicals and pharmaceutical services to meet the needs of the residents.<BR/>1.The facility failed to ensure MA L re-ordered medications in a timely manner for Residents #289 (Lasix ), Resident #290 (Lasix), and Resident #61 (Entresto).<BR/>2.The facility failed to ensure MA J re-ordered medications in a timely manner for Residents #79 (Metoprolol). <BR/>3.The facility failed to ensure LVN B re-ordered medications in a timely manner for Resident #16 (Famotidine).<BR/>This failure placed the residents at risk of not receiving medications as ordered by the physician.<BR/>Findings included: <BR/>1.Review of Resident #289's Face Sheet dated 04/10/2024 reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included pleural effusion (accumulation of excessive fluid on the space that surrounds each lung), acute systolic congestive heart failure (condition in which the heart cannot pump blood well enough to meet the body's needs), and fluid overload (too much fluid in the body). <BR/>Review of Resident #289's Quarterly MDS assessment dated [DATE] reflected Residetn#289 had congestive heart failure and was taking diuretics (medications that help reduce fluid buildup in the body).<BR/>Review of Resident #289's Comprehensive Care Plan dated 04/08/2024 reflected resident was on diuretic and one of the interventions was to administer medication as ordered.<BR/>Review of Resident #289's Physician's Order for Lasix dated 03/28/2024 reflected, Lasix Oral Tablet 20 MG (Furosemide). Give 1 tablet by mouth one time a day for CHF (congestive heart failure).<BR/>Review of Resident #290's Face Sheet dated 04/10/2024 reflected that resident was a [AGE] year-old male admitted on [DATE]. One of the diagnoses was acute kidney failure.<BR/>Review of Resident #290's Quarterly MDS assessment dated [DATE] reflected Resident #290 was cognitively intact. The Quarterly MDS Assessment also indicated that the resident had renal failure (kidney stopped working).<BR/>Review of Resident #290's Comprehensive Care Plan dated 04/09/2024 reflected resident was on diuretic and one of the interventions was to administer medication as ordered.<BR/>Review of Resident #290's Physician Order for Lasix dated 03/29/2024 reflected Lasix Oral Tablet (Furosemide). Give 10 mg by mouth one time a day for Diuretic.<BR/>Review of Resident #61's Face Sheet dated 04/10/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. One of the relevant diagnoses was biventricular heart failure (combination of symptoms associated with both left heart failure and right-side failure).<BR/>Review of Resident #61's Comprehensive MDS assessment dated [DATE] reflected Resident #61 had a moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment also indicated resident had heart failure. <BR/>Review of Resident #61's Comprehensive Care Plan on 04/09/2024 reflected resident had congestive heart failure and one of the interventions was give cardiac medications as ordered.<BR/>Review of Resident #61's Physician Order for Entresto dated 03/13/2024 reflected Sacubitril-Valsartan Oral Tablet 24-26 MG (Sacubitril-Valsartan). Give 1 tablet by mouth two times a day for CHF.<BR/>Observation and interview with MA L on 04/10/2024 at 11:26 AM revealed MA L opened her cart for inspection. Three blister packs were noted running low. Residents #289's Lasix 20 mg (milligrams) only had one tablet, Resident #290's Lasix 10 mg only had two tablets, and Resident #61's Entresto 24-26 mg only had three tablets. MA L confirmed both Lasix were to be administered once daily and Entresto was to be administered twice daily. When asked if the medications were already re-ordered, MA L checked the cart and said there were no other blister packs for Residents #289's Lasix 20 mg, Resident #290's Lasix 10 mg, and Resident #61's Entresto 24-26 mg. MA L checked the system, and the system showed the three medications where not re-order yet. MA L said she was not able to re-order the medications. MA L then clicked the re-order button on the system for the three medications. She said the medications should have been re-ordered when the medication reach the light blue portion of the blister pack. MA L said medication should be re-ordered four to five days before the medications were consumed. MA L stated whichever nurse saw that the tablets were running low should re-order the medications. MA L added if the medications were not re-ordered, the residents would not have any medications to take. She stated skipping Lasix could result to fluid retention and skipping Entresto could result to exacerbation of the symptoms of the heart failure.<BR/>2.Review of Resident #79's Face Sheet dated 04/10/2024 reflected resident was an [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses was hypertension.<BR/>Review of Resident #79's Comprehensive MDS assessment dated [DATE] reflected Resident #79 had a moderate impairment in cognition. The Comprehensive MDS Assessment also indicated resident had hypertension. <BR/>Review of Resident #79's Physician Order for metoprolol reflected Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate). Give 1 tablet by mouth two times a day for hypertension Hold SBP (systolic blood pressure) less than 110, DBP (diastolic blood pressure) less than 60 and HR (heart rate) less than 60.<BR/>Observation and interview with MA J on 04/10/2024 at 1:04 PM revealed MA J opened her medication cart for inspection. It was noted that the blister pack for Resident #61's metoprolol was running low with only one tablet. MA J checked the cart and confirmed there were no other blister pack for Resident #61's metoprolol. She also confirmed that the resident was to take the anti-hypertensive tablet twice a day. MA J checked the system and the system showed Resident #61's metoprolol was not yet re-ordered. MA J proceeded to re-order the medication. MA J added if the residents do not have their medications, their medical concerns could get worse. MA J said she would audit her cart to check if there were medications that needed to be re-ordered.<BR/>3.Review of Resident #16's Face Sheet dated 04/10/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses was gastro-esophageal reflux disease. <BR/>Review of Resident #16's Comprehensive MDS assessment dated [DATE] reflected Resident #16 had a severe impairment in cognition. The Comprehensive MDS Assessment also indicated resident had heart failure. <BR/>Review of Resident #16's Comprehensive Care Plan on 04/12/2024 reflected resident had GERD (gastro-esophageal reflux disease: stomach acid repeatedly flows back into the tube connecting the mouth and stomach) without esophagitis (inflammation of the esophagus).<BR/>Review of Resident #16's Physician Order for Famotidine reflected Famotidine Tablet 20 MG Give 1 tablet . two times a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS.<BR/>Observation and interview with LVN B on 04/11/2024 at 7:06 AM revealed LVN B was preparing Resident #16's medication. She said she would prepare first the resident's famotidine that she took from the e-kit. LVN B said she gave the last one yesterday. LVN B said the medication was re-ordered the night before, but the pharmacy was not able to deliver because of the weather. She added medications should be re-ordered as soon as the medications reached the part of the blister pack that says refill to ensure enough supply. She said it should not be re-ordered last minute because the residents would not have adequate supply of medication in circumstances that the delivery was late or was not able to come. LVN B said they had an e-kit (emergency kit) but it was supposed to be for new admissions and STAT (urgent) medications. She said it was not proper for a medication to be taken from the e-kit just because the medication was not re-ordered timely. <BR/>In an interview with the DON on 04/11/2024 at 8:07 AM, the DON stated medications should be re-ordered 3 to 4 days before the pills were consumed. The DON said it could be done through the system or by calling the pharmacy. The DON added if the medications were not re-ordered in a timely manner, the resident would run out of medications, and they would not have any medications to take especially if the order was to take the medications routinely. The DON stated the medication aide, and the nurses were responsible for re-ordering the medications. The DON further added if the resident will not have their medications, their condition could get worse. The DON said the expectation was to re-order the medications in a timely manner. She said she would remind the medication aides and the nurses to re-order timely to ensure there was enough supply of medications and to always audit the carts for the needed medications.<BR/>In an interview with the Administrator on 04/11/2024 at 8:23 PM, the Administrator stated the staff must make sure that the medications were re-ordered on a timely manner to make sure that the residents have the medications they need. He said that moving forward, he and the clinical managers would educate and monitor if the staff were following the policy and procedures.<BR/>Record review of facility policy, Medication Ordering and Receiving from Pharmacy Provider revealed Procedures . 2. Repeat medications (refill) are written on a medication order . a. Reorder medication (seven) days in advance of need to assure an adequate supply is on hand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure medication was labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for one (Resident #81) of two residents reviewed for labelling of drugs and biologicals.<BR/>The facility failed to ensure MA L placed a change of instruction label for Resident #81's Sertraline blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) after the order was changed.<BR/>This failure could place residents at risk for wrong medication administration, mismanagement of care, adverse effects, and physical harm. <BR/>Findings included: <BR/>Review of Resident #81's Face Sheet dated 04/10/2024 reflected the resident was an [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses was depression.<BR/>Review of Resident #81's Quarterly MDS assessment dated [DATE] reflected resident had a moderately impaired cognition with a BIMS score of 07. The Quarterly MDS Assessment indicated the resident had depression.<BR/>Review of Resident #81's Comprehensive Care Plan dated 04/09/2023 reflected resident was taking antidepressant medication and one of the interventions was to administer antidepressant medications ordered by physician. <BR/>Review of Resident #81's Physician's order for Sertraline dated 04/09/2024 reflected Zoloft Oral Tablet 100 MG (Sertraline HCl). Give 1 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED.<BR/>Review of Resident #81's discontinued Physician's order for Sertraline on 04/09/2024 reflected Zoloft Oral Tablet 50 MG (Sertraline HCl). Give 1 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED.<BR/>Observation and interview on 04/10/2024 at 11:26 AM revealed MA L was checking Resident #81's blister pack for sertraline. It was noted that the blister pack's instruction was to give 50 mg (milligrams) once a day while the instruction in the eMAR (electronic medication administration record) was to give 100 mg once a day. MA L acknowledged that the instruction on the blister pack was different from the instruction in the system. MA L stated the dose for the sertraline was increased from 50 mg to 100 mg. MA L said the staff use a sticker that says change in instruction, check the eMAR or the staff could write a note on the blister pack to denote the change in order. MA L said since there was a change in instruction, she should had placed a change in instruction note or sticker on the sertraline 50 mg blister pack while waiting for the sertraline 100 mg blister pack. MA L opened her medication cart and looked for the sticker. She said she had no change of direction sticker so she would just write a note on the blister pack to ensure the right dosage of medication was administered and avoid medication error.<BR/>In an interview with MA J on 04/10/2024 at 1:04 PM, MA J stated the staff giving the medications should make sure they were reading the order and comparing the blister pack with the order in the system. She said the MAs and nurses were responsible in placing a change of direction sticker on blister pack if there was a change in direction. MA J said if there was change in order, the blister pack should have a note of change of direction to avoid medication error, undermedication, overmedication, or confusion among the staff.<BR/>In an interview with the DON on 04/10/2024 at 10:52 AM, the DON stated whoever staff that received the new order should have placed a change in order instruction on the blister pack to avoid confusion. The DON said the risk were overmedication or undermedication which could have an adverse effect for the residents. The DON said the expectation was to provide the right dosage of medication as per order and make sure the medications correlate with the eMAR and the order in the package.<BR/>In an interview with the Administrator on 04/11/2024 at 8:23 PM, the Administrator stated whatever the procedure was in giving the medications, it should have been followed to prevent any errors.<BR/>Record review of facility's policy Medication Orders revealed Procedures . g. orders . 2. The following steps are initiated . d). Transcribe newly prescribed medications on the MAR . When a new order changes the dosage of a previously prescribed medication, discontinue the previous entry by (writing DC'd [discontinued] .).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure physician orders were obtained for lab services and failed to promptly notify the physician of laboratory results that fall outside of clinical reference ranges in accordance with facility policy and procedures for notification of a practitioner or per the ordering physician orders for one of two (Resident #6) reviewed for labs. <BR/>1. The Facility failed to transcribe the physician orders for a lab draw to obtain a Dilantin (medication used for seizure control) level on 02/13/24 and 03/28/24 into Resident #6's clinical record. <BR/>2. The Facility failed to provide timely notification to the physician or nurse practitioner of laboratory results that fell outside of clinical reference ranges of the Dilantin level drawn on 02/13/24 for Resident #6 and failed to document notification of results obtained on 03/29/24 for the repeat Dilantin level request for Resident #6. <BR/>This failure could affect residents by placing them at risk for ineffective treatment of seizure control or side effects from toxicity. <BR/>Findings included: <BR/>Record review of Resident #6's annual MDS assessment dated [DATE] reflected a [AGE] year-old female with a BIMS of 0 which indicated she was severely cognitively impaired but could sometimes make herself understood and could sometimes understand others. She required extensive assistance with ADL care and had current diagnoses of aphasia (language disorder that affects ability to communicate), cerebral vascular accident (stroke), dementia, and seizure disorder. <BR/>Record review of Resident #6 's care plan imitated on 09/14/22 reflected, Has seizure disorder (unspecified) .Interventions .Give Medications as ordered .Obtain and monitor lab/diagnostic work as ordered. Report results to ME and follow up as indicated . <BR/>Record review of Resident #6's Order Summary Report for February 2024 through April 2024 did not reflect orders for Dilantin Level lab request. <BR/>Record review of Laboratory results for Resident #6 reflected:<BR/>1. Therapeutic Phenytoin (Dilantin), Total Serum- Results 22.4 (H) Reference Ranges- 10.0-20.0 - note Patient drug level exceeds published reference range. Evaluate clinically for signs of potential toxicity. - Lab was drawn on 02/13/24 and was reported to the facility on [DATE] at 05:13 a.m.<BR/>2. Therapeutic Phenytoin (Dilantin), Total Serum- Results 20.8 (H) Reference Ranges- 10.0-20.0 - note Patient drug level exceeds published reference range. Evaluate clinically for signs of potential toxicity. - Lab was drawn on 03/28/24 and was reported to the facility on [DATE] at 06:13 a.m.<BR/>Record review of Resident #6's Nurse's Progress notes for February 2024 did not reflect physician notification of the laboratory results received on 02/14/24. <BR/>Record review of Resident #6 Nurse Progress note written by ADON A on 03/27/24 at 12:58 p.m. reflected, New orders to repeat Dilantin level d/t previous high levels .<BR/>Record review of Resident #6's Nurse Progress notes from 03/29/24 through 04/11/24 did not reflect notification to the physician or nurse practitioner of the lab results received on 03/29/24. <BR/>In an interview with the DON on 04/10/24 at 1:55 p.m. she stated the nurses were responsible for checking the lab portal each day for any lab updates and were responsible for notifying the physician at that time. She stated most of the laboratory results are received on the morning shift. She stated there should be an order for the laboratory test requested and would check to see if the orders had not been scanned into the electronic record. <BR/>In an interview with LVN B on 04/10/24 at 2:15 p.m. she stated she had received the laboratory results on 03/29/24 and had notified the NP for Resident #6 but stated she had not documented the notification. She stated she was the primary day shift charge nurse for Resident #6. She stated she was aware there was delay in the notification of the lab results for the Dilantin level drawn on 02/13/24, which was why a new request to repeat the lab draw was ordered on 03/28/24. She stated when they get an order for a lab, they placed it into the laboratory portal. She stated only recently had they had the system connect with the resident's electronic record which allowed the physician to be able to view the lab results as soon as the lab posted them into the portal. She stated she did not realize the orders did not transcribe over into the resident clinical record, and assumed when they put the order request into the lab portal it created the physician's order. She stated they also used a secured communication portal on a separate electronic device where they updated the physicians on lab results or changes in the resident's condition. She stated those notifications do not show up in the electronic record. She stated she realized now she needed to update the progress notes on any notifications to the physician and needed to place the order into the electronic record. She stated these failures could result in delays of notifications of lab results and any necessary follow up for the oncoming shifts. <BR/>In an interview with the NP for Resident #6 on 04/10/24 at 4:33 p.m. she stated she had requested some Dilantin levels but could not recall when she had requested them. She stated if she had been contacted about a Dilantin level that was outside of the reference range, she would have requested a re-draw of the lab to ensure it was a correct range before making any changes to the residents' medications. She stated since there was no request for a re-draw in February, she most likely was not made aware of the laboratory results. She stated she does not get excited when the lab is outside of the reference range, until it gets into the 30's or if the resident is having seizures. She stated Resident #6 had been stable and was not showing any signs or symptoms of toxicity and had not had any reported seizures. <BR/>In an interview with the DON on 04/11/24 at 8:55 a.m. she stated she was not able to locate an order for the labs that were requested on 02/13/24 and 03/28/24. She stated she was also unable to locate any documentation that the physician or NP had been notified of the lab results. She stated failure to notify the physician regarding lab results could result in a delay in treatment or the need to adjust a medication depending on which labs were drawn. She stated all lab requests had to have a physician order. <BR/>Interview with ADON A on 04/11/24 at 9:32 a.m. stated she was the one who had spoken to the NP for Resident #6 on 03/27/24. She stated the resident had been starting to pocket her food when eating, so she had reviewed the labs the resident had done and discovered the lab drawn on 02/13/24 did not indicate the physician had not been notified. She stated she spoke with the NP who was in the building that day and informed her about the previous lab results and she stated the NP requested the lab to be re-drawn. She stated she had informed the charge nurse but did not write an order for the lab. She stated she should have written the odor for the request. She stated it was the nurse's responsibility to check the labs every day. She stated the lab will contact the facility by phone if there was a critical lab level and will document who they gave those critical levels to. <BR/>Review of the facility's policy titled, Diagnostic Test Results Notification, dated January 2022, reflected, It is the policy of this facility to obtain laboratory and radiology services when ordered by a Physician, Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) and to promptly notify the ordering provider of test results .Results of laboratory, radiological, and diagnostic test outside the clinical reference ranges shall be reported to the resident's attending physician, PA, NP or CNS promptly or as specified in the order. Notification of test results will be documented in the resident's clinical record. Results of lab, radiology, & diagnostic services shall be made a part of the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span for 1 of 3 residents (Resident #1) reviewed for timely meals, in that:<BR/>The facility failed to ensure residents were offered snacks at bedtimes as required due to meal times being more than 14 hours apart.<BR/>This failure could affect all 70 residents who received meals served from the facility's only kitchen by placing residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. <BR/>Findings included: <BR/>Observation on 04/09/2024 at 9:15 AM, of the posted Meal Service Times in the dining room revealed the following:<BR/>Breakfast - 7:30 -9:30 AM <BR/>Lunch - 11:45-1:45 PM <BR/>Evening meal - 5:00 -7:00 PM <BR/>Observation on 04/10/2024 at 9:32 AM, of the posted Meal Service Times in the dining room revealed the same as the previous date. There is no posting to advise any resident a snack or availability of type of snack after specified times. During interviewing residents, it has been brought to the attention of the state surveyors that they have not been made aware of options of snack which are available to residents. <BR/>Interview on 04/10/2024 at 9:45 AM, with DM Z. revealed staff could request a snack for resident, but options were not provided to residents. <BR/>On 04/10/2024 10:00 AM, during a confidential Resident Council meeting 6 of 6 residents said they were not offered any HS snacks. <BR/>Observation on 04/11/2024 at 09:30 AM, in main dining area, observed in addition to the daily menu for posted for Breakfast, lunch and dinner. An additional posting advising residents with a suggested option to the daily menu and alternatives. It clearly shows a choice for one (1) Entr&eacute;e for resident, with the option of other items. <BR/>Interview on 04/11/2024 at 9:45 AM, DM Z advised that in the past the staff would ask the resident if they would like a snack or alternative meal. This has been what they have done in the past. It was asked do you think this should be a normal routine on providing residents an option that being both a snack and a meal. It was also addressed that residents had no knowledge of the ability to request an alternative menu item. <BR/>Fall winter menus had the options presented on the slip and they were able to <BR/>Spring menu does not have the options she emphasized that they had just started the spring calendar menu. <BR/>Record Review of Facility Policies and Procedures dated 06/2017, reflects serve meals at the times specified/posted. AD advised the following in addition to what is included in the policy, we follow the guidelines of the Texas Food Establishment Rules. We do not have a policy for snacks. We follow the reg and offer 8 pm (HS) snacks and the recommended best practice of 10a/2pm snacks.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to ensure that five (Resident #289, Resident #290, Resident #61, Resident # 79, and Resident #16) of ten residents were provided medications and/or biologicals and pharmaceutical services to meet the needs of the residents.<BR/>1.The facility failed to ensure MA L re-ordered medications in a timely manner for Residents #289 (Lasix ), Resident #290 (Lasix), and Resident #61 (Entresto).<BR/>2.The facility failed to ensure MA J re-ordered medications in a timely manner for Residents #79 (Metoprolol). <BR/>3.The facility failed to ensure LVN B re-ordered medications in a timely manner for Resident #16 (Famotidine).<BR/>This failure placed the residents at risk of not receiving medications as ordered by the physician.<BR/>Findings included: <BR/>1.Review of Resident #289's Face Sheet dated 04/10/2024 reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included pleural effusion (accumulation of excessive fluid on the space that surrounds each lung), acute systolic congestive heart failure (condition in which the heart cannot pump blood well enough to meet the body's needs), and fluid overload (too much fluid in the body). <BR/>Review of Resident #289's Quarterly MDS assessment dated [DATE] reflected Residetn#289 had congestive heart failure and was taking diuretics (medications that help reduce fluid buildup in the body).<BR/>Review of Resident #289's Comprehensive Care Plan dated 04/08/2024 reflected resident was on diuretic and one of the interventions was to administer medication as ordered.<BR/>Review of Resident #289's Physician's Order for Lasix dated 03/28/2024 reflected, Lasix Oral Tablet 20 MG (Furosemide). Give 1 tablet by mouth one time a day for CHF (congestive heart failure).<BR/>Review of Resident #290's Face Sheet dated 04/10/2024 reflected that resident was a [AGE] year-old male admitted on [DATE]. One of the diagnoses was acute kidney failure.<BR/>Review of Resident #290's Quarterly MDS assessment dated [DATE] reflected Resident #290 was cognitively intact. The Quarterly MDS Assessment also indicated that the resident had renal failure (kidney stopped working).<BR/>Review of Resident #290's Comprehensive Care Plan dated 04/09/2024 reflected resident was on diuretic and one of the interventions was to administer medication as ordered.<BR/>Review of Resident #290's Physician Order for Lasix dated 03/29/2024 reflected Lasix Oral Tablet (Furosemide). Give 10 mg by mouth one time a day for Diuretic.<BR/>Review of Resident #61's Face Sheet dated 04/10/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. One of the relevant diagnoses was biventricular heart failure (combination of symptoms associated with both left heart failure and right-side failure).<BR/>Review of Resident #61's Comprehensive MDS assessment dated [DATE] reflected Resident #61 had a moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment also indicated resident had heart failure. <BR/>Review of Resident #61's Comprehensive Care Plan on 04/09/2024 reflected resident had congestive heart failure and one of the interventions was give cardiac medications as ordered.<BR/>Review of Resident #61's Physician Order for Entresto dated 03/13/2024 reflected Sacubitril-Valsartan Oral Tablet 24-26 MG (Sacubitril-Valsartan). Give 1 tablet by mouth two times a day for CHF.<BR/>Observation and interview with MA L on 04/10/2024 at 11:26 AM revealed MA L opened her cart for inspection. Three blister packs were noted running low. Residents #289's Lasix 20 mg (milligrams) only had one tablet, Resident #290's Lasix 10 mg only had two tablets, and Resident #61's Entresto 24-26 mg only had three tablets. MA L confirmed both Lasix were to be administered once daily and Entresto was to be administered twice daily. When asked if the medications were already re-ordered, MA L checked the cart and said there were no other blister packs for Residents #289's Lasix 20 mg, Resident #290's Lasix 10 mg, and Resident #61's Entresto 24-26 mg. MA L checked the system, and the system showed the three medications where not re-order yet. MA L said she was not able to re-order the medications. MA L then clicked the re-order button on the system for the three medications. She said the medications should have been re-ordered when the medication reach the light blue portion of the blister pack. MA L said medication should be re-ordered four to five days before the medications were consumed. MA L stated whichever nurse saw that the tablets were running low should re-order the medications. MA L added if the medications were not re-ordered, the residents would not have any medications to take. She stated skipping Lasix could result to fluid retention and skipping Entresto could result to exacerbation of the symptoms of the heart failure.<BR/>2.Review of Resident #79's Face Sheet dated 04/10/2024 reflected resident was an [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses was hypertension.<BR/>Review of Resident #79's Comprehensive MDS assessment dated [DATE] reflected Resident #79 had a moderate impairment in cognition. The Comprehensive MDS Assessment also indicated resident had hypertension. <BR/>Review of Resident #79's Physician Order for metoprolol reflected Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate). Give 1 tablet by mouth two times a day for hypertension Hold SBP (systolic blood pressure) less than 110, DBP (diastolic blood pressure) less than 60 and HR (heart rate) less than 60.<BR/>Observation and interview with MA J on 04/10/2024 at 1:04 PM revealed MA J opened her medication cart for inspection. It was noted that the blister pack for Resident #61's metoprolol was running low with only one tablet. MA J checked the cart and confirmed there were no other blister pack for Resident #61's metoprolol. She also confirmed that the resident was to take the anti-hypertensive tablet twice a day. MA J checked the system and the system showed Resident #61's metoprolol was not yet re-ordered. MA J proceeded to re-order the medication. MA J added if the residents do not have their medications, their medical concerns could get worse. MA J said she would audit her cart to check if there were medications that needed to be re-ordered.<BR/>3.Review of Resident #16's Face Sheet dated 04/10/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses was gastro-esophageal reflux disease. <BR/>Review of Resident #16's Comprehensive MDS assessment dated [DATE] reflected Resident #16 had a severe impairment in cognition. The Comprehensive MDS Assessment also indicated resident had heart failure. <BR/>Review of Resident #16's Comprehensive Care Plan on 04/12/2024 reflected resident had GERD (gastro-esophageal reflux disease: stomach acid repeatedly flows back into the tube connecting the mouth and stomach) without esophagitis (inflammation of the esophagus).<BR/>Review of Resident #16's Physician Order for Famotidine reflected Famotidine Tablet 20 MG Give 1 tablet . two times a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS.<BR/>Observation and interview with LVN B on 04/11/2024 at 7:06 AM revealed LVN B was preparing Resident #16's medication. She said she would prepare first the resident's famotidine that she took from the e-kit. LVN B said she gave the last one yesterday. LVN B said the medication was re-ordered the night before, but the pharmacy was not able to deliver because of the weather. She added medications should be re-ordered as soon as the medications reached the part of the blister pack that says refill to ensure enough supply. She said it should not be re-ordered last minute because the residents would not have adequate supply of medication in circumstances that the delivery was late or was not able to come. LVN B said they had an e-kit (emergency kit) but it was supposed to be for new admissions and STAT (urgent) medications. She said it was not proper for a medication to be taken from the e-kit just because the medication was not re-ordered timely. <BR/>In an interview with the DON on 04/11/2024 at 8:07 AM, the DON stated medications should be re-ordered 3 to 4 days before the pills were consumed. The DON said it could be done through the system or by calling the pharmacy. The DON added if the medications were not re-ordered in a timely manner, the resident would run out of medications, and they would not have any medications to take especially if the order was to take the medications routinely. The DON stated the medication aide, and the nurses were responsible for re-ordering the medications. The DON further added if the resident will not have their medications, their condition could get worse. The DON said the expectation was to re-order the medications in a timely manner. She said she would remind the medication aides and the nurses to re-order timely to ensure there was enough supply of medications and to always audit the carts for the needed medications.<BR/>In an interview with the Administrator on 04/11/2024 at 8:23 PM, the Administrator stated the staff must make sure that the medications were re-ordered on a timely manner to make sure that the residents have the medications they need. He said that moving forward, he and the clinical managers would educate and monitor if the staff were following the policy and procedures.<BR/>Record review of facility policy, Medication Ordering and Receiving from Pharmacy Provider revealed Procedures . 2. Repeat medications (refill) are written on a medication order . a. Reorder medication (seven) days in advance of need to assure an adequate supply is on hand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure medication was labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for one (Resident #81) of two residents reviewed for labelling of drugs and biologicals.<BR/>The facility failed to ensure MA L placed a change of instruction label for Resident #81's Sertraline blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) after the order was changed.<BR/>This failure could place residents at risk for wrong medication administration, mismanagement of care, adverse effects, and physical harm. <BR/>Findings included: <BR/>Review of Resident #81's Face Sheet dated 04/10/2024 reflected the resident was an [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses was depression.<BR/>Review of Resident #81's Quarterly MDS assessment dated [DATE] reflected resident had a moderately impaired cognition with a BIMS score of 07. The Quarterly MDS Assessment indicated the resident had depression.<BR/>Review of Resident #81's Comprehensive Care Plan dated 04/09/2023 reflected resident was taking antidepressant medication and one of the interventions was to administer antidepressant medications ordered by physician. <BR/>Review of Resident #81's Physician's order for Sertraline dated 04/09/2024 reflected Zoloft Oral Tablet 100 MG (Sertraline HCl). Give 1 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED.<BR/>Review of Resident #81's discontinued Physician's order for Sertraline on 04/09/2024 reflected Zoloft Oral Tablet 50 MG (Sertraline HCl). Give 1 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED.<BR/>Observation and interview on 04/10/2024 at 11:26 AM revealed MA L was checking Resident #81's blister pack for sertraline. It was noted that the blister pack's instruction was to give 50 mg (milligrams) once a day while the instruction in the eMAR (electronic medication administration record) was to give 100 mg once a day. MA L acknowledged that the instruction on the blister pack was different from the instruction in the system. MA L stated the dose for the sertraline was increased from 50 mg to 100 mg. MA L said the staff use a sticker that says change in instruction, check the eMAR or the staff could write a note on the blister pack to denote the change in order. MA L said since there was a change in instruction, she should had placed a change in instruction note or sticker on the sertraline 50 mg blister pack while waiting for the sertraline 100 mg blister pack. MA L opened her medication cart and looked for the sticker. She said she had no change of direction sticker so she would just write a note on the blister pack to ensure the right dosage of medication was administered and avoid medication error.<BR/>In an interview with MA J on 04/10/2024 at 1:04 PM, MA J stated the staff giving the medications should make sure they were reading the order and comparing the blister pack with the order in the system. She said the MAs and nurses were responsible in placing a change of direction sticker on blister pack if there was a change in direction. MA J said if there was change in order, the blister pack should have a note of change of direction to avoid medication error, undermedication, overmedication, or confusion among the staff.<BR/>In an interview with the DON on 04/10/2024 at 10:52 AM, the DON stated whoever staff that received the new order should have placed a change in order instruction on the blister pack to avoid confusion. The DON said the risk were overmedication or undermedication which could have an adverse effect for the residents. The DON said the expectation was to provide the right dosage of medication as per order and make sure the medications correlate with the eMAR and the order in the package.<BR/>In an interview with the Administrator on 04/11/2024 at 8:23 PM, the Administrator stated whatever the procedure was in giving the medications, it should have been followed to prevent any errors.<BR/>Record review of facility's policy Medication Orders revealed Procedures . g. orders . 2. The following steps are initiated . d). Transcribe newly prescribed medications on the MAR . When a new order changes the dosage of a previously prescribed medication, discontinue the previous entry by (writing DC'd [discontinued] .).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that comprehensive person-centered care plans were developed and implemented 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 for 1 of 3 residents (Resident #175) reviewed for Care Plans. <BR/>The facility failed to ensure Resident #175's Care Plan included goals and interventions for her oxygen therapy.<BR/>This failure could place residents at risk of their needs not being met. <BR/>Findings Included:<BR/>Review of Resident #175's Face Sheet, dated 03/08/23, revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses (process of identifying a disease, condition or injury) included type 2 diabetes, digestive system diseases, chronic obstructive respiratory disease, generalized anxiety, dementia, and heart failure. <BR/>Review of Resident #175's re-entry MDS, dated [DATE] stated she was moderately cognitively intact with a BIMS score of 12. She required extensive assistance of one staff for bed mobility, toilet use, and personal hygiene. <BR/>Record review of Resident #175's physician orders revealed, Check & Record O2 Saturation . every shift . with a start date of 03/03/2023.Elevate HOB to promote lung expansion . every shift related to chronic obstructive pulmonary disease with (acute) exacerbation with a start date of 03/06/2023. No physician orders related to the administration of oxygen therapy were documented during review. <BR/>Record review of Resident #175's Comprehensive Care Plan, dated 12/15/2022 revealed that Resident #175 had no documentation of oxygen therapy, nor any interventions, or goals related to oxygen therapy.<BR/>In observation and interview with Resident #175 on 03/07/2023 at 11:53am revealed resident sitting in her wheelchair with her oxygen concentrator turned on and the end of the nasal cannula positioned appropriately in her nares. She stated she sometimes needed oxygen upon physical exertion, as she would become short of breath. <BR/>In observation and interview with Resident #175 on 03/08/2023 at 11:23am revealed resident in wheelchair with her oxygen concentrator turned off. Resident did not have a nasal cannula in her nares. She did not appear to be in any distress upon observation and denied any distress upon interview. <BR/>In observation and interview with RN A on 03/08/2023 at 1:06pm revealed RN A stated that Resident #175 was on oxygen yesterday but did not need oxygen today. RN A was observed referencing the electronic medical record and stated that Resident #175 did not currently have any physician orders for oxygen at this time. She stated she was not certain who applied oxygen to Resident #175 yesterday and that the resident was not capable of doing it herself. RN A stated it was required for residents on oxygen to have a physician order for safety purposes and that she would call the physician next to obtain an order. <BR/>In interview with the MDS Coordinator on 03/09/2023 at 10:33am, she stated that it was a shared responsibility to ensure care plans were updated and accurate to reflect the resident's care needs and requirements. She stated it was a team effort, as the DON was responsible for completing the initial or admission care plan and she was responsible to updating resident care plans. She stated the physician orders were what triggered her to update resident care plans and unless a physician order was obtained, it would not initiate her to re-evaluate or update resident care plans. She stated if resident care plans were not updated to reflect resident care needs and requirements, the facility cannot ensure that the best care was provided. <BR/>In interview with the DON on 03/09/2023 at 9:57am she stated oxygen therapy would not necessarily need to be included in Resident #175's care plan, but it would be best if it was on there. She stated that care plans were important as they guide the facility on the care needs and requirements of the resident. She stated it was the MDS nurse's responsibility to ensure updates were completed to resident care plans. <BR/>Record review of facility policy, Comprehensive Person-Centered Care Planning, rev. Jan. 2022, revealed Policy It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

**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 who needs respiratory care was provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Resident #54 and Resident #175) reviewed for respiratory care.<BR/>1.The facility failed to ensure Resident #54 and Resident #175 had oxygen concentrator filters free of sediment and debris. <BR/>2.The facility failed to ensure Resident #175 had physician orders for her oxygen therapy. <BR/>These failures could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met.<BR/>Findings Included:<BR/>Review of Resident #54's Face Sheet, dated 03/08/23, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses (process of identifying a disease, condition or injury) included acute respiratory failure with hypoxia, type 2 diabetes, chronic obstructive pulmonary (lung) disease, major depressive disorder, heart failure, and atrial fibrillation (cardiac dysfunction). <BR/>Review of Resident #54's admission MDS, dated [DATE] stated she was cognitively intact with a BIMS score of 15. She required limited assistance of one staff with bed mobility, extensive assistance of one staff with toileting, and was independent with personal hygiene.<BR/>Record review of Resident #54's physician orders revealed: Change 02 tubing & humidifier bottle every night shift every Sunday with a start date of 02/05/2023. Document Temp/O2 sats and monitor for . cough, new shortness of breath or difficulty breathing . every shift . with a start date of 01/06/2023. O2 at 3 L/min continuous per nasal cannula every shift related to chronic obstructive pulmonary disease . with a start date of 01/09/2023. <BR/>Record review of Resident #54's Comprehensive Care Plan, dated 01/08/2023 revealed that Resident #54 has oxygen therapy r/t respiratory illness . interventions/tasks . oxygen settings: O2 nasal cannula @ 3 LPM continuously humidified.<BR/>Review of Resident #175's Face Sheet, dated 03/08/23, revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included type 2 diabetes, digestive system diseases, chronic obstructive respiratory disease, generalized anxiety, dementia, heart failure. <BR/>Review of Resident #175's Re-entry MDS, dated [DATE] stated she was moderately cognitively intact with a BIMS score of 12. She required extensive assistance of one staff for bed mobility, toilet use, and personal hygiene. <BR/>Record review of Resident #175's physician orders revealed: <BR/>Check & Record O2 Saturation . every shift . with a start date of 03/03/2023.<BR/>Elevate HOB to promote lung expansion . every shift related to chronic obstructive pulmonary disease with (acute) exacerbation with a start date of 03/06/2023. <BR/>No physician orders related to the administration of oxygen therapy were documented during review. <BR/>Record review of Resident #175's Comprehensive Care Plan, dated 12/15/2022 revealed that Resident #175 had no documentation of oxygen therapy, nor any interventions, or goals related to oxygen therapy.<BR/>In observation and interview of Resident #54 on 03/07/2023 at 12:09pm revealed resident sitting in her wheelchair with her oxygen concentrator turned on and the end of the nasal cannula positioned appropriately in her nares. Her oxygen concentrator had filter receptacles on the left and right side of the device. The filter on the left was missing entirely with a thin coat of dust, debris, and sediment present on the plastic where the filter should be located. The filter on the right was present and had a thick layer of dust, sediment, and debris present. Resident #54 stated she was not sure when the oxygen concentrator filter was cleaned, if at all. <BR/>In observation of Resident #54 on 03/08/2023 at 11:24am revealed resident sitting in her wheelchair with her oxygen concentrator turned on and the distal end of the nasal cannula in her nares. The filter on the left was missing entirely with a thin coat of dust, debris, and sediment present on the plastic where the filter should be located. The filter on the right was present and had a thick layer of dust, sediment, and debris present.<BR/>In observation and interview with RN A on 03/08/2023 at 11:29am revealed RN A observed Resident #54's oxygen concentrator filter as dirty. She stated she was not sure when it was cleaned last. She stated that if the oxygen concentrator filters are dirty, infection can be caused to the resident. <BR/>In observation and interview with Resident #175 on 03/07/2023 at 11:53am revealed resident sitting in her wheelchair with her oxygen concentrator turned on and the end of the nasal cannula positioned appropriately in her nares. The filter located on the back of the machine had a thick layer of dust, sediment, and debris present. Resident #175 stated she was not sure when the oxygen concentrator filter was cleaned, if at all. She stated she sometimes needs oxygen upon physical exertion, as she gets short of breath. <BR/>In observation and interview with Resident #175 on 03/08/2023 at 11:23am revealed resident in wheelchair with her oxygen concentrator turned off. Resident did not have a nasal cannula in her nares. She did not appear to be in any distress upon observation and denied any distress upon interview. The filter located on the back of the machine had a thick layer of dust, sediment, and debris present.<BR/>In observation and interview with RN A on 03/08/2023 at 1:06pm revealed RN A stated Resident #175's oxygen concentrator filter was dirty. She stated that night shift [nurses] might be responsible for cleaning it [the filters] but she was not certain. She further stated that Resident #175 was on oxygen yesterday but did not need oxygen today. RN A was observed referencing the electronic medical record and stated that Resident #175 did not currently have any physician orders for oxygen at this time. She stated she was not certain who applied oxygen to Resident #175 yesterday and that the resident was not capable of doing it herself. RN A stated it was required for residents on oxygen to have a physician order for safety purposes and that she would call the physician next to obtain an order. <BR/>In interview with the DON on 03/09/2023 at 9:57am she stated at her facility oxygen is a standing order and if she [Resident #175] needs it [oxygen] she can have it. She further stated that Resident #175 did not need oxygen and she was not sure how that happened. The DON stated that the potential outcome of Resident #175 receiving oxygen without a physician notification and order was not concerning, as oxygen does not hurt her [Resident #175.] She later stated that physician orders are required for resident care and interventions at her facility for safety reasons. She stated that her expectations were for resident oxygen concentrator filters to be present and clean as it was an infection control risk, and that residents can get sick from debris going into resident respiratory systems. She stated that it was the nurse's responsibility to ensure this was performed weekly and as needed. When asked Resident #175's care plan, she stated that oxygen therapy would not necessarily need to be included, but it would be best if it was on there. She stated that care plans were important as they guide the facility on the care needs and requirements of the resident. She stated it was the MDS nurse's responsibility to ensure updates were completed to resident care plans. <BR/>Record review of facility policy, Comprehensive Person-Centered Care Planning, rev. Jan. 2022, revealed Policy It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.<BR/>Record review of facility policy, Oxygen Concentrator filter, rev. 07/24/2021, revealed The facility shall implement and follow cleaning of the Oxygen concentrator filters as follows: 1. Nursing is responsible to clean the concentrators weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of six (Resident #5) residents reviewed for infection control.<BR/>1. <BR/>The facility failed to ensure CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #5 on 03/06/2025.<BR/>This failure could place residents at risk of cross-contamination and development of infections.<BR/>The findings included:<BR/>1. <BR/>Record review of Resident #5's Face Sheet, dated 03/06/2025, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included urinary tract infection (infection in any part of the urinary system) and the need for assistance with personal care. <BR/>Record review of Resident #5's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 03/02/2025, reflected a BIMS (screening tool used to assess cognitive status) assessment was not completed for the resident. Section H reflected Resident #5 was always incontinent of bowel and bladder. <BR/>Record review of Resident #5's Comprehensive Care Plan, dated 02/26/2025, reflected a potential for pressure ulcer development related to hypertension (high blood pressure), the use of pain medication, and the need for assistance with ADLs (collective term for all the basic skills needed in regular daily life) and personal care. One intervention was notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care.<BR/>On 03/06/2025 at 1:40 PM, CNA B was observed providing incontinence care for Resident #5. There were wipes, gloves, and a clean brief on Resident #5's bedside table. CNA B washed her hands in the resident's restroom. CNA B pulled the privacy curtain around Resident #5's bed and told the resident she was going to change her brief. CNA B put on clean gloves, pulled back the sheet and blanket to uncover Resident #5, and unfastened the tabs on the sides of the brief. CNA B used wipes to clean the front of the resident, wiping from the top down. CNA B dropped the wipes into the wastebasket next to her. CNA B removed the wet brief, dropped it into the wastebasket, and changed her gloves. CNA B did not use hand sanitizer or wash her hands when changing gloves. CNA wiped the residents bottom with a clean wipe and dropped it into the wastebasket. The CNA changed gloves, picked up a clean wipe, and wiped the resident's bottom again. CNA B kept the hand she used to wipe the resident's bottom to her side and did not touch anything with that hand. She used the other gloved hand to place the clean brief under Resident #5. The resident rolled to her back and CNA B secured the brief on each side. CNA B removed her gloves and used hand sanitizer from a pump on the wall near Resident #5's bathroom. CNA B took a pair of clean gloves from a box near the resident's door. CNA B put on the gloves and then put a pair of pants on Resident #5. CNA B removed her gloves and used hand sanitizer from the pump on the wall to clean her hands. CNA B carried the bag of trash out of Resident #5's room and disposed of it. <BR/>During an interview on 03/06/2025 at 1:55 PM, CNA B stated she should have used hand sanitizer or washed her hands each time she changed her gloves. CNA B stated it was important for infection control and she did not want to transmit urine to other surfaces. CNA B stated she usually had a small container of hand sanitizer on the bedside table with the other supplies. When asked about facility training, CNA B stated the facility provided in-services often about handwashing and the use of hand sanitizer when caring for residents. She stated it wasn't long ago staff was in-serviced about hand hygiene. CNA B stated she wasn't sure how often to change her gloves when a brief just had urine and not stool on it and ran out of gloves before she put the clean brief on. She stated she was nervous about being watched and missed steps. <BR/>During an interview on 03/06/2025 at 2:10 PM, the DON stated CNA B should have used hand sanitizer or washed her hands each time she changed gloves. The DON stated CNA B had worked in the facility for several years and knew how to provide incontinence care properly. The DON stated CNA B was nervous while being observed providing incontinence care. The DON stated CNA B probably changed gloves too frequently when cleaning the resident and used all her gloves before putting on the clean brief. The DON stated she would in-service staff immediately.<BR/>Review of the facility's policy Perineal Care, revised 05/2007, reflected steps to wash, rinse, and thoroughly dry the resident's skin. The policy did not reflect the use of gloves while providing perineal care. <BR/>Review of the facility's policy Infection Control, revised 10/2022, reflected Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of six (Resident #5) residents reviewed for infection control.<BR/>1. <BR/>The facility failed to ensure CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #5 on 03/06/2025.<BR/>This failure could place residents at risk of cross-contamination and development of infections.<BR/>The findings included:<BR/>1. <BR/>Record review of Resident #5's Face Sheet, dated 03/06/2025, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included urinary tract infection (infection in any part of the urinary system) and the need for assistance with personal care. <BR/>Record review of Resident #5's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 03/02/2025, reflected a BIMS (screening tool used to assess cognitive status) assessment was not completed for the resident. Section H reflected Resident #5 was always incontinent of bowel and bladder. <BR/>Record review of Resident #5's Comprehensive Care Plan, dated 02/26/2025, reflected a potential for pressure ulcer development related to hypertension (high blood pressure), the use of pain medication, and the need for assistance with ADLs (collective term for all the basic skills needed in regular daily life) and personal care. One intervention was notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care.<BR/>On 03/06/2025 at 1:40 PM, CNA B was observed providing incontinence care for Resident #5. There were wipes, gloves, and a clean brief on Resident #5's bedside table. CNA B washed her hands in the resident's restroom. CNA B pulled the privacy curtain around Resident #5's bed and told the resident she was going to change her brief. CNA B put on clean gloves, pulled back the sheet and blanket to uncover Resident #5, and unfastened the tabs on the sides of the brief. CNA B used wipes to clean the front of the resident, wiping from the top down. CNA B dropped the wipes into the wastebasket next to her. CNA B removed the wet brief, dropped it into the wastebasket, and changed her gloves. CNA B did not use hand sanitizer or wash her hands when changing gloves. CNA wiped the residents bottom with a clean wipe and dropped it into the wastebasket. The CNA changed gloves, picked up a clean wipe, and wiped the resident's bottom again. CNA B kept the hand she used to wipe the resident's bottom to her side and did not touch anything with that hand. She used the other gloved hand to place the clean brief under Resident #5. The resident rolled to her back and CNA B secured the brief on each side. CNA B removed her gloves and used hand sanitizer from a pump on the wall near Resident #5's bathroom. CNA B took a pair of clean gloves from a box near the resident's door. CNA B put on the gloves and then put a pair of pants on Resident #5. CNA B removed her gloves and used hand sanitizer from the pump on the wall to clean her hands. CNA B carried the bag of trash out of Resident #5's room and disposed of it. <BR/>During an interview on 03/06/2025 at 1:55 PM, CNA B stated she should have used hand sanitizer or washed her hands each time she changed her gloves. CNA B stated it was important for infection control and she did not want to transmit urine to other surfaces. CNA B stated she usually had a small container of hand sanitizer on the bedside table with the other supplies. When asked about facility training, CNA B stated the facility provided in-services often about handwashing and the use of hand sanitizer when caring for residents. She stated it wasn't long ago staff was in-serviced about hand hygiene. CNA B stated she wasn't sure how often to change her gloves when a brief just had urine and not stool on it and ran out of gloves before she put the clean brief on. She stated she was nervous about being watched and missed steps. <BR/>During an interview on 03/06/2025 at 2:10 PM, the DON stated CNA B should have used hand sanitizer or washed her hands each time she changed gloves. The DON stated CNA B had worked in the facility for several years and knew how to provide incontinence care properly. The DON stated CNA B was nervous while being observed providing incontinence care. The DON stated CNA B probably changed gloves too frequently when cleaning the resident and used all her gloves before putting on the clean brief. The DON stated she would in-service staff immediately.<BR/>Review of the facility's policy Perineal Care, revised 05/2007, reflected steps to wash, rinse, and thoroughly dry the resident's skin. The policy did not reflect the use of gloves while providing perineal care. <BR/>Review of the facility's policy Infection Control, revised 10/2022, reflected Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. <BR/>

Based on observation, interview and record review the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure the Iced Tea Dispenser, located in the facility's only kitchen, had the cover placed on top after filing it with tea. <BR/>This failure could place residents at risk for cross contamination and other air-borne illnesses.<BR/>Findings include:<BR/>Observation and interviews on 03/07/23 at 09:30 AM in the facility's only kitchen revealed an Iced Tea dispenser filled with tea, but it did not have a top on it and it was exposed. The Dietary Manager she stated her dietary aide made the tea. The Dietary Manager asked Dietary Aide A when the tea was made, and he advised her that the tea was made around 6:30 AM. The Dietary Manager and Dietary Aide A acknowledged the container was uncovered for over 3 hours. The Dietary Manager stated they had not served any tea to residents from this dispenser, and it will be thrown out. <BR/>Interview with the Dietary Manager on 03/09/23 at 09:30 AM revealed she expected her staff to ensure the tea dispenser is covered once it had been filled. She stated Dietary Aide A was responsible for filling the Tea dispenser and he should have placed the top on it once it was filled. She stated the risk of not placing the cover on top of the tea dispenser was things could fall into the dispenser and residents could get sick. <BR/>Interview with Dietary Aide A on 03/09/23 at 09:40 AM revealed he was responsible for filling the Tea dispenser the morning of 03/07/23 and he was advised by his Dietary Manager that he failed to place the cover on top of the dispenser. He stated he had just finished making coffee and the tea, and he just forgot to place the top back on the dispenser once he had filled it. He stated the risk of the dispenser not being covered could result in something falling in it and the residents could get sick. <BR/>Interview with Administrator on 03/09/23 at 2:00 PM revealed he was made aware of the Iced Tea Dispenser not having a top placed on it, after just filling it with tea. He stated the expectation is for staff to ensure they are practicing sanitary conditions for residents throughout the facility and the risk to the residents would not be good. <BR/>Record Review of FDA(Food and Drug Administration) Food Code Guide , dated 2017 revealed, When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be:Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD.

Based on observation, interview and record review the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure the Iced Tea Dispenser, located in the facility's only kitchen, had the cover placed on top after filing it with tea. <BR/>This failure could place residents at risk for cross contamination and other air-borne illnesses.<BR/>Findings include:<BR/>Observation and interviews on 03/07/23 at 09:30 AM in the facility's only kitchen revealed an Iced Tea dispenser filled with tea, but it did not have a top on it and it was exposed. The Dietary Manager she stated her dietary aide made the tea. The Dietary Manager asked Dietary Aide A when the tea was made, and he advised her that the tea was made around 6:30 AM. The Dietary Manager and Dietary Aide A acknowledged the container was uncovered for over 3 hours. The Dietary Manager stated they had not served any tea to residents from this dispenser, and it will be thrown out. <BR/>Interview with the Dietary Manager on 03/09/23 at 09:30 AM revealed she expected her staff to ensure the tea dispenser is covered once it had been filled. She stated Dietary Aide A was responsible for filling the Tea dispenser and he should have placed the top on it once it was filled. She stated the risk of not placing the cover on top of the tea dispenser was things could fall into the dispenser and residents could get sick. <BR/>Interview with Dietary Aide A on 03/09/23 at 09:40 AM revealed he was responsible for filling the Tea dispenser the morning of 03/07/23 and he was advised by his Dietary Manager that he failed to place the cover on top of the dispenser. He stated he had just finished making coffee and the tea, and he just forgot to place the top back on the dispenser once he had filled it. He stated the risk of the dispenser not being covered could result in something falling in it and the residents could get sick. <BR/>Interview with Administrator on 03/09/23 at 2:00 PM revealed he was made aware of the Iced Tea Dispenser not having a top placed on it, after just filling it with tea. He stated the expectation is for staff to ensure they are practicing sanitary conditions for residents throughout the facility and the risk to the residents would not be good. <BR/>Record Review of FDA(Food and Drug Administration) Food Code Guide , dated 2017 revealed, When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be:Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide each resident with a nourishable, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences for 1 (Resident # 31) of 24 residents reviewed for needs and preferences.<BR/>The facility failed to ensure Resident # 31 was offered alternative meal options. <BR/>This failure placed residents at risk of not having their needs and preferences honored.<BR/>Findings included:<BR/>A record review of Resident #31's face sheet dated 04/12/2024 reflected she was an [AGE] year-old female and admitted to the facility on [DATE]. Her diagnoses included Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. <BR/>During an interview on 4/09/24 at 11:30 am., Resident #31 stated the food was not appetizing. Resident #1 stated she was unaware of available options, so she does not ask for any. Resident #1 stated she does not eat much. <BR/>The confidential group meeting on 4/10/24 at 10:00 am., revealed, if a food item is not on the menu, it's not an option. The residents stated they were unaware of alternative food options. <BR/>During an observation and interview on 4/10/24 at 11:45 am., Resident #1 was observed sitting in the dining room with her lunch plate sitting on the table. Resident #1 stated, I like the okra but not the seasoned beans and potatoes. Resident #1 stated she requested and was provided a chef salad instead. <BR/>Observation on 04/10/24 at 9:44am revealed the facility meal times and menu were posted on the wall near the dining room and the facility meals times were posted. Observation revealed there was no posting of the alternative meal option, snacks, or the availability of snacks between mealtimes.<BR/>Interview with the Dietary Manager on 04/11/24 at 9:45 am revealed the Fall/Winter menu cycle contained alternative meal options but the Spring menu does not have alternative meal options. The Dietary Manager stated the Spring menu recently started.<BR/>A record review of the facility's policy titled Policy/Procedure-Section: Dietary Services, Subject: Menus and Food dated June 2017 revealed the policy did not reflect alternative meal options for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to retain and use personal possessions for one (Resident #32) of five residents reviewed for personal property.<BR/>The Activity Director utilized residents' personal inventories of crayons/markers for the purpose of group activities.<BR/>This failure could place residents at risk of not being able to retain and use personal property.<BR/>Findings included:<BR/>Review of Resident #32's Face Sheet, dated 05/08/25, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including Attention-Deficit/Hyperactivity Disorder (a type of brain difference that can make it hard to pay attention, finish tasks and sit still) and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities).<BR/>Observation of an interaction between Resident #32 and the Activity Director on 05/06/25 at 10:30AM revealed the Activity Director asked Resident #32 if he could borrow from her personal inventory of crayons/markers for resident activities. Resident #32 stated she was very particular about her crayons/markers and did not want them to return broken after being used by other residents. The Activity Director agreed that broken crayons/markers had been an issue at the facility, and he told Resident #32 to disregard the request.<BR/>During an interview with Resident #32 on 05/06/25 at 10:36AM, she stated this was the first time the Activity Director had requested to utilize her personal belongings for resident activities. She stated she was not bothered by this request.<BR/>During an interview with the Activity Director on 05/06/25 at 12:50PM, he stated he had been requesting and utilizing residents' personal inventories of crayons/markers for resident activities for the past week. He stated the facility's inventory of crayons/markers were smashed up and/or broken. The Activity Director stated he did not feel as though there was an issue or a risk in asking to utilize residents' personal belongings for wide-spread group activities.<BR/>During an interview with the Director of Nursing on 05/07/25 at 2:00PM, she stated the expectation was for the Activity Director to utilize the facility's supplies for activities. She stated it was not appropriate for the Activity Director to request to utilize a resident's personal inventory of crayons/markers for a wide-spread group activity. The Director of Nursing stated the risk in doing so was that the request could be misconstrued as misappropriation of resident property.<BR/>Review of the facility's Resident Rights policy, dated 07/2017, reflected, .As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States .