Arlington Heights Health and Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 3 of 10 residents (Residents #2, #3, and #4) reviewed for abuse, neglect, and exploitation.<BR/>The facility failed to ensure Resident #2, #3, and #4 were free of abuse from Resident #1. Resident #1 hit Resident #2 and #3 with her doll in the face and head when she was upset and punched Resident #4 in the stomach after she approached her boyfriend. <BR/>An Immediate Jeopardy (IJ) was identified on 02/11/25 at 3:47 PM. The IJ template was provided to the facility on 2/11/25 at 4:00 PM. While the IJ was removed on 02/13/25, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. <BR/>This failure could place residents at risk of physical abuse from other residents. <BR/>Findings included:<BR/>Record review of Resident #1's Quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), stroke, seizure disorder, and profound intellectual disabilities. Resident #1 was not able to complete a BIMS due to her impaired cognition and she was rarely understood by others and rarely/never understood others. The MDS further reflected Resident #1 was independent with walking and did not have any impairment to upper and lower extremities. <BR/>Record review of Resident #1's care plan initiated on 06/16/23 reflected she had the potential to demonstrate physical behaviors related to poor impulse control. Resident #1 had poor impulse control and would utilize her baby doll to make contact with other residents in an aggressive way and would also get upset and physical when felt that others were talking to her boyfriend. Intervention included to analyze key times, places, circumstances, triggers, and what de-escalates the behaviors and document. Other interventions included to intervene before agitation escalated and guide away from source of distress and immediately intervene to protect the residents involved and call for assistance. <BR/>Record review of Resident #2's Annual MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), stroke, hemiplegia (medical condition that causes paralysis or weakness on one side of the body), reduced mobility, and difficulty in walking. Resident #2 had a BIMS of 13 which indicated his cognition was intact. The MDS also reflected the resident had impairment on one side to his upper extremity and impairment on both sides to his lower extremity and used a wheelchair for mobility. <BR/>Record review of Resident #3's Quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included coronary artery disease (condition in which the arteries that supply blood to the heart muscle become narrowed or blocked), stroke, difficulty in walking, and muscle weakness. Resident #3 had a BIMS of 8 which indicated his cognition was moderately impaired. The MDS further reflected the resident had impairment on one side to upper and lower extremities. <BR/>Record review of Resident #4's annual MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included heart failure, stroke, difficulty in walking, weakness and history of falling. Resident #4 had a BIMS of 7 indicating her cognition was severely impaired. The MDS further reflected the resident was independent with walking and most all ADL's. <BR/>Record review of the facility's Provider Investigation Reports reflected the following:<BR/>12/05/24<BR/> On 11/25/24, [Resident #2] was sitting one table down from [Resident #1] in the main dining room. According to [Resident #2], [Resident #1] threw her doll at him. He in turn grabbed the doll and threw it on the floor. [Resident #1] got up and picked her doll up and started crying. [Housekeeper D] saw the altercation and intervened. According to her statement, [Resident #1] hit [Resident #2] several times but after interviewing [Resident #2], he was only struck by the doll when it was thrown at him ]<BR/>01/23/25<BR/>[Resident #3] was sitting one table down to [Resident #1] in the dining room during breakfast. After breakfast was complete, [Resident #1] was tapping her foot on the floor and [Resident #3] asked her to stop tapping so loud because he could not hear the TV. [Resident #3] turned back around to look at the TV and [Resident #1] took her doll and hit [Resident #3] in the forehead. Another resident saw the altercation and went to tell the nurse <BR/>01/26/25<BR/>[Resident #1] was sitting in her usual spot in the dining room. [Resident #4] went up to [Resident #1] to ask her a question. [Resident #1] responded by saying that is my boyfriend don't talk to my man and punched her with a closed hand. [Resident #4] retaliated by hitting [Resident #1]. Residents were pulling hair. Staff intervened and separated both residents Skin assessments were conducted with [Resident #4] showing a quarter size bruise to inner upper left arm. No injuries to [Resident #1] <BR/>Record review of Resident #1's progress notes on the following dates reflected:<BR/>10/21/24 - documented by the Social Worker<BR/>Visit with [Resident #1] regarding the incident where she threw her baby doll at another resident. She did not act like she knew what this SW was talking about. SW discussed with her that her baby is little and can get hurt. She needs to be a good Mom and not throw her baby. She said she knew not to hurt baby <BR/>11/15/24 - documented by LVN CC<BR/>Resident continues with loud laughing, taunting other residents in dining room, yelling and crying @ random intervals. Was recently started on Klonopin in afternoon by psych <BR/>11/16/24 - documented by LVN E<BR/>Res in dining room yelling and laughing at other residents, CNA approached and told her to go to her room, res then ran up to cna and grabbed her by her hair, and started hitting her in the face. Another staff member intervene and separates Res from staff <BR/>11/25/24 - documented by LVN CC<BR/>Noted resident sitting in dining room, sticking her tongue out at several male residents and yelling at them get out of here, I don't like you and flipping them off with the middle finger of her left hand. Resident's chair was moved so that her back was turned toward the male residents and toward the TV so she can continue watching the program that was on. She was instructed that this behaviour is not acceptable and she can't remain in the dining room if she continues to act out toward other residents in this way. Resident stated I won't do it and was holding her baby doll and smiling as writer left at table<BR/>Observation and interview on 02/11/25 at 9:58 AM of Resident #1 revealed she was sitting at a dining room table next to another male resident. The resident had 7 stuffed animals and two dolls in a chair next to her. The two dolls had a soft, cloth stuffing and the hands, feet, and head were a firm plastic/rubber material. Attempted to interview Resident #1 but she was only able to give simple 2 to 3 word sentences and did not recall any incident or altercations with other residents. <BR/>Observation and interview on 02/11/25 at 10:05 AM with Resident #2 revealed he was in his room. He was slowly self-transferring from his wheelchair to the bed and appeared to have paralysis to the left side of body. Resident #2 was asked about the incident with Resident #1 and he said he was in his room and Resident #1 approached his door and took a few steps inside and threw her doll at him. Resident #2 said the doll hit his face so he then threw the doll back at Resident #1 and she then began to yell and curse. Resident #2 also said there was an incident where Resident #1 pushed his wheelchair with him in it against the wall but he was not hurt and there was no one around at that time nor did he tell anyone. Resident #2 further stated he was not afraid of Resident #1 just rather he was irritated at the things she did. He described Resident #1 as a rude person who cursed and yelled at others so he now preferred to keep his distance and did not go out to the dining room much to avoid Resident #1. <BR/>Observation and interview on 02/11/25 at 10:52 AM with Resident #4 revealed she was in her room sitting on the side of her bed. She was asked about the incident with Resident #1 and she said she had approached Resident #1's male friend that was sitting with her at the dining room table and asked him for a quarter. At that time Resident #1 told Resident #4 to get away from her man and then stood up and punched her in the stomach so she then in return pulled Resident #1's hair and hit her back. Resident #4 stated she was not afraid but if Resident #1 was going to hit her, she was going to hit her back. <BR/>Observation and interview on 02/11/25 at 10:22 AM with Resident #3 revealed he was sitting in the dining room listening to bible study and eating a snack. The resident was observed using a wheelchair and getting up to walk short distances. Resident #3 said Resident #1 has history of acting out in the mornings and said the day of the incident, 01/23/25, Resident #1 was hitting the bottom of the dining room table and he asked her to stop and that is when Resident #1 came around and hit him in the head with her doll. Resident #3 said the doll hurt his head when it made contact with his forehead because the doll contained some hard parts. Resident #3 further stated Resident #1 would get upset with different people when they would talk to her boyfriend who sat at her table and Resident #1 always started the fights. Resident #3 said he was not afraid of Resident #1 but the residents were annoyed with her behaviors. <BR/>Interview on 02/11/25 at 12:08 PM with Housekeeper D revealed during the incident with Resident #2 she was across the hall and heard yelling but could not make out what was being said. As she turned she saw Resident #1 hitting Resident #2 on the head with her baby doll. This incident occurred outside of the rooms, as they used to be neighbors. Housekeeper D said she separated the residents and went to report the incident to the Administrator. The Housekeeper said had heard Resident #1 yell at other residents but that was the first time she had seen her become physical with them. <BR/>Interview on 02/11/25 at 12:13 PM with LVN D revealed she was told by CNA F that Resident #1 was in the dining room, on 11/16/24, and she believed Resident #1 might have been trying to hit someone with her baby doll when CNA F tried to intervene. CNA F told her Resident #1 then grabbed CNA F's hair and began to hit her in the face with her other hand. LVN D further stated Resident #1 had a history of becoming verbal with others especially when other residents tried to talk to her male friend that sat with her at the dining room table. <BR/>Interview on 02/11/25 at 12:29 PM with CNA F revealed she approached Resident #1 and told her to go to her room so she could change her. Resident #1's male friend told Resident #1 she needed to go with CNA F and CNA F touched her male friend on his shoulder and Resident #1 jumped up out of her chair and grabbed CNA F by the hair and began to punch her. CNA F said that had been the first time Resident #1 had hit her and it all happened because Resident #1 would become defensive if anyone was around her male friend. CNA F further stated Resident #1 had a history of hitting others with her baby dolls and cursing at staff and residents all day long. CNA F said it was difficult to prevent Resident #1 from hitting and yelling at others because she would not stay in her room and stayed in the dining room all day long. If and when they tried to redirect Resident #1 she would begin to yell and curse. CNA F also said Resident #2 now preferred to stay in his room to avoid Resident #1 and others resident would also get frustrated and leave the dining room so they did not have to hear Resident #1 yell out. <BR/>Interview on 02/11/25 at 12:39 PM with the Weekend Supervisor revealed during the incident between Resident #1 and Resident #4, she was in the wound care office next to the dining room when she heard Resident #1 screaming. When they heard Resident #1, they usually knew something was going on because the resident had a history of swinging at people. When the Weekend Supervisor entered the dining room Resident #4 had Resident #1 by her hair and they were immediately separated and Resident #1 was put on 1:1 safety checks. The Weekend Supervisor said she had not worked at the facility long but had been told Resident #1 had a history of hitting but she had never witnessed it prior to that incident. Resident #1 would sit in the dining room all day and yell and scream random things at others and they would try to redirect the resident to her room but she always refused to go. The Weekend Supervisor further stated everyone just had to work around Resident #1. <BR/>Interview on 02/11/25 at 12:50 PM with the Social Worker revealed they were seeing some regression with Resident #1's developmental disability and the resident had begun to throw her baby dolls at others and there were not patterns to her behaviors. The Social Worker described Resident to be very territorial of her space and of her male friend that sat with her and they tried to redirect her behavior if they saw it coming. She said Resident #1 has previously been treated for a UTI and they had discussed her behaviors with the PASSR representative. The Social Worker further stated she had spoken to Resident #1 after her physical incidents but due to her cognition the resident did not really seem to recall the incidents and forgot as soon as they occurred. <BR/>Interview on 02/11/25 at 1:32 PM with the DON revealed he had only been working at the facility for less than 2 months and he had been made aware of the incidents between Resident #1 and Residents #3 and #4. The DON said they had inserviced staff in the past about techniques to deescalate physical altercations between the residents. Staff were also to frequently monitor Resident #1 and they had just adjusted the resident's medications. The DON said they had not tried to take Resident #1's dolls because that would infringe on her rights but they had encouraged her to not have so many baby dolls in the dining room. <BR/>Interview on 02/11/25 at 1:42 PM with the Administrator revealed they had met and discussed to limit how many dolls Resident #1 kept and to make sure staff frequently monitored to prevent altercations with other residents. The Administrator said there had not been any injuries as a result of the incidents and also said Resident #1 would not let go of her baby dolls because she was really attached to them. <BR/>Record review of the facility's policy titled Abuse/Neglect revised 03/2018 reflected the following:<BR/>The resident has the right to be free of abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Resident should 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, family members or legal guardians, friends, or other individuals <BR/>An Immediate Jeopardy/Immediate Threat was identified on 02/11/25. The Administrator, DON and the Regional Nurse Consultant were notified of the Immediate Jeopardy on 02/11/25 at 3:43 PM. The IJ template was provided to the facility on [DATE] at 4:00 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. <BR/>The facility's Plan of Removal for the Immediate Jeopardy was accepted on 02/12/25 at 9:44 AM and reflected the following:<BR/>Plan for Removal: F600 Failure to Prevent Abuse and Neglect<BR/>Interventions:<BR/>Resident #1 was immediately placed on 1:1 supervision on 2.11.25 with facility staff.<BR/>Resident #1 discharged to alternate facility with guardians' approval 2.11.25.<BR/>Resident #1's baby doll with the plastic heads were immediately removed from Resident #1's possession and from resident #1's room on 2.11.25 by regional compliance nurse. <BR/>Resident's #1's care plan was reviewed by Regional Compliance Nurse for appropriate interventions to prevent resident and staff altercations on 2.11.25. <BR/>Resident #1's care plan was updated by the Regional Compliance Nurse to reflect additional interventions of 1:1 supervision and removal of baby dolls with hard plastic pieces on 2.11.25.<BR/>IDT team will schedule a care plan meeting with Responsible Party, Physician, and Resident to review and evaluate interventions to prevent repeated altercations with staff and residents starting 2.11.25. <BR/>The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics. Completed 2.11.25<BR/>o <BR/>Abuse and Neglect- Prevention of abuse/neglect and ensuring interventions listed on the care plan are implemented to prevent abuse.<BR/>o <BR/>Behavior Management Policy- Managing behaviors and intervening appropriately. <BR/>The Medical Director was notified on 2.11.25 of the immediate jeopardy. <BR/>An ADHOC QAPI was held with the IDT Team on 2.11.25 to discuss the immediate jeopardy and plan of removal. <BR/>In-services <BR/>All staff will be in-serviced on the following topics below by the Administrator, Regional Compliance Nurse, DON, and ADON to prevent resident to resident abuse and ensure appropriate response to aggressive behaviors. In-servicing initiated on 2.11.25 and will be completed by 2.12.25. All staff who are not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to starting their shift. <BR/>o <BR/>Abuse and Neglect- Prevention of abuse/neglect and ensuring interventions listed on the care plan are implemented. <BR/>o <BR/>Behavior Management Policy- Managing behaviors and intervening appropriately.<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>Observation on 02/12/25 at 10:04 AM revealed Resident #1 was no longer at the facility and had been discharged to another nursing facility. <BR/>Record review of Resident #1's progress notes dated 02/11/25 documented by LVN C reflected the following<BR/>Resident transferred to sister [facility] due to behaviors. Vitals within normal limits, medication and belongings sent with her. Guardian notified of transfer <BR/>Record review of the facility's inservices titled Abuse/Neglect dated 02/11/25 reflected all facility staff were educated on the different types of abuse, abuse prevention and ensuring interventions were implemented to prevent abuse, and managing behaviors and intervening appropriately. If staff are to witness resident to resident abuse, they are to immediately intervene, ensure the residents are safe and report the incident to the Administrator. To prevent abuse, staff are to redirect residents away from aggressive or agitated behaviors and watch for signs of aggression. <BR/>Interviews on 02/12/25 at 1:02 PM to 02/13/25 at 2:35 PM from staff from various shifts were the Administrator, DON ADON P, Weekend Supervisor, Social Worker, Transportation, BOM , Medical Records, Dietary Manager, PTA, OT, LVN A, LVN C, Housekeeper D, LVN E, CNA F, LVN G, MA I, MDS Nurse K, MDS Nurse L, CNA N, CNA O, MA Q, CNA R, Housekeeper T, Housekeeper U, CNA V, [NAME] W, [NAME] X, MA, Z, CNA AA, and CNA BB. All staff were able to identify the following:<BR/>- <BR/>The different types of abuse.<BR/>- <BR/>What to do if they witness resident to resident abuse.<BR/>- <BR/>What signs to watch for in residents to prevent resident to resident abuse/behaviors<BR/>- <BR/>Who to report any incidents of abuse<BR/>- <BR/>All staff stated there were no other residents they were aware of that were having consistent physical altercations in the facility. <BR/>The Administrator was notified on 02/13/25 at 3:30 PM, the Immediate Jeopardy was removed. While the IJ was removed on 02/13/25, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for one (Resident #3) of five resident rooms reviewed for accidents and hazards. <BR/>The facility failed to ensure the closet doors in Resident #3's room were maintained in a safe and functional manner.<BR/>This failure could place residents at risk of accidents or injury. <BR/>Findings included:<BR/>Record review of Resident #3's face sheet dated 01/17/24 indicated the resident was a [AGE] year-old male, initially admitted on [DATE], and readmitted on [DATE] with diagnoses that included weakness, reduced mobility, contracture (shortening of muscles) unspecified joint, contracture unspecified knee, muscle weakness, history of falling, age related nuclear cataract, bilateral (major cause of blindness), epilepsy (nerve cell activity in the brain is disturbed causing seizures). <BR/>Record review of Resident #3's MDS assessment dated [DATE] indicated Resident #3 had moderately impaired cognition with a BIMS score of 9. The resident's active diagnoses included cataracts, epilepsy, and anxiety disorder. Resident #3 had vision impairment and had behaviors with difficulty focusing attention and disorganized thinking. Resident #3 required extensive assistance with two people for toileting, bed mobility and transfers. He required set up assistance for eating, and limited assistance with one person for hygiene, and he used a wheelchair for mobility. <BR/>Record review of Resident #3's current, undated care plan revealed Resident #3 was at risk for frequent falls related to weakness and unsteady gait. The care plan reflected: Goal: Resident #3 will minimize risk and injury potential. Intervention: Resident #3 will receive assistance out of bed, educate and redirect resident about slouching in wheelchair, anticipate resident needs and wants, encourage resident not to transfer himself without assistance, and keep bed in low position during transfers.<BR/>Observation and interview on 01/17/24 at 10:17 AM revealed Resident #3 in his room, in his wheelchair. Resident #3 communicated that he recently had a fall out of bed and injured himself. Resident #3 stated he was blind and had a hard time seeing out of both eyes. During the interview, Resident #3 was observed attempting to wheel himself out of his room. Resident #3 was observed bumping his chair first into the wall and then heading towards his closet. Observation of the closet revealed one closet door leaning up against the back wall and another door hanging off the closet hinge. <BR/>Interview on 01/17/24 at 1:07 PM with Medication Aide F revealed she worked with Resident #3. She stated the resident would yell and scream when he wanted something, so she would hear him and assist him with his needs. Most of the time he was screaming because he wanted to get out of his room or wanted a snack or water. Medication Aide F stated she did not know if Resident #3 was blind, but she knew the resident's vision was impaired. She stated the resident continually repeated that he was. Since the resident was having a hard time with his vision, his door was always left open. She stated she was aware of the closet doors being damaged. Medication Aide F stated the doors often were damaged due to Resident #3's impaired vision. She stated Resident #3 became anxious when he attempted to leave his room and thought the closet doors were an exit. She stated Resident #3 would try to exit through the closet causing the doors to become damaged or come off the hinge. She stated once the closet doors were damaged, she would inform the nurse. According to Medication Aide F, having damaged closet doors or the doors hanging off the hinges could cause a risk to Resident #3 becoming injured if the door fell off the hinge and hit Resident #3 in the head or caused other injury. <BR/>Interview on 01/17/24 at 1:48 PM with ADON C revealed he began working at the facility in March 2023. He stated Resident #3 at that time was able to self-propel in his wheelchair without any issues. However, recently Resident #3 had become confused and stated he was having issues with his vision. ADON C stated within the last couple of weeks Resident #3 had been running into doors and walls while in the facility. ADON C stated Resident #3 had been stating he was blind. According to ADON C, Resident #3 had been running into his closet door thinking he was exiting his room, causing the doors to be torn down. ADON C stated he thought maintenance replaced the doors back on the hinges. According to ADON C, having the closet doors hanging off the hinges or leaning up against the wall in the resident room would cause a hazard to Resident #3 causing possible injuries. ADON C stated Resident #3's current condition of having impaired vision could cause Resident #3 to run into the closet door causing the doors to fall on him causing him to have head or bodily injury. <BR/>Interview and observation on 01/17/24 at 1:57 PM with the Maintenance Supervisor revealed one closet door leaning up against the back wall in Resident #3's room and a second door hanging off the closet hinges at the top of the closet entry way. According to the Maintenance Supervisor, he had replaced the closet doors in Resident #3's room on several occasions. The Maintenance Supervisor stated he was not sure how to secure the doors on the closet to prevent Resident #3 from bumping into the doors and tearing them down. He stated he thought about removing the doors; but he did not want to be out of compliance. According to the Maintenance Supervisor, not having the doors secured on the hinges would place Resident #3 at risk of injury, due to him having impaired vision. <BR/>Interview on 01/17/24 at 1:59 PM with ADON D revealed Resident #3 had recently become physically weaker and his vision had become impaired causing him to need more assistance from staff. ADON D stated Resident #3 had an eye appointment last week resulting with him not being a candidate for surgery. <BR/>Interview on 01/17/24 at 2:12 PM with CNA E revealed Resident #3 made his needs known by yelling help or screaming out. CNA E stated Resident #3 rarely used the call light for assistance because he was not able to see that well. According to CNA E, Resident #3's closet doors were broken for a while, but she was not sure how long. CNA E stated she had not seen Resident #3 run into the doors while in his wheelchair. According to CNA E, she was alerted that Resident #3 had a recent fall, crawled to the wall or the closet door causing injury to his eye. CNA E stated she had reported the doors off the hinge in Resident #3's room by alerting the nurse. CNA E stated not having the doors replaced could cause Resident #3 to injure himself. <BR/>Interview on 01/17/24 at 5:37 PM with the DON revealed Resident #3 did have a fall that resulted in an injury last week. Resident #3 had impaired vision which caused him to keep his eyes closed most of the time. The DON stated Resident #3 did have a history of scooting around on the floor until someone heard him yelling out for help. According to the DON, she was aware Resident #3's doors were off the closet and in a safe area. She was not aware they were in his room. The DON stated maintenance had placed the doors back on the door at this time and requested they be replaced in a manner they could not be easily removed by Resident #3. The DON stated she did not know how often the closet doors were checked by maintenance. The DON stated due to the closet door continually being damaged hanging off the hinges perhaps Resident #3's care plan should be updated, and the closet doors removed. The DON stated not having the closet doors secured could cause the doors to fall on his head. <BR/>On 01/17/24 at 5:00 PM, the Administrator was asked to provide the facility's policy; however, the policy was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plans for 3 (Residents #1, #2, and #3) of 5 residents reviewed for comprehensive care plans in that:<BR/>The MDS Coordinators failed to individualize the care plans, to include interventions, for Residents #1, #2, and #3.<BR/>This failure could place the residents at risk of receiving the individualized care they required.<BR/>Findings included:<BR/>Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of right lower leg. morbid obesity, heart failure, and asthma.<BR/>Review of Resident #1's admission MDS assessment, dated 01/04/24, revealed a BIMS score of 10 indicating she had mild cognitive impairment. Her Functional Status indicated she required assistance with most of her ADLs. <BR/>Review of Resident #1's care plan, dated 01/01/24 revealed her care plan had not been individualized. Resident #1 has a rash (specify location, type, and extent) r/t; The resident is risk for falls r/t; and The resident has potential fluid deficit r/t. The majority of Resident #1's Focuses as well as Interventions had not been individualized. <BR/>Review of Resident #2's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included open wound to scalp post cancer surgery, heart disease, and high blood pressure. <BR/>Review of Resident #2's admission MDS assessment, dated 02/18/24, revealed a BIMS score of 13, indicating he was cognitively intact. His Functional Status indicated he was independent in most of his ADLs except eating and hygiene. <BR/>Review of Resident #2's care plan, dated 02/16/24, revealed his care plan had not been individualized. Resident #2 has a pacemaker (specify type) r/t; The resident is at risk for falls r/t; and The resident has hypertension r/t. The majority of Resident #2's Focuses and Interventions had not been individualized. <BR/>Review of Resident #3's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, diabetes, and alcoholic liver disease. <BR/>Review of Resident #3's admission MDS assessment, dated 02/15/24, revealed a BIMS score of 9 indicating he had moderate cognitive impairment. His Functional Status indicated he required minimal assistance with his ADLs. <BR/>Review of Resident #3's care plan, dated 02/09/24, revealed his care plan had not been individualized. Resident #3 is at risk for falls r/t; The resident has a communication problem r/t; and The resident has potential fluid deficit r/t. The rest of Resident #3's Focuses and Interventions had not been individualized. <BR/>Interview on 04/04/24 at 3:00 PM with the MDS Coordinator revealed she had been in her position since August 2023. She stated when she and the other Coordinator took over the roles the MDSs, care plans, and PASRR were all a mess. She stated the two of them had been trying to catch things up. The MDS Coordinator stated care plans should all be individualized to each resident. She stated the DON or the ADON enter the baseline care plan which triggers alerts in the comprehensive care plan. The MDS Coordinators were then responsible for completing the comprehensive care plan after they completed the MDS. The MDS Coordinators stated Residents #1, #2, and #3 were all being worked on, but had not been completed. <BR/>Interview on 04/04/24 at 3:11 PM with the DON revealed each department (Dietary, Rehabilitation, etc .) add their part of the care plan, and the MDS Coordinators were responsible for keeping them updated with information provided during the morning meetings. The DON stated the risk to residents to not have individualized care plans, staff might not know what care the resident needed. The DON stated she was ultimately responsible for everything in the facility including MDS and care plans, but she relied on everyone doing their job properly. There was no true oversight of each department. <BR/>Review of the facility's current, undated Comprehensive Care Planning policy reflected: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his preferences and goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who enters the facility with an indwelling catheter receives appropriate treatment and services for 1 of 3 (Resident #1) reviewed for catheters.The facility failed to obtain physician orders to address the treatment and services that were to be provided to care for Resident #1's Foley catheter.The failure placed residents at risk for catheter complications and infection. Findings included: Record review of Resident #1's MDS dated [DATE] reflected the resident was [AGE] year-old male admitted to the facility on [DATE] and discharged [DATE]. The MDS reflected Resident #1's cognition was intact with a BIMS score of 15, and his diagnoses included quadriplegia (a condition characterized by the loss of function or paralysis in all four limbs and sometimes the torso), neurogenic bladder (a dysfunction that results from interference with the normal nerve pathways associated with urination), and Stage 2 pressure ulcer of the right buttock (a shallow open wound, where the skin has broken down, revealing the dermis (the second layer of skin). The MDS reflected the resident was dependent upon staff for toileting hygiene, and he had a catheter for the entire 7 days of the assessment. Record review of Resident #1's care plan, dated 05/16/25, reflected it did not address the resident's Foley catheter.Record review of Resident #1's physician orders, dated 05/09/25, reflected there were no physician orders addressing the resident's Foley catheter.Record review on 07/15/25 at 11:07 AM of the Nurse Practitioner Notes, dated 05/21/25, reflected: ensure catheter securement device is in place to prevent pressure.Interview on 07/15/25 at 1:40 PM with LVN A revealed Resident #1 had been a resident at the facility for over a month. She stated she was aware he had a Foley catheter, but she was not sure of the orders to change the Foley catheter. She stated it was the admitting nurse's responsibility to put orders in and other nurses to notify the doctor if the orders were missing. She stated she had not noticed the Foley catheter orders were missing. She stated failure to have orders could result in the resident missing care and could cause infection. She stated she had done in-service training on documentation of orders, but she could not remember when.Interview on 07/15/25 at 3:18 PM with the Regional Compliance Nurse revealed her expectation was that the admitting nurse would ensure the orders were put in the electronic records system. She stated it was her responsibility and the ADON to follow-up the next morning and ensure all orders were correct, accurate, and entered on the MAR and TAR. She confirmed the orders were missed. She stated the facility failed to follow-up with the primary physician to get the Foley catheter orders from admission, since he did not come with Foley orders on his discharge orders. She stated failure to have orders could lead to the resident missing care like having his Foley catheter changed. She stated Foley catheters were only changed as needed or as instructed by the physician. She stated the facility had done training regarding the documentation of orders, but she did not provide evidence of the training. Interview with the ADON on 07/15/25 at 4:22 PM revealed it was her responsibility to follow-up on admissions and ensure the orders were correct. She stated she was also supposed to follow-up when there was a new order. She stated the orders for the resident's Foley catheter were missed. The risk of not having a physician order for the Foley catheter care was that it could lead to infection.Record review of the facility's Physician's Orders policy, dated 2015, reflected: Nurse will review the order and if needed contact the prescriber for any clarification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that an alleged violation involving abuse was reported immediately but not later than 2 hours after the allegation was made to the Administrator of the facility for 1 of 3 residents (Resident #1) reviewed for abuse. <BR/>LVN A failed to immediately report an abuse allegation to the Administrator, who was the facility's abuse coordinator, when she overheard CNA B verbally abusing Resident #1 in early May 2025.<BR/>This failure could have caused residents to experience abuse by staff. <BR/>Findings included: <BR/>Record review of Resident #1's admission Record, dated 06/04/25, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #1's Quarterly MDS Assessment, dated 04/01/25, reflected she had a BIMS score of 06, which indicated severe cognitive impairment. Her active diagnoses included Non-Alzheimer's Dementia (a general decline in cognitive abilities that affects a person's ability to perform everyday activities), Schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), and Borderline Personality Disorder (a mental health condition that affects the way people feel about themselves and others).<BR/>Observation and attempted interview on 06/04/25 at 10:00 AM with Resident #1 revealed she was lying in bed in her room. Resident #1 did not answer any questions the surveyor asked, instead she just stared at the surveyor. <BR/>Interview on 06/04/25 at 9:31 AM with LVN A revealed she worked with Resident #1 on the secured unit. LVN A said she saw CNA B go in to provide care to Resident #1 one day in early May 2025 and overheard the aide tell the resident, You need to get your pissy ass back in bed. LVN A said she wrote out a witness statement and turned it into the Administrator who was the Abuse Coordinator for the facility since this was an instance of verbal abuse. <BR/>Interview on 06/04/25 at 10:15 AM with the Administrator revealed he had not received any witness statements regarding an abuse allegation and CNA B or Resident #1. <BR/>Interview on 06/04/25 at 10:52 AM with CNA B revealed she cared for Resident #1 but had never abused her. CNA B said she never said anything verbally abusive towards Resident #1 or any other resident. CNA B said she felt like LVN A was trying to get her in trouble or fired because they did not get along as co-workers. CNA B said she no longer worked with Resident #1.<BR/>Follow-up interview on 06/04/25 at 11:30 AM with LVN A revealed she wrote a witness statement informing the Administrator about the verbal abuse she witnessed by CNA B towards Resident #1. LVN A said the Administrator's door was closed at the time, but she put it under his door. LVN A said she never received any follow-up from the witness statement but did not bring it up again to the Administrator. LVN A said she thought she followed the procedure by filling out the witness statement and giving it to the Administrator. <BR/>Interview on 06/04/25 at 12:57 PM with the Interim DON revealed when she interviewed LVN A about the abuse allegation regarding CNA B and Resident #1, LVN A said she wrote a witness statement and left it under the Administrator's door. The Interim DON said LVN A should have called the Administrator instead of just writing a witness statement, so she was immediately in-serviced on the facility's abuse policy. <BR/>Interview on 06/04/25 at 2:26 PM with the Administrator revealed he interviewed LVN A about the abuse allegation regarding CNA B and Resident #1. The Administrator said LVN A told him she wrote a witness statement and then slipped it under his door while he was out on PTO. The Administrator said when he returned from PTO, there was nothing under his door. The Administrator said all staff knew to report all abuse to him immediately, which usually meant they would call or text him; even if he was out on leave or out of the building. The Administrator said the purpose of staff immediately reporting abuse allegations to him was to protect the residents from further abuse. The Administrator said if staff did not immediately report an abuse allegation to him then the same situation could happen with another resident. The Administrator said all staff were responsible for ensuring they reported any allegation of abuse to him immediately. The Administrator expected that all staff immediately report any abuse allegation to him. <BR/>Record review of the facility's Abuse/Neglect policy, revised 03/29/18, reflected: <BR/> .E. Reporting .1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator [sic], state and/or adult protective services .2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were treated with respect, dignity, and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 8 residents (Resident #5) reviewed for resident rights. <BR/>The facility failed to treat Resident #5 with dignity when staff failed to assist the resident with colostomy care, resulting in it leaking and causing her to feel embarrassed in front of her roommate. <BR/>This failure could cause the resident embarrassment and a decreased sense of self-worth.<BR/>Findings included:<BR/>Record review of Resident #5's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke affecting the rights side of her body, legal blindness, and rectal cancer requiring the creation of a colostomy (opening in the intestine to drain feces into a bag). <BR/>Record review of Resident #5's quarterly MDS, dated [DATE] reflected a BIMS score of 10 indicating she was moderately cognitively impaired. Her Functional Status reflected she required set-up and clean up assistance with her toileting hygiene. Her Bowel and Bladder assessment indicated she had an ostomy. <BR/>Record review of Resident #5's care plan, dated 12/22/24, reflected she had a visual impairment related to being legally blind, and ADL self-care deficit related to paralysis, and had an ostomy. <BR/>Interview on 02/11/25 at 9:50 AM with Resident #5 revealed she often had to change her briefs because the staff took too long to respond to her call light. Resident #5 stated she thought staff knew if they waited, she would do it herself. She stated she did need staff assistance to make sure she was completely clean, and she needed assistance with applying her colostomy bag to make sure it was on properly to prevent it from leaking. Resident #5 stated in the evening on 02/07/25 her colostomy bag was leaking, and she had tried to clean up with her wipes. She stated CNA B answered her call light and told her he would have to get the nurse to help her. She stated LVN A came to her room and told her she could not help because she was the only nurse monitoring the evening meal in the dining area. She stated LVN A put a new colostomy bag on the resident's overbed table and left. Resident #5 stated she waited for about 20 minutes and no one came to help her, so she applied the bag herself and cleaned herself up. She stated she must not have applied it correctly because later that evening the bag began to leak again. Resident #5 stated her colostomy was very smelly when being changed. She stated she was embarrassed by it leaking because she had a roommate, and the door to the hall was open. Resident #5 stated she usually changed it every other day when she was taking her shower to limit the smell affecting others. She stated a nurse from the night shift helped her secure the bag properly. <BR/>Interview on 02/11/25 at 3:00 PM with CNA B revealed he responded to Resident #5's call light on 02/07/25. He stated the resident's colostomy bag was leaking and needed to be changed. He stated he told Resident #5 he would have to get the nurse as that was beyond his scope of practice. He notified LVN A, who was monitoring residents in the dining area, and she went to check on the resident. <BR/>Interview on 02/11/25 at 3:25 PM with LVN A revealed she was called to Resident #5's room by CNA B from the dining area where she was monitoring the evening meal. LVN A stated Resident #5 told her she needed a new colostomy bag, so she put one on the resident's table. LVN A told her she could not help because she had to get back to the dining area. LVN A stated there was a second nurse on the hall, who was supposed to care for the residents, while she was in the dining area. LVN A stated she did not notify the other nurse that Resident #5 needed help. LVN A stated she did not follow-up with Resident #5 when she returned from the dining area.<BR/>Interview on 02/11/25 at 3:28 PM with LVN C reveale she had not been made aware of Resident #5 needing assistance with her colostomy. She stated LVN A never had a conversation with her on 02/07/25, and the interview with the surveyor was the first she time she had been made aware of the situation. <BR/>Interview on 02/12/25 at 10:35 AM with the DON revealed his expectation of the nurses would be if they could not assist a resident right away, they should have a conversation with their teammate and ask them to assist the resident. The DON stated that was why they had two nurses on the hall. He stated all residents deserved to be treated with respect and dignity. He stated LVN A did not treat Resident #5 with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 3 of 10 residents (Residents #2, #3, and #4) reviewed for abuse, neglect, and exploitation.<BR/>The facility failed to ensure Resident #2, #3, and #4 were free of abuse from Resident #1. Resident #1 hit Resident #2 and #3 with her doll in the face and head when she was upset and punched Resident #4 in the stomach after she approached her boyfriend. <BR/>An Immediate Jeopardy (IJ) was identified on 02/11/25 at 3:47 PM. The IJ template was provided to the facility on 2/11/25 at 4:00 PM. While the IJ was removed on 02/13/25, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. <BR/>This failure could place residents at risk of physical abuse from other residents. <BR/>Findings included:<BR/>Record review of Resident #1's Quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), stroke, seizure disorder, and profound intellectual disabilities. Resident #1 was not able to complete a BIMS due to her impaired cognition and she was rarely understood by others and rarely/never understood others. The MDS further reflected Resident #1 was independent with walking and did not have any impairment to upper and lower extremities. <BR/>Record review of Resident #1's care plan initiated on 06/16/23 reflected she had the potential to demonstrate physical behaviors related to poor impulse control. Resident #1 had poor impulse control and would utilize her baby doll to make contact with other residents in an aggressive way and would also get upset and physical when felt that others were talking to her boyfriend. Intervention included to analyze key times, places, circumstances, triggers, and what de-escalates the behaviors and document. Other interventions included to intervene before agitation escalated and guide away from source of distress and immediately intervene to protect the residents involved and call for assistance. <BR/>Record review of Resident #2's Annual MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), stroke, hemiplegia (medical condition that causes paralysis or weakness on one side of the body), reduced mobility, and difficulty in walking. Resident #2 had a BIMS of 13 which indicated his cognition was intact. The MDS also reflected the resident had impairment on one side to his upper extremity and impairment on both sides to his lower extremity and used a wheelchair for mobility. <BR/>Record review of Resident #3's Quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included coronary artery disease (condition in which the arteries that supply blood to the heart muscle become narrowed or blocked), stroke, difficulty in walking, and muscle weakness. Resident #3 had a BIMS of 8 which indicated his cognition was moderately impaired. The MDS further reflected the resident had impairment on one side to upper and lower extremities. <BR/>Record review of Resident #4's annual MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included heart failure, stroke, difficulty in walking, weakness and history of falling. Resident #4 had a BIMS of 7 indicating her cognition was severely impaired. The MDS further reflected the resident was independent with walking and most all ADL's. <BR/>Record review of the facility's Provider Investigation Reports reflected the following:<BR/>12/05/24<BR/> On 11/25/24, [Resident #2] was sitting one table down from [Resident #1] in the main dining room. According to [Resident #2], [Resident #1] threw her doll at him. He in turn grabbed the doll and threw it on the floor. [Resident #1] got up and picked her doll up and started crying. [Housekeeper D] saw the altercation and intervened. According to her statement, [Resident #1] hit [Resident #2] several times but after interviewing [Resident #2], he was only struck by the doll when it was thrown at him ]<BR/>01/23/25<BR/>[Resident #3] was sitting one table down to [Resident #1] in the dining room during breakfast. After breakfast was complete, [Resident #1] was tapping her foot on the floor and [Resident #3] asked her to stop tapping so loud because he could not hear the TV. [Resident #3] turned back around to look at the TV and [Resident #1] took her doll and hit [Resident #3] in the forehead. Another resident saw the altercation and went to tell the nurse <BR/>01/26/25<BR/>[Resident #1] was sitting in her usual spot in the dining room. [Resident #4] went up to [Resident #1] to ask her a question. [Resident #1] responded by saying that is my boyfriend don't talk to my man and punched her with a closed hand. [Resident #4] retaliated by hitting [Resident #1]. Residents were pulling hair. Staff intervened and separated both residents Skin assessments were conducted with [Resident #4] showing a quarter size bruise to inner upper left arm. No injuries to [Resident #1] <BR/>Record review of Resident #1's progress notes on the following dates reflected:<BR/>10/21/24 - documented by the Social Worker<BR/>Visit with [Resident #1] regarding the incident where she threw her baby doll at another resident. She did not act like she knew what this SW was talking about. SW discussed with her that her baby is little and can get hurt. She needs to be a good Mom and not throw her baby. She said she knew not to hurt baby <BR/>11/15/24 - documented by LVN CC<BR/>Resident continues with loud laughing, taunting other residents in dining room, yelling and crying @ random intervals. Was recently started on Klonopin in afternoon by psych <BR/>11/16/24 - documented by LVN E<BR/>Res in dining room yelling and laughing at other residents, CNA approached and told her to go to her room, res then ran up to cna and grabbed her by her hair, and started hitting her in the face. Another staff member intervene and separates Res from staff <BR/>11/25/24 - documented by LVN CC<BR/>Noted resident sitting in dining room, sticking her tongue out at several male residents and yelling at them get out of here, I don't like you and flipping them off with the middle finger of her left hand. Resident's chair was moved so that her back was turned toward the male residents and toward the TV so she can continue watching the program that was on. She was instructed that this behaviour is not acceptable and she can't remain in the dining room if she continues to act out toward other residents in this way. Resident stated I won't do it and was holding her baby doll and smiling as writer left at table<BR/>Observation and interview on 02/11/25 at 9:58 AM of Resident #1 revealed she was sitting at a dining room table next to another male resident. The resident had 7 stuffed animals and two dolls in a chair next to her. The two dolls had a soft, cloth stuffing and the hands, feet, and head were a firm plastic/rubber material. Attempted to interview Resident #1 but she was only able to give simple 2 to 3 word sentences and did not recall any incident or altercations with other residents. <BR/>Observation and interview on 02/11/25 at 10:05 AM with Resident #2 revealed he was in his room. He was slowly self-transferring from his wheelchair to the bed and appeared to have paralysis to the left side of body. Resident #2 was asked about the incident with Resident #1 and he said he was in his room and Resident #1 approached his door and took a few steps inside and threw her doll at him. Resident #2 said the doll hit his face so he then threw the doll back at Resident #1 and she then began to yell and curse. Resident #2 also said there was an incident where Resident #1 pushed his wheelchair with him in it against the wall but he was not hurt and there was no one around at that time nor did he tell anyone. Resident #2 further stated he was not afraid of Resident #1 just rather he was irritated at the things she did. He described Resident #1 as a rude person who cursed and yelled at others so he now preferred to keep his distance and did not go out to the dining room much to avoid Resident #1. <BR/>Observation and interview on 02/11/25 at 10:52 AM with Resident #4 revealed she was in her room sitting on the side of her bed. She was asked about the incident with Resident #1 and she said she had approached Resident #1's male friend that was sitting with her at the dining room table and asked him for a quarter. At that time Resident #1 told Resident #4 to get away from her man and then stood up and punched her in the stomach so she then in return pulled Resident #1's hair and hit her back. Resident #4 stated she was not afraid but if Resident #1 was going to hit her, she was going to hit her back. <BR/>Observation and interview on 02/11/25 at 10:22 AM with Resident #3 revealed he was sitting in the dining room listening to bible study and eating a snack. The resident was observed using a wheelchair and getting up to walk short distances. Resident #3 said Resident #1 has history of acting out in the mornings and said the day of the incident, 01/23/25, Resident #1 was hitting the bottom of the dining room table and he asked her to stop and that is when Resident #1 came around and hit him in the head with her doll. Resident #3 said the doll hurt his head when it made contact with his forehead because the doll contained some hard parts. Resident #3 further stated Resident #1 would get upset with different people when they would talk to her boyfriend who sat at her table and Resident #1 always started the fights. Resident #3 said he was not afraid of Resident #1 but the residents were annoyed with her behaviors. <BR/>Interview on 02/11/25 at 12:08 PM with Housekeeper D revealed during the incident with Resident #2 she was across the hall and heard yelling but could not make out what was being said. As she turned she saw Resident #1 hitting Resident #2 on the head with her baby doll. This incident occurred outside of the rooms, as they used to be neighbors. Housekeeper D said she separated the residents and went to report the incident to the Administrator. The Housekeeper said had heard Resident #1 yell at other residents but that was the first time she had seen her become physical with them. <BR/>Interview on 02/11/25 at 12:13 PM with LVN D revealed she was told by CNA F that Resident #1 was in the dining room, on 11/16/24, and she believed Resident #1 might have been trying to hit someone with her baby doll when CNA F tried to intervene. CNA F told her Resident #1 then grabbed CNA F's hair and began to hit her in the face with her other hand. LVN D further stated Resident #1 had a history of becoming verbal with others especially when other residents tried to talk to her male friend that sat with her at the dining room table. <BR/>Interview on 02/11/25 at 12:29 PM with CNA F revealed she approached Resident #1 and told her to go to her room so she could change her. Resident #1's male friend told Resident #1 she needed to go with CNA F and CNA F touched her male friend on his shoulder and Resident #1 jumped up out of her chair and grabbed CNA F by the hair and began to punch her. CNA F said that had been the first time Resident #1 had hit her and it all happened because Resident #1 would become defensive if anyone was around her male friend. CNA F further stated Resident #1 had a history of hitting others with her baby dolls and cursing at staff and residents all day long. CNA F said it was difficult to prevent Resident #1 from hitting and yelling at others because she would not stay in her room and stayed in the dining room all day long. If and when they tried to redirect Resident #1 she would begin to yell and curse. CNA F also said Resident #2 now preferred to stay in his room to avoid Resident #1 and others resident would also get frustrated and leave the dining room so they did not have to hear Resident #1 yell out. <BR/>Interview on 02/11/25 at 12:39 PM with the Weekend Supervisor revealed during the incident between Resident #1 and Resident #4, she was in the wound care office next to the dining room when she heard Resident #1 screaming. When they heard Resident #1, they usually knew something was going on because the resident had a history of swinging at people. When the Weekend Supervisor entered the dining room Resident #4 had Resident #1 by her hair and they were immediately separated and Resident #1 was put on 1:1 safety checks. The Weekend Supervisor said she had not worked at the facility long but had been told Resident #1 had a history of hitting but she had never witnessed it prior to that incident. Resident #1 would sit in the dining room all day and yell and scream random things at others and they would try to redirect the resident to her room but she always refused to go. The Weekend Supervisor further stated everyone just had to work around Resident #1. <BR/>Interview on 02/11/25 at 12:50 PM with the Social Worker revealed they were seeing some regression with Resident #1's developmental disability and the resident had begun to throw her baby dolls at others and there were not patterns to her behaviors. The Social Worker described Resident to be very territorial of her space and of her male friend that sat with her and they tried to redirect her behavior if they saw it coming. She said Resident #1 has previously been treated for a UTI and they had discussed her behaviors with the PASSR representative. The Social Worker further stated she had spoken to Resident #1 after her physical incidents but due to her cognition the resident did not really seem to recall the incidents and forgot as soon as they occurred. <BR/>Interview on 02/11/25 at 1:32 PM with the DON revealed he had only been working at the facility for less than 2 months and he had been made aware of the incidents between Resident #1 and Residents #3 and #4. The DON said they had inserviced staff in the past about techniques to deescalate physical altercations between the residents. Staff were also to frequently monitor Resident #1 and they had just adjusted the resident's medications. The DON said they had not tried to take Resident #1's dolls because that would infringe on her rights but they had encouraged her to not have so many baby dolls in the dining room. <BR/>Interview on 02/11/25 at 1:42 PM with the Administrator revealed they had met and discussed to limit how many dolls Resident #1 kept and to make sure staff frequently monitored to prevent altercations with other residents. The Administrator said there had not been any injuries as a result of the incidents and also said Resident #1 would not let go of her baby dolls because she was really attached to them. <BR/>Record review of the facility's policy titled Abuse/Neglect revised 03/2018 reflected the following:<BR/>The resident has the right to be free of abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Resident should 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, family members or legal guardians, friends, or other individuals <BR/>An Immediate Jeopardy/Immediate Threat was identified on 02/11/25. The Administrator, DON and the Regional Nurse Consultant were notified of the Immediate Jeopardy on 02/11/25 at 3:43 PM. The IJ template was provided to the facility on [DATE] at 4:00 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. <BR/>The facility's Plan of Removal for the Immediate Jeopardy was accepted on 02/12/25 at 9:44 AM and reflected the following:<BR/>Plan for Removal: F600 Failure to Prevent Abuse and Neglect<BR/>Interventions:<BR/>Resident #1 was immediately placed on 1:1 supervision on 2.11.25 with facility staff.<BR/>Resident #1 discharged to alternate facility with guardians' approval 2.11.25.<BR/>Resident #1's baby doll with the plastic heads were immediately removed from Resident #1's possession and from resident #1's room on 2.11.25 by regional compliance nurse. <BR/>Resident's #1's care plan was reviewed by Regional Compliance Nurse for appropriate interventions to prevent resident and staff altercations on 2.11.25. <BR/>Resident #1's care plan was updated by the Regional Compliance Nurse to reflect additional interventions of 1:1 supervision and removal of baby dolls with hard plastic pieces on 2.11.25.<BR/>IDT team will schedule a care plan meeting with Responsible Party, Physician, and Resident to review and evaluate interventions to prevent repeated altercations with staff and residents starting 2.11.25. <BR/>The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics. Completed 2.11.25<BR/>o <BR/>Abuse and Neglect- Prevention of abuse/neglect and ensuring interventions listed on the care plan are implemented to prevent abuse.<BR/>o <BR/>Behavior Management Policy- Managing behaviors and intervening appropriately. <BR/>The Medical Director was notified on 2.11.25 of the immediate jeopardy. <BR/>An ADHOC QAPI was held with the IDT Team on 2.11.25 to discuss the immediate jeopardy and plan of removal. <BR/>In-services <BR/>All staff will be in-serviced on the following topics below by the Administrator, Regional Compliance Nurse, DON, and ADON to prevent resident to resident abuse and ensure appropriate response to aggressive behaviors. In-servicing initiated on 2.11.25 and will be completed by 2.12.25. All staff who are not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to starting their shift. <BR/>o <BR/>Abuse and Neglect- Prevention of abuse/neglect and ensuring interventions listed on the care plan are implemented. <BR/>o <BR/>Behavior Management Policy- Managing behaviors and intervening appropriately.<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>Observation on 02/12/25 at 10:04 AM revealed Resident #1 was no longer at the facility and had been discharged to another nursing facility. <BR/>Record review of Resident #1's progress notes dated 02/11/25 documented by LVN C reflected the following<BR/>Resident transferred to sister [facility] due to behaviors. Vitals within normal limits, medication and belongings sent with her. Guardian notified of transfer <BR/>Record review of the facility's inservices titled Abuse/Neglect dated 02/11/25 reflected all facility staff were educated on the different types of abuse, abuse prevention and ensuring interventions were implemented to prevent abuse, and managing behaviors and intervening appropriately. If staff are to witness resident to resident abuse, they are to immediately intervene, ensure the residents are safe and report the incident to the Administrator. To prevent abuse, staff are to redirect residents away from aggressive or agitated behaviors and watch for signs of aggression. <BR/>Interviews on 02/12/25 at 1:02 PM to 02/13/25 at 2:35 PM from staff from various shifts were the Administrator, DON ADON P, Weekend Supervisor, Social Worker, Transportation, BOM , Medical Records, Dietary Manager, PTA, OT, LVN A, LVN C, Housekeeper D, LVN E, CNA F, LVN G, MA I, MDS Nurse K, MDS Nurse L, CNA N, CNA O, MA Q, CNA R, Housekeeper T, Housekeeper U, CNA V, [NAME] W, [NAME] X, MA, Z, CNA AA, and CNA BB. All staff were able to identify the following:<BR/>- <BR/>The different types of abuse.<BR/>- <BR/>What to do if they witness resident to resident abuse.<BR/>- <BR/>What signs to watch for in residents to prevent resident to resident abuse/behaviors<BR/>- <BR/>Who to report any incidents of abuse<BR/>- <BR/>All staff stated there were no other residents they were aware of that were having consistent physical altercations in the facility. <BR/>The Administrator was notified on 02/13/25 at 3:30 PM, the Immediate Jeopardy was removed. While the IJ was removed on 02/13/25, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #5) reviewed for ostomy care. <BR/>The facility failed to assist Resident #5 with colostomy care resulting in her colostomy leaking.<BR/>This failure could place the resident at risk of skin irritation and breakdown from exposure to fecal matter. <BR/>Findings included:<BR/>Record review of Resident #5's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke affecting the rights side of her body, legal blindness, and rectal cancer requiring the creation of a colostomy (opeing in the intestines to allow feces to drain into a bag). <BR/>Record review of Resident #5's quarterly MDS, dated [DATE] reflected a BIMS score of 10 indicating she was moderately cognitively impaired. Her Functional Status reflected she required set-up and clean up assistance with her toileting hygiene. Her Bowel and Bladder assessment indicated she had an ostomy. <BR/>Record review of Resident #5's care plan, dated 12/22/24, reflected she had a visual impairment related to being legally blind, and ADL self-care deficit related to paralysis, and had an ostomy. <BR/>Interview on 02/11/25 at 9:50 AM with Resident #5 revealed she often had to change her briefs because the staff took too long to respond to her call light. Resident #5 stated she thought staff knew if they waited, she would do it herself. She stated she did need staff assistance to make sure she was completely clean, and she needed assistance with applying her colostomy bag to make sure it was on properly to prevent it leaking. Resident #5 stated in the evening on 02/07/25 her colostomy bag was leaking, and she was trying to clean up with her wipes. She stated CNA B answered her call light and told her he would have to get the nurse to help her. She stated LVN A came to the resident's room and told her she could not help the resident because she was the only nurse monitoring the evening meal in the dining area. She stated LVN A put a new colostomy bag on the resident's overbed table and left. Resident #5 stated she waited for about 20 minutes, and no one came to help her, so she applied the bag herself and cleaned herself up. She stated she must not have applied it correctly because later that evening the bag began to leak again. She stated a nurse from the night shift helped her secure the bag properly. <BR/>Interview on 02/11/25 at 3:25 PM with LVN A revealed she was called to Resident #5's room by CNA B from the dining area where she was monitoring the evening meal. LVN A stated Resident #5 told her she needed a new colostomy bag, so she put one on the resident's table. LVN A told her she could not help because she had to get back to the dining area. LVN A stated there was a second nurse on the hall, who was supposed to care for the residents, while she was in the dining area. LVN A stated she did not notify the other nurse that Resident #5 needed help. LVN A stated she did not follow-up with Resident #5 when she returned from the dining area.<BR/>Interview on 02/11/25 at 3:28 PM with LVN C revealed she had not been made aware of Resident #5 needing assistance with her colostomy. She stated LVN A never had a conversation with her on 02/07/25, and the interview with the surveyor was the first she time she had been made aware of the situation. <BR/>Interview on 02/12/25 at 10:35 AM with the DON revealed his expectation of the nurses would be if they could not assist a resident right away, they should have a conversation with their teammate and ask them to assist the resident. He stated that was why they had two nurses on the hall. The DON stated skin exposure to fecal matter could quickly lead to skin irritation and skin breakdown. <BR/>Record review of the facility's Ostomy Care policy, dated 2003, reflected:<BR/> .Goals<BR/>1. <BR/>The resident will maintain continuous or intermittent drainage via bowel diversion without complications.<BR/>2. <BR/>The resident will complete/receive correct and proper care of stoma, skin, and collection procedures.<BR/>3. <BR/>The resident will be maintaining optimal skin integrity at stoma site.<BR/> .18. Persistent leakage or poorly fitted appliances can cause injury to the stoma and skin breakdown

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plans for 3 (Residents #1, #2, and #3) of 5 residents reviewed for comprehensive care plans in that:<BR/>The MDS Coordinators failed to individualize the care plans, to include interventions, for Residents #1, #2, and #3.<BR/>This failure could place the residents at risk of receiving the individualized care they required.<BR/>Findings included:<BR/>Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of right lower leg. morbid obesity, heart failure, and asthma.<BR/>Review of Resident #1's admission MDS assessment, dated 01/04/24, revealed a BIMS score of 10 indicating she had mild cognitive impairment. Her Functional Status indicated she required assistance with most of her ADLs. <BR/>Review of Resident #1's care plan, dated 01/01/24 revealed her care plan had not been individualized. Resident #1 has a rash (specify location, type, and extent) r/t; The resident is risk for falls r/t; and The resident has potential fluid deficit r/t. The majority of Resident #1's Focuses as well as Interventions had not been individualized. <BR/>Review of Resident #2's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included open wound to scalp post cancer surgery, heart disease, and high blood pressure. <BR/>Review of Resident #2's admission MDS assessment, dated 02/18/24, revealed a BIMS score of 13, indicating he was cognitively intact. His Functional Status indicated he was independent in most of his ADLs except eating and hygiene. <BR/>Review of Resident #2's care plan, dated 02/16/24, revealed his care plan had not been individualized. Resident #2 has a pacemaker (specify type) r/t; The resident is at risk for falls r/t; and The resident has hypertension r/t. The majority of Resident #2's Focuses and Interventions had not been individualized. <BR/>Review of Resident #3's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, diabetes, and alcoholic liver disease. <BR/>Review of Resident #3's admission MDS assessment, dated 02/15/24, revealed a BIMS score of 9 indicating he had moderate cognitive impairment. His Functional Status indicated he required minimal assistance with his ADLs. <BR/>Review of Resident #3's care plan, dated 02/09/24, revealed his care plan had not been individualized. Resident #3 is at risk for falls r/t; The resident has a communication problem r/t; and The resident has potential fluid deficit r/t. The rest of Resident #3's Focuses and Interventions had not been individualized. <BR/>Interview on 04/04/24 at 3:00 PM with the MDS Coordinator revealed she had been in her position since August 2023. She stated when she and the other Coordinator took over the roles the MDSs, care plans, and PASRR were all a mess. She stated the two of them had been trying to catch things up. The MDS Coordinator stated care plans should all be individualized to each resident. She stated the DON or the ADON enter the baseline care plan which triggers alerts in the comprehensive care plan. The MDS Coordinators were then responsible for completing the comprehensive care plan after they completed the MDS. The MDS Coordinators stated Residents #1, #2, and #3 were all being worked on, but had not been completed. <BR/>Interview on 04/04/24 at 3:11 PM with the DON revealed each department (Dietary, Rehabilitation, etc .) add their part of the care plan, and the MDS Coordinators were responsible for keeping them updated with information provided during the morning meetings. The DON stated the risk to residents to not have individualized care plans, staff might not know what care the resident needed. The DON stated she was ultimately responsible for everything in the facility including MDS and care plans, but she relied on everyone doing their job properly. There was no true oversight of each department. <BR/>Review of the facility's current, undated Comprehensive Care Planning policy reflected: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his preferences and goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two (Resident #1 and Resident #2) of four residents reviewed for and pharmacy services.<BR/>1. The facility failed to follow physician orders and provide Resident #1's treatment to her newly amputated leg sutures and incision site on 12/25/23, 12/27/23, 01/01/24 and 01/03/24.<BR/>2. The facility failed to follow physician orders and provide Resident #2 her analgesic topical pain medications of Diclofenac Sodium External Gel on 01/05/23 and a Lidocaine Patch on 01/02/24, 01/03/24 and 01/05/23.<BR/>The failure could place residents at risk for increased pain, infection and physical discomfort. <BR/>Findings included:<BR/>1. Record review of Resident #1's Face Sheet dated 12/27/23 reflected she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses which included atherosclerosis (thickening and hardening of the arteries) of native arteries of left leg with ulceration (a long-lasting (chronic) sore that takes more than 2 weeks to heal) of other part of foot, paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days), acute kidney failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days), dysphagia (difficulty swallowing), dependence on renal dialysis (a treatment for people whose kidneys are failing), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problem), acute respiratory failure with hypoxia (loss of breath) and acquired absence of left leg below knee (amputation).<BR/>Record review of Resident #1's admission MDS assessment dated [DATE] reflected she had no hearing, vision or speech issues and her BIMS score was 13, which indicated her cognition was intact. Resident #1 had no signs or symptoms of delirium, no negative mood issues and no behavioral symptoms which included rejection of care. Resident #1 required limited assistance of staff for her ADLs and had range of motions limitation in her lower extremity on one side and used a wheelchair for mobility. Resident #1 was frequently incontinent of bowel. Resident #1 had a recent major surgery of a below knee amputation prior to admission which required active SNF care. Resident #1 was five foot four and weighed 115 pounds and was at risk of developing pressure ulcers. Resident #1 had one unhealed pressure ulcer that was unstageable and present upon admission and she required pressure ulcer care. Resident #1 received a high risk medication called antiplatelet therapy, and she also received oxygen therapy and dialysis. <BR/>Record review of Resident #1's care plan dated 12/22/23 did not address her amputation or need for amputation care. <BR/>Record review of Resident #1's physician order dated 12/23/23 reflected, LBKA incision cleanse with NS, pat dry, apply Bacitracin ointment, cover with island dressing Q MWF and PRN as needed every Mon, Wed, Fri.<BR/>Record review of Resident #1's December 2023 TAR reflected no documentation the incision was treated per physician's orders on 12/25/23, 12/27/23, 01/01/24 and 01/03/24.<BR/>Record review of nursing progress notes on the dates Resident #1 did not have documented wound care to her incision site for 12/25/23, 12/27/23, 01/01/24 and 01/03/24 ordered.<BR/>An interview with ADON A on 01/05/23 at 3:50 PM revealed she remembered doing treatment to Resident #1's pressure ulcer on her sacrum on 01/01/24 when the wound care nurse was not working, but she did not treat her amputation suture site. ADON A stated when a resident admits with a new amputation, they generally came into the facility with orders for wound care and wound care nurse [LVN D] did the stump incision treatment orders and they were usually communicated to management in the morning meetings. ADON A stated the facility usually knew ahead of time that there was a new admission coming with recent amputation and talk about the pending admission before that resident arrived. ADON A stated if LVN D was not working, on leave or sick, then the treatments were the responsibility for the unit managers/ADONs. <BR/>An observation and interview with Resident #1 occurred on 01/05/23 at 5:15 PM. Resident #1 was interviewable and had just arrived back to the facility from dialysis. She was sitting upright in her wheelchair eating a hamburger. Resident #1 stated the facility was not consistent in treating the incision site/sutures on her newly amputated leg/stump. She was frustrated at their slow response time to answer the call light and did not feel like her pain medication was sufficient at times to treat the discomfort she had on her bottom and newly amputated stump that had healing stitches. <BR/>An interview with LVN D on 01/08/23 at 10:50 AM revealed Resident #1 had incisions where her fresh amputation was and LVN D did treatment to that site to make sure the sutures did not get pulled out. LVN D stated if she was not at the facility, the charge nurses or weekend supervisors were supposed to continue the treatment orders and she always stocked her treatment cart with all the necessary supplies. LVN D stated the main thing with Resident #1's stump was to clean it with normal saline and put a dry dressing on it to protect the sutures. LVN D stated if the treatment to the stump did not occur there would be no negative outcome. She stated the hospital did not order any type of treatment at discharge, But they don't understand this environment, she is getting up and down. I don't think anything would happen but I am scared that with her moving around in the bed that the sutures don't get hung, that's all I am doing, is protecting those sutures. <BR/>An interview with ADON B on 01/08/23 at 11:21 AM revealed when the wound care nurse was not available, ideally the charge nurse would complete treatment orders for Resident #1, unless the charge nurse was busy, then it would be the ADON/Unit managers. ADON B remembered doing wound care for a couple of days in December 2023 and January 2024 when LVN D was not at work, but whether or not I did in the TAR I can't day, that is a part of the chart I do not access that much. ADON B stated Resident #1 needed to have her stump clean with normal saline and to put some type of ointment on it and keep it dry. ADON B stated, Documentation, I did not do. Bottom line is if it is not documented, it didn't get done.<BR/>2. Record review of Resident #2's Face Sheet dated 01/05/24 reflected she was a [AGE] year old female admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness), cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting right dominant side, idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions) and unspecified osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time).<BR/>Record review of Resident #2's admission MDS dated [DATE] reflected she had unclear speech and was sometimes understood and sometimes understood by others. Resident #2's BIMS score was a 12, which indicated moderate cognitive impairment. Resident #2 had fluctuating signs and symptoms of delirium to include inattention and disorganized thinking and she had a high mood score of 15, which showed issues with depression and fatigue. Resident #2 had no rejection of care issues. She had range of motion impairments on both sides of her upper and lower extremities and used a wheelchair for mobility. Resident #2 was on pain management and indicated she had no pain presence during the admission MDS. <BR/>Record review of Resident #2's care plan dated 11/24/23 reflected the was at risk for alteration in level of comfort related to osteoarthritis and was prescribed routine diclofenac PRN, tizanidine and ibuprofen. Goals included to anticipate Resident #2's need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions. <BR/>Record review of Resident #2's physician order dated 09/29/23 reflected, Diclofenac Sodium External Gel 1 % Sodium (Topical)- Apply to Effected areas topically four times a day for Arthritis and an order dated 01/03/24, Lidocaine External Patch 4 % Apply to right shoulder topically one time a day for pain right arm 12 hours on, 12 hours off and remove per schedule.<BR/>Record review of Resident #2's January 2024 MAR reflected Lidocaine External Patch 4 % Apply to right shoulder topically one time a day for pain right arm 12 hours on, 12 hours off and remove per schedule-Apply 0800/Remove 1959. (8:00 AM/5:59PM) The MAR reflected MA I administer the patch on the morning of 01/05/23. <BR/>Record review of Resident #2's January 2024 nursing MAR reflected Diclofenac Sodium External Gel was not provided on 01/02/24, 01/03/24 and 01/05/23 during the morning shifts. <BR/>Review of Resident #2's eMAR-Administration Notes reflected the following: <BR/>-01/02/2024 11:50 Note Text : Diclofenac Sodium External Gel 1 % Apply to Effected areas topically four times a day for Arthritis--waiting on medication [documented by LVN K]<BR/>-01/03/2024 09:33 Note Text : Diclofenac Sodium External Gel 1 % Apply to Effected areas topically four times a day for Arthritis--waiting for medication [documented by LVN K]<BR/>-01/05/2024 09:03 Note Text : Diclofenac Sodium External Gel 1 % Apply to Effected areas topically four times a day for Arthritis--waiting on medication [documented by LVN K]<BR/>-01/05/2024 11:31 Note Text : Diclofenac Sodium External Gel 1 % Apply to Effected areas topically four times a day for Arthritis--waiting on medication [documented by LVN K]<BR/>An interview with Resident #2 on 01/05/24 at 3:15 PM revealed she had not been provided topical medication, a gel and a patch, for her arthritis consistently and had not received it so far that day (01/05/23). Resident #1 stated the nurse/medication aide on applied the medication in the evening and they were supposed to put it on her right shoulder and both knees four times a day but they were doing it. Resident #1 also stated she had not been provided a lidocaine patch either and did not have one placed on her body. She stated at night, a female staff (name unknown) took off her lidocaine patch and put a new one on and it was supposed to stay on for 12 hours. She stated someone came into her room that morning (name unknown) and took the lidocaine patch off but did not put a new one on. Resident #2 stated the charge nurse had not come to her room that day (01/05/23), only the medication aide [MA I], but he did not apply the patch or gel. Resident #2 stated the lidocaine patch had been ordered and started the day prior (01/04/24) and was supposed to help with pain and the gel medication stopped the arthritis from hurting. <BR/>An interview with ADON A on 01/05/24 at 3:50 PM revealed she thought the topical pain gel was not on the nurses' cart so the morning charge nurse [LVN K] did not have it to apply, but the facility had gotten in a supply of items that were now stocked in central supply, so it should have been available at that time. <BR/>An observation of ADON A and Resident #2 occurred on 01/05/24 at 3:55 PM where ADON A looked at Resident #2's skin under her clothing and verified she did not have a lidocaine patch on her body. ADON A stated the lidocaine patch had been ordered the day prior (01/04/24) by the physician because Resident #2 had chronic pain and muscle spasms. ADON A stated she would talk to the morning charge nurse [LVN K] because she should have asked ADON A where the medication was if she could not locate it. ADON A stated LVN K was fairly new licensed nurse of six months but she still knew to come and ask the unit managers/ADONs when they have any questions. <BR/>An interview with LVN J on 01/05/24 at 3:50 PM revealed she applied the gel to both of Resident #2's shoulders and both knees twice a day on the 2pm-10pm shift. LVN J stated the lidocaine patch would have been applied by MA I. LVN J stated the gel- Diclofenac Sodium External Gel was always available, it was that the morning charge nurse [LVN K] did not recognize the medication was in a new tubing and she probably did not know what it was. LVN J stated there were two tubes of Diclofenac Sodium External Gel on the nursing cart. LVN J stated if the gel was ordered four times a day by the physician, it needed to be applied four times a day and the nurse could not change the order. <BR/>An interview with ADON B on 01/08/23 at 11:21 AM revealed she looked at Resident #1's MAR/TAR and confirmed MA I documented that he applied Resident #1's lidocaine patch on 01/05/23 but it was not on her body. ADON B stated as unit managers, she was responsible to check the e-charting system to see if medications/treatments were administered to the residents and the nurses and medication aides knew they had to document when they provided a medication or treatment. ADON B stated, If it was Christmas Day, god knows what happened, it can be awful with the holidays. ADON B stated if no medication/treatment was given to Resident #2 for pain, the possible negative outcome would be that she would be in pain and discomfort. ADON B stated documentation was the proof that a medication/treatment administration was done. If the nurse or medication aide forgot to document the administration for whatever reason but they knew they gave it, that nurse/medication aide was supposed to document a late entry in the progress notes to explain why. <BR/>An interview with MA I on 01/08/24 at 12:05 PM revealed it was an accident that he documented he provided Resident #2 with her lidocaine patch on 01/05/23 in the morning, when he in fact, did not apply it. MA I stated Resident #2 was still sleeping and he let the CNA do her morning routine with the resident and gave her some time to wake up, but when he went back to apply the patch, she did not want it. He stated he did not know why she refused the lidocaine patch and he stated he did not know why she needed it because he had never heard her complain of pain. MA I stated when he went to complete his charting, he did not know what happened, but he documented he placed the lidocaine patch on the resident but he did not actually do it. MA I stated if a resident refused a medication/treatment, the medication aide was supposed to notify the charge nurse because they may have better rapport with the resident. MA I stated he had never had Resident #2 refuse a medication/treatment before. MA I stated on 01/08/24, Resident #2 was provided her lidocaine patch and was able to indicate to him where she wanted it to be placed on her right shoulder. <BR/>An interview with the DON on 01/08/24 at 12:35 PM revealed she contacted MA I on 01/05/24 and asked him why he documented he provided a topical medication to Resident #2 when he did not actually do it. The DON stated there was no lidocaine patch applied to Resident #2 on 01/05/24 and the resident had made a previous complaint a few weeks ago that she was not receiving all of her medications and the DON told MA I to start taking a witness with him when he did the med pass. MA I told her that he did but after a few days there were no issues so he did not take a witness in anymore. The DON stated with LVN K, she was going to have to figure out how she missed applying the gel and she had not answered the DON's calls over the past few days to follow up. The DON stated the pharmacy was getting to where nursing facilities could purchase the same gel over the counter and it was called Voltran and there was some in central supply, but it was not the generic name that was on the physician's order/MAR/TAR. The DON stated she would have to talk with LVN K to make sure she knew what the medication looked like and would in-service and educate her on her next working day. The DON stated the gel was for arthritic pain. <BR/>Review of the facility's policy titled, Medication Administration Procedures revised 10/25/17, reflected, .20. The 10 rights of medication should always be adhered to: 1. Right patient, 2. Right medication, 3. Right dose, 4. Right route, 5. Right time, 6. Right patient edification, 7. Right documentation, 8. Right to refuse, 9. Right assessment, 10. Right evaluation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination and the PASARR evaluation report for 8 (Residents #2, #3, #15, #23, #29, #39, #62, #71) of 10 residents reviewed for PASARR assessments. <BR/>The facility failed to submit a Nursing Facility Specialized Services (NFSS) form request by the specific deadline for Residents #2, #3, #15, #23, #29, #39, #62, and #71.<BR/>This failure could place residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. <BR/>Findings included:<BR/>Review of Resident #2's face sheet, dated [DATE], reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Review of Resident #2's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected a BIMS of 06 indicating severe cognitive impairment. Resident #2 had diagnoses of anxiety disorder (significant and uncontrollable feelings), Depression (mental state of low mood), and Schizophrenia (mental disorders of hallucinations, delusions, disorganized thinking, and behavior). <BR/>Review of Resident #2's care plan revealed she has a Mental Illness & Intellectual Disability Diagnosis and was PASRR positive. Diagnoses of Schizophrenia, Schizoaffective Disorder, Major Depressive Disorder, Developmental Disorder of Scholastic Skills. Goal included resident will have specialized services recommended by local authority per PASRR. Specialized Services program as needed. Interventions included Specialized Services of Habilitation Coordinator, Physical Therapy and Occupational Therapy will be provided per Local Authority recommendations. [DATE] Local Authority Representative here in the facility will add Customized Manual Wheelchair and also Pressure Reducing Mattress (seat cushion and back support). Will continue with Physical Therapy & Occupational Therapy. Local Authority will be invited annually to the care plan meeting for review of Specialized Services.<BR/>Review of Resident #3's face sheet, dated [DATE], reflected a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Review of Resident #3's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected a BIMS of 11 indicating moderate cognitive impairment. Resident #3 had a diagnoses of anxiety disorder (significant and uncontrollable feelings), Psychotic Disorder (severe mental disorders that cause abnormal thinking and perceptions), and Schizophrenia (mental disorders of hallucinations, delusions, disorganized thinking, and behavior), Intellectual Disabilities (learning disability formally known as mental retardation). <BR/>Review of Resident #3's care plan revealed he has a diagnosis of Intellectual Disability and was PASRR positive. Goal included resident will have specialized services recommended by local authority per PASRR. Specialized Services program as needed. Interventions included Quarterly PASRR meeting held. Will continue with Habilitation Coordinator and Resident to be placed on Physical Therapy services. Specialized Services, Habilitative Services, will be provided per Local Authority recommendations. Local Authority will be invited annually to the care plan meeting for review of Specialized Services.<BR/>Review of Resident #15's face sheet, dated [DATE], reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Review of Resident #15's most recent Comprehensive MDS (Minimum Data Set) Assessment, dated [DATE], reflected she had a BIMS of 04 indicating severe cognitive impairment. Resident #15 had diagnoses of Non-Traumatic Brain Dysfunction (injuries caused by internal factors), anxiety disorder (significant and uncontrollable feelings), Major Depressive Disorder (clinical depression), Pseudobulbar Affect (uncontrollable episodes of crying or laughing). <BR/>Review of Resident #15's care plan revealed she has a Diagnosis of Intellectual Disability and was PASRR positive. Goal included resident will have specialized services recommended by local authority per PASRR. Specialized Services program as needed. Interventions included [DATE] PASRR here for Resident's Quarterly meeting/review. Specialized Services of Occupational Therapy with a specialized wheelchair will be provided per Local Authority recommendations. Local Authority will be invited annually to the care plan meeting for review of Specialized Services.<BR/>Review of Resident #23's face sheet, dated [DATE], reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Review of Resident #23's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected she had a diagnoses of Anxiety Disorder (significant and uncontrollable feelings), Depression (mental state of low mood), Bipolar Disorder (mental disorder by periods of depression and periods of abnormally elevated mood), Psychotic Disorder (mental illness that cause a person to lose touch with reality), Schizophrenia (mental disorder by hallucinations, delusions, disorganized thinking and behavior), Mental Disorder (mental illness or psychiatric disability). <BR/>Review of Resident #23's care plan revealed she has diagnoses of Mental Illness, Intellectual Disability and was PASRR positive. Diagnoses of Schizoaffective Disorder, Bipolar II Disorder, Psychosis, Developmental Disorder of Scholastic Skills, Goal included resident will have specialized services recommended by local authority per PASRR. Specialized Services program as needed. Interventions included Specialized Services Habilitation Coordinator and Therapy Services will be provided per Local Authority recommendations. [DATE] Local Authority Representative here in the facility discussed that will continue with Habilitation Coordinator and Physical Therapy. Local Authority will be invited annually to the care plan meeting for review of Specialized Services.<BR/>Review of Resident #29's face sheet, dated [DATE], reflected a [AGE] year-old female initially admitted to the facility on [DATE].<BR/>Review of Resident #29's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected she had a BIMS of 08 indicating moderate cognitive impairment. Resident #29 had diagnoses of Schizophrenia (mental disorder by hallucinations, delusions, disorganized thinking, and behavior), borderline personality disorder (emotionally unstable personality disorder), Mild Intellectual Disabilities (learning disability formerly mental retardation). <BR/>Review of Resident #29's care plan revealed she has diagnoses of Mental Illness, Intellectual Disability and was PASRR positive. Diagnoses of Schizoaffective Disorder, Borderline Personality Disorder, Mild Intellectual Disabilities, Goal included resident will have specialized services recommended by local authority per PASRR. Specialized Services program as needed. Interventions included PASRR here for Resident's Quarterly meeting. Resident to continue Physical Therapy, Occupational Therapy, Habilitation Coordinator, and Independent Living Services. Resident will be receiving therapy and Habilitation Coordinator services. Specialized Services, and Resident is on ILS and Habilitative Services which will be provided per Local Authority recommendations. <BR/>Review of Resident #39's face sheet, dated [DATE], reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Review of Resident #39's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected she had a diagnosis of Moderate Intellectual Disabilities. <BR/>Review of Resident #39's care plan revealed she has diagnoses of Mental Illness, Intellectual Disability and Developmental Disability and was PASRR positive. Diagnoses of Scholastic Skills, Mental Disorder, Schizoaffective Disorder, Moderate Intellectual Disability, Personality Disorder, Psychosis, Major Depressive Disorder. Goal included resident will have specialized services recommended by local authority per PASRR. Specialized Services program as needed. Interventions included [DATE] PASRR here for Resident's Quarterly review. Resident to remain on Physical Therapy, Occupational Therapy and Habilitation Coordinator services. Specialized Services Habilitation Coordinator and Physical Therapy will be provided per Local Authority recommendations. [DATE] Local Authority Representative here in the facility Discussed that will continue with Habilitation Coordinator and Physical Therapy. Local Authority will be invited annually to the care plan meeting for review of Specialized Services <BR/>Review of Resident #62's face sheet, dated [DATE], reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE].<BR/>Review of Resident #62's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected she had a BIMS of 02 indicating severe cognitive impairment. Resident #62 had diagnosis of Intellectual Disabilities (learning disability formerly mental retardation). <BR/>Review of Resident #62's care plan revealed she has diagnosis of Intellectual Disability and was PASRR positive. Goal included resident will have specialized services recommended by local authority per PASRR Specialized Services program as needed. Interventions included Specialized Services will be provided per Local Authority recommendations. Local Authority will be invited annually to the care plan meeting for review of Specialized Services<BR/>Review of Resident #71's face sheet, dated [DATE], reflected a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE].<BR/>Review of Resident #71's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected he had a BIMS of 08 indicating moderate cognitive impairment. Resident #71 had diagnosis of Intellectual Disabilities (learning disability formerly mental retardation). <BR/>Review of Resident #71's care plan revealed he has diagnosis of Intellectual Disability and was PASRR positive. Goal included resident will have specialized services recommended by local authority per PASRR Specialized Services program as needed. Interventions included [DATE] PASRR here for Resident's Quarterly review. Resident to remain on Physical Therapy, Occupational Therapy, Habilitative Coordinator, and Independent Living Services. Specialized Services Occupational Therapy and Physical Therapy will be provided per Local Authority recommendations. Local Authority will be invited annually to the care plan meeting for review of Specialized Services<BR/>Request for Residents #2, #3, #15, #23, #29, #39, #62, #71's NFSS forms revealed forms were not available. <BR/>In an interview on [DATE] at 3:55 PM the Director of Rehabilitation stated she was hired mid [DATE]. The Director of Rehabilitation stated she had not been formally trained on the PASRR process however, she was responsible for filling out the NFSS forms, placing them in a box for the physician to sign, and after she got them back with the physician's signature she would then give the forms to the Administrator. The Director of Rehabilitation stated after the Administrator signed and reviewed the forms she would contact her supervisor, the Regional Operations Director, to let her know the forms were ready to upload along with the evaluations. The Director of Rehabilitation stated she was not sure how to upload the documents in the portal and that she had not been trained to do so, therefore her supervisor (Regional Operations Director) would ensure the forms were uploaded to the portal in a timely manner. The Director of Rehabilitation stated once the documents were uploaded, she would get an email from her supervisor to reflect which forms had been uploaded. According to the Director of Rehabilitation not getting the forms uploaded in a timely manner would place resident at risk of not getting the desired PASRR services. <BR/>Record review of an email dated [DATE] reflected the Regional Operations Director emailed the Local Authority. The email revealed I am trying to help staff get PASSR up and going at the facility. I had some submitted prior and the Medicaid number failed. I also had some that were submitted as restart and should have been recertification. We have a new director at this site, and we are trying to get them completed. The original email was sent to the wrong person, and I was notified of the meeting today. I will be working on getting these corrected and up to date. <BR/>Record review of an email dated [DATE] reflected the Local Authority responded to the Regional Operations Director. The email revealed, Since the authorizations have mostly been expired, you will need to do all the NFSS forms as NEW and start from the very beginning. It is recommended to do the recertifications about a month to two weeks BEFORE the expiration of the authorizations to ensure there is no lapses in the coverage dates. Since we are having PASRR meeting tomorrow, [DATE] you will have 20 business days to submit the services (NEW NFSS forms)- so that would make it a [DATE]th, 2024, deadline.<BR/>1. Resident #3 - Habilitation Coordinator and Physical Therapy<BR/>2. Resident #39 - Physical Therapy <BR/>3. Resident 71 - Physcial Threapy and Occupational Therapy<BR/>4. Resident #29 - needed services of Physical Therapy, Occupational Therapy and Speech Therapy<BR/>5. Resident #15 - Physical Therapy, Occupational Therapy, and Speech Therapy<BR/>6. Resident #62 - Physical Therapy and Occupational Therapy<BR/>7. Resident #2 - needs a customized manual wheelchair, Physical Therapy, Occupational Therapy<BR/>8. Resident #23 - Physical Therapy and Occupational Therapy. <BR/>In an interview on [DATE] at 4:16 PM with the Regional Operations Director, she stated the Director of Rehabilitation was fairly new to the position, so she was responsible for ensuring NFSS documents were uploaded to the portal after they were filled out and signed by the physician and Administrator. The Regional Operations Director stated for some time there was an Interim Director of Rehabilitation at the facility and thought the documents from the [DATE] meeting may have gotten lost. The Regional Operations Director stated by the time she received the notice that they missed the deadline to upload the documents it was too late, and the forms were past due. She stated she did upload the documents to the portal once she found out, however, several documents were with errors, so they were kicked back. The Regional Operations Director stated she was currently working with the Local Authority to correct the errors and get the documents uploaded as quickly as possible. Regional Operations Director stated she did not see a risk to the residents as their services were going and they did not have a lapse in services. The Regional Director of Operations stated the Director of Rehabilitation was responsible for ensuring the NFSS documents were uploaded to the portal. <BR/>Interview and record review on [DATE] at 4:30 PM with the Regional DON revealed she was not aware the PASARR forms for Residents #2, #3, #15, #23, #29, #39, #62, and #71 were late. Record review of the portal revealed the NFSS forms were not uploaded, and she could not clearly identify the last time they had been uploaded to the portal. The Regional DON said the purpose of submitting the forms on time was so that the resident had access to the agreed upon services. The Regional DON said she was not sure why the forms were late however she would speak with the Director of Rehabilitation who was responsible for uploading the NFSS forms to make sure they were submitted as soon as possible. <BR/>In an interview on [DATE] at 4:45 PM with the DON revealed the facility did not have a PASARR policy that covered PASRR positive policy and procedures.

**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 is unable to carry out activities of daily living, receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #1) of 3 residents reviewed for ADLs. <BR/>The facility failed to ensure Resident #1 was not left in a soiled brief for an extended period of time on 04/04/24.<BR/>This failure could place the resident at risk for skin breakdown.<BR/>Findings included:<BR/>Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of right lower leg, morbid obesity, heart failure, and asthma.<BR/>Review of Resident #1's admission MDS assessment, dated 01/04/24, revealed a BIMS score of 10 indicating she was mildly cognitively impaired. Her Functional Status indicated she required assistance with most of her ADLs, and assistance of 1-2 people for toileting. Her Bowel and Bladder Assessment indicated she was always incontinent of bowel.<BR/>Review of Resident #1's care plan, dated 01/01/24 revealed her care plan had not been individualized. Resident #1 was a risk for pressure ulcer development, the resident had a skin tear, laceration or abrasions to. The resident has a surgical site to:The resident has an ADL Self Care Performance Deficit. Resident #1 was not care planned for bowel and bladder incontinence. <BR/>Observation and interview on 04/04/24 at 9:05 AM Resident #1 stated she was currently soiled, and she had called for help at 8:40 AM. The resident had times and dates documented on her cell phone and showed them to the surveyor. Resident #1 stated CNA A had answered the call light within a few minutes and stated she was going to find help. CNA A was observed to have returned with the Staffing Coordinator at 9:26 AM to perform incontinence care. Resident #1 stated it was the second time that morning she had to wait and extended period of time to be changed. She stated she pushed the call light at 6:18 AM and CNA B answered at 6:59 AM, CNA B went for help, and she was finally changed at 7:18 AM. Resident #1 stated she has had to call her family at home to come help her get changed because staff had not responded or there was not enough help for two people to come in and help. Resident #1 stated she felt like she had developed skin breakdown because of lying in her waste for long periods of time. <BR/>Interview on 04/04/24 at 9:20 AM with Resident #1's family member revealed they had been called at home multiple times by the resident when she was not getting the help she needed. They stated often they would come in to help with incontinence care only to observe the nurse sitting at the nurse station not doing anything. and the CNA and he would change the resident. The family member stated they stay at the facility most of the day every day to assist with care because there is never enough staff to give prompt care. The CNAs always had to look for someone to help them, so he ended up assisting the CNA. The family member stated they knew they would be helping the resident when she went home, but he did not think he should have to be so involved while she was still at the facility. <BR/>Observation on 04/04/24 at 1:07 PM of incontinence care provided by CNA B and the family member revealed the resident had soft stool. CNA B provided the resident with perineal care, while the family member held the resident up. The resident had reddened areas in the skin folds on both sides of her perineal area, and barrier cream was applied, The resident had reddened areas to both buttocks, also treated with barrier cream. No skin breakdown was observed.<BR/>Interview on 04/04/24 at 1:35 PM with the ADON revealed stated his expectation for call light response was for it to be answered within 5-15 minutes. He stated anything longer than that would be unacceptable depending on what else was going on in the unit. The ADON stated a 45-minute response time was definitely excessive. The staff should answer the call light. If help was needed,they should be able to find someone to help within 5-10 minutes. If it was taking longer than that they needed to update the resident to let them know they had not been forgotten. <BR/>Interview on 04/04/24 at 1:40 PM with the DON revealed she expected call lights to be answered within 5-10 minutes depending on what was going on in the hall. The DON stated if a CNA needed help with a resident, they should be able to find someone within 10-20 minutes. She stated they had no staffing shortages, all open positions were covered by staff. The DON stated she was unaware that Resident #1's family was being called at home to come help with the resident. She stated the family needed to learn to care for the resident as she was due to be discharged in a few days, so it was good training.<BR/>Interview on 04/04/24 at 2:00 PM with CNA A revealed the incontinence care for Resident #1 at 9:30 AM was delayed because she could not find any help. CNA A stated the other CNA was out monitoring the smoking residents, she could not find the nurse, she asked for help on the 200 hall, and finally asked the Staffing Coordinator to help her. CNA A stated leaving the resident in soiled briefs for extended periods could cause skin breakdown. <BR/>Interview on 04/04/24 at 2:10 PM with CNA B revealed she had been out with the smokers from 9:00 AM-9:30 AM. CNA B stated they often used the help of Resident #1's family because they could not find the other CNA, and the nurses usually would not help because they had something else to do. CNA B stated the risk of leaving a resident in soiled briefs was that it could cause skin breakdown or urinary tract infections. <BR/>Interview on 04/04/24 at 2:15 PM with the Staffing Coordinator revealed CNA A came to her for help because she could not find any help for Resident #1. The Staffing Coordinator stated it was rare for the CNAs to have to come to her for help. <BR/>Review of the facility's current Perineal Care Female policy, dated 12/08/09, reflected the steps of providing care, but did not reference time frames for care or define what would be considered prolonged wait times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for one (Resident #3) of five resident rooms reviewed for accidents and hazards. <BR/>The facility failed to ensure the closet doors in Resident #3's room were maintained in a safe and functional manner.<BR/>This failure could place residents at risk of accidents or injury. <BR/>Findings included:<BR/>Record review of Resident #3's face sheet dated 01/17/24 indicated the resident was a [AGE] year-old male, initially admitted on [DATE], and readmitted on [DATE] with diagnoses that included weakness, reduced mobility, contracture (shortening of muscles) unspecified joint, contracture unspecified knee, muscle weakness, history of falling, age related nuclear cataract, bilateral (major cause of blindness), epilepsy (nerve cell activity in the brain is disturbed causing seizures). <BR/>Record review of Resident #3's MDS assessment dated [DATE] indicated Resident #3 had moderately impaired cognition with a BIMS score of 9. The resident's active diagnoses included cataracts, epilepsy, and anxiety disorder. Resident #3 had vision impairment and had behaviors with difficulty focusing attention and disorganized thinking. Resident #3 required extensive assistance with two people for toileting, bed mobility and transfers. He required set up assistance for eating, and limited assistance with one person for hygiene, and he used a wheelchair for mobility. <BR/>Record review of Resident #3's current, undated care plan revealed Resident #3 was at risk for frequent falls related to weakness and unsteady gait. The care plan reflected: Goal: Resident #3 will minimize risk and injury potential. Intervention: Resident #3 will receive assistance out of bed, educate and redirect resident about slouching in wheelchair, anticipate resident needs and wants, encourage resident not to transfer himself without assistance, and keep bed in low position during transfers.<BR/>Observation and interview on 01/17/24 at 10:17 AM revealed Resident #3 in his room, in his wheelchair. Resident #3 communicated that he recently had a fall out of bed and injured himself. Resident #3 stated he was blind and had a hard time seeing out of both eyes. During the interview, Resident #3 was observed attempting to wheel himself out of his room. Resident #3 was observed bumping his chair first into the wall and then heading towards his closet. Observation of the closet revealed one closet door leaning up against the back wall and another door hanging off the closet hinge. <BR/>Interview on 01/17/24 at 1:07 PM with Medication Aide F revealed she worked with Resident #3. She stated the resident would yell and scream when he wanted something, so she would hear him and assist him with his needs. Most of the time he was screaming because he wanted to get out of his room or wanted a snack or water. Medication Aide F stated she did not know if Resident #3 was blind, but she knew the resident's vision was impaired. She stated the resident continually repeated that he was. Since the resident was having a hard time with his vision, his door was always left open. She stated she was aware of the closet doors being damaged. Medication Aide F stated the doors often were damaged due to Resident #3's impaired vision. She stated Resident #3 became anxious when he attempted to leave his room and thought the closet doors were an exit. She stated Resident #3 would try to exit through the closet causing the doors to become damaged or come off the hinge. She stated once the closet doors were damaged, she would inform the nurse. According to Medication Aide F, having damaged closet doors or the doors hanging off the hinges could cause a risk to Resident #3 becoming injured if the door fell off the hinge and hit Resident #3 in the head or caused other injury. <BR/>Interview on 01/17/24 at 1:48 PM with ADON C revealed he began working at the facility in March 2023. He stated Resident #3 at that time was able to self-propel in his wheelchair without any issues. However, recently Resident #3 had become confused and stated he was having issues with his vision. ADON C stated within the last couple of weeks Resident #3 had been running into doors and walls while in the facility. ADON C stated Resident #3 had been stating he was blind. According to ADON C, Resident #3 had been running into his closet door thinking he was exiting his room, causing the doors to be torn down. ADON C stated he thought maintenance replaced the doors back on the hinges. According to ADON C, having the closet doors hanging off the hinges or leaning up against the wall in the resident room would cause a hazard to Resident #3 causing possible injuries. ADON C stated Resident #3's current condition of having impaired vision could cause Resident #3 to run into the closet door causing the doors to fall on him causing him to have head or bodily injury. <BR/>Interview and observation on 01/17/24 at 1:57 PM with the Maintenance Supervisor revealed one closet door leaning up against the back wall in Resident #3's room and a second door hanging off the closet hinges at the top of the closet entry way. According to the Maintenance Supervisor, he had replaced the closet doors in Resident #3's room on several occasions. The Maintenance Supervisor stated he was not sure how to secure the doors on the closet to prevent Resident #3 from bumping into the doors and tearing them down. He stated he thought about removing the doors; but he did not want to be out of compliance. According to the Maintenance Supervisor, not having the doors secured on the hinges would place Resident #3 at risk of injury, due to him having impaired vision. <BR/>Interview on 01/17/24 at 1:59 PM with ADON D revealed Resident #3 had recently become physically weaker and his vision had become impaired causing him to need more assistance from staff. ADON D stated Resident #3 had an eye appointment last week resulting with him not being a candidate for surgery. <BR/>Interview on 01/17/24 at 2:12 PM with CNA E revealed Resident #3 made his needs known by yelling help or screaming out. CNA E stated Resident #3 rarely used the call light for assistance because he was not able to see that well. According to CNA E, Resident #3's closet doors were broken for a while, but she was not sure how long. CNA E stated she had not seen Resident #3 run into the doors while in his wheelchair. According to CNA E, she was alerted that Resident #3 had a recent fall, crawled to the wall or the closet door causing injury to his eye. CNA E stated she had reported the doors off the hinge in Resident #3's room by alerting the nurse. CNA E stated not having the doors replaced could cause Resident #3 to injure himself. <BR/>Interview on 01/17/24 at 5:37 PM with the DON revealed Resident #3 did have a fall that resulted in an injury last week. Resident #3 had impaired vision which caused him to keep his eyes closed most of the time. The DON stated Resident #3 did have a history of scooting around on the floor until someone heard him yelling out for help. According to the DON, she was aware Resident #3's doors were off the closet and in a safe area. She was not aware they were in his room. The DON stated maintenance had placed the doors back on the door at this time and requested they be replaced in a manner they could not be easily removed by Resident #3. The DON stated she did not know how often the closet doors were checked by maintenance. The DON stated due to the closet door continually being damaged hanging off the hinges perhaps Resident #3's care plan should be updated, and the closet doors removed. The DON stated not having the closet doors secured could cause the doors to fall on his head. <BR/>On 01/17/24 at 5:00 PM, the Administrator was asked to provide the facility's policy; however, the policy was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for one (Resident #3) of five resident rooms reviewed for accidents and hazards. <BR/>The facility failed to ensure the closet doors in Resident #3's room were maintained in a safe and functional manner.<BR/>This failure could place residents at risk of accidents or injury. <BR/>Findings included:<BR/>Record review of Resident #3's face sheet dated 01/17/24 indicated the resident was a [AGE] year-old male, initially admitted on [DATE], and readmitted on [DATE] with diagnoses that included weakness, reduced mobility, contracture (shortening of muscles) unspecified joint, contracture unspecified knee, muscle weakness, history of falling, age related nuclear cataract, bilateral (major cause of blindness), epilepsy (nerve cell activity in the brain is disturbed causing seizures). <BR/>Record review of Resident #3's MDS assessment dated [DATE] indicated Resident #3 had moderately impaired cognition with a BIMS score of 9. The resident's active diagnoses included cataracts, epilepsy, and anxiety disorder. Resident #3 had vision impairment and had behaviors with difficulty focusing attention and disorganized thinking. Resident #3 required extensive assistance with two people for toileting, bed mobility and transfers. He required set up assistance for eating, and limited assistance with one person for hygiene, and he used a wheelchair for mobility. <BR/>Record review of Resident #3's current, undated care plan revealed Resident #3 was at risk for frequent falls related to weakness and unsteady gait. The care plan reflected: Goal: Resident #3 will minimize risk and injury potential. Intervention: Resident #3 will receive assistance out of bed, educate and redirect resident about slouching in wheelchair, anticipate resident needs and wants, encourage resident not to transfer himself without assistance, and keep bed in low position during transfers.<BR/>Observation and interview on 01/17/24 at 10:17 AM revealed Resident #3 in his room, in his wheelchair. Resident #3 communicated that he recently had a fall out of bed and injured himself. Resident #3 stated he was blind and had a hard time seeing out of both eyes. During the interview, Resident #3 was observed attempting to wheel himself out of his room. Resident #3 was observed bumping his chair first into the wall and then heading towards his closet. Observation of the closet revealed one closet door leaning up against the back wall and another door hanging off the closet hinge. <BR/>Interview on 01/17/24 at 1:07 PM with Medication Aide F revealed she worked with Resident #3. She stated the resident would yell and scream when he wanted something, so she would hear him and assist him with his needs. Most of the time he was screaming because he wanted to get out of his room or wanted a snack or water. Medication Aide F stated she did not know if Resident #3 was blind, but she knew the resident's vision was impaired. She stated the resident continually repeated that he was. Since the resident was having a hard time with his vision, his door was always left open. She stated she was aware of the closet doors being damaged. Medication Aide F stated the doors often were damaged due to Resident #3's impaired vision. She stated Resident #3 became anxious when he attempted to leave his room and thought the closet doors were an exit. She stated Resident #3 would try to exit through the closet causing the doors to become damaged or come off the hinge. She stated once the closet doors were damaged, she would inform the nurse. According to Medication Aide F, having damaged closet doors or the doors hanging off the hinges could cause a risk to Resident #3 becoming injured if the door fell off the hinge and hit Resident #3 in the head or caused other injury. <BR/>Interview on 01/17/24 at 1:48 PM with ADON C revealed he began working at the facility in March 2023. He stated Resident #3 at that time was able to self-propel in his wheelchair without any issues. However, recently Resident #3 had become confused and stated he was having issues with his vision. ADON C stated within the last couple of weeks Resident #3 had been running into doors and walls while in the facility. ADON C stated Resident #3 had been stating he was blind. According to ADON C, Resident #3 had been running into his closet door thinking he was exiting his room, causing the doors to be torn down. ADON C stated he thought maintenance replaced the doors back on the hinges. According to ADON C, having the closet doors hanging off the hinges or leaning up against the wall in the resident room would cause a hazard to Resident #3 causing possible injuries. ADON C stated Resident #3's current condition of having impaired vision could cause Resident #3 to run into the closet door causing the doors to fall on him causing him to have head or bodily injury. <BR/>Interview and observation on 01/17/24 at 1:57 PM with the Maintenance Supervisor revealed one closet door leaning up against the back wall in Resident #3's room and a second door hanging off the closet hinges at the top of the closet entry way. According to the Maintenance Supervisor, he had replaced the closet doors in Resident #3's room on several occasions. The Maintenance Supervisor stated he was not sure how to secure the doors on the closet to prevent Resident #3 from bumping into the doors and tearing them down. He stated he thought about removing the doors; but he did not want to be out of compliance. According to the Maintenance Supervisor, not having the doors secured on the hinges would place Resident #3 at risk of injury, due to him having impaired vision. <BR/>Interview on 01/17/24 at 1:59 PM with ADON D revealed Resident #3 had recently become physically weaker and his vision had become impaired causing him to need more assistance from staff. ADON D stated Resident #3 had an eye appointment last week resulting with him not being a candidate for surgery. <BR/>Interview on 01/17/24 at 2:12 PM with CNA E revealed Resident #3 made his needs known by yelling help or screaming out. CNA E stated Resident #3 rarely used the call light for assistance because he was not able to see that well. According to CNA E, Resident #3's closet doors were broken for a while, but she was not sure how long. CNA E stated she had not seen Resident #3 run into the doors while in his wheelchair. According to CNA E, she was alerted that Resident #3 had a recent fall, crawled to the wall or the closet door causing injury to his eye. CNA E stated she had reported the doors off the hinge in Resident #3's room by alerting the nurse. CNA E stated not having the doors replaced could cause Resident #3 to injure himself. <BR/>Interview on 01/17/24 at 5:37 PM with the DON revealed Resident #3 did have a fall that resulted in an injury last week. Resident #3 had impaired vision which caused him to keep his eyes closed most of the time. The DON stated Resident #3 did have a history of scooting around on the floor until someone heard him yelling out for help. According to the DON, she was aware Resident #3's doors were off the closet and in a safe area. She was not aware they were in his room. The DON stated maintenance had placed the doors back on the door at this time and requested they be replaced in a manner they could not be easily removed by Resident #3. The DON stated she did not know how often the closet doors were checked by maintenance. The DON stated due to the closet door continually being damaged hanging off the hinges perhaps Resident #3's care plan should be updated, and the closet doors removed. The DON stated not having the closet doors secured could cause the doors to fall on his head. <BR/>On 01/17/24 at 5:00 PM, the Administrator was asked to provide the facility's policy; however, the policy was not provided prior to exit.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program system for preventing and controlling infections for three (CNA A, CNA B, and CNA C) of three staff reviewed for hand hygiene. <BR/>1. CNA A and CNA B failed to perform hand hygiene and change gloves during incontinence care for Resident #1.<BR/>2. CNA C failed to perform hand hygiene before donning and after doffing gloves during the incontinence care of Resident #2.<BR/>These failures placed residents at risk for infections and cross-contamination.<BR/>Findings included: <BR/>Observation on 03/01/23 at 11:30 AM revealed CNA A and CNA B did not perform hand hygiene before entering Resident #1's room and before donning gloves to provide incontinence care for Resident #1, who had had a bowel movement. They were observed each donning two pairs of gloves. While wearing soiled gloves, CNA A was observed getting wipes from the wipes packet. After providing Resident #1 with incontinence care, CNA A removed one pair of gloves. Without performing hand hygiene, she touched the clean brief, the bedding, bed control and Resident#1. CNA A and CNA B then turned the resident, and CNA B cleansed Resident #1 on the right side. She doffed one pair of gloves. Without performing hand hygiene, CNA B then touched the clean brief and the draw sheet. CNA A was observed leaving Resident #1's room, carrying the clean linen in a plastic bag from Resident #1's room to the shower room, which was considered a clean area, without performing hand hygiene after doffing the second pair of gloves she had been wearing. CNA B was observed leaving Resident #1's room and going to the soiled linen closet without performing hand hygiene after doffing the second pair of gloves she had been wearing. CNA B then later walked to the nurses' station.<BR/> . <BR/>Interview with CNA B on 03/01/23 at 12:44 PM revealed she knew she was supposed to perform hand hygiene before entering the resident's room. She stated she thought she sanitized outside before she entered the room. She also stated she knew she was not supposed to wear two pairs of gloves. She stated if she did, she was supposed to change both pair of gloves and perform hand hygiene when they were soiled and when moving from dirty to clean. She stated she knew she was supposed to perform hand hygiene after incontinence care and before leaving Resident #1's room. CNA B stated she forgot because she was nervous. She also stated she had been trained on incontinence care, handwashing, and infection control. She stated she knew the failure to perform hand hygiene and not changing her gloves could cause cross-contamination and the spread of infection.<BR/>Interview with CNA A on 03/01/23 at 1:03 PM revealed she knew she was supposed to perform hand hygiene before entering the resident's room. She also stated she knew she was not supposed to wear two pairs of gloves. She revealed she was supposed to wear one pair of gloves and perform hand hygiene before putting on and after removing her gloves. She stated she was supposed to change her gloves and perform hand hygiene when they were soiled and when moving from dirty to clean. She stated she knew she was not supposed to remove supplies from the resident room to another room. If they were clean, they should remain in Resident #1's room. She stated she forgot because she was nervous. She also stated she had been trained on incontinence care, handwashing, and infection control. She stated she knew the failure to perform hand hygiene and not changing her gloves and moving supplies from one room to another would spread infection and contamination.<BR/>Interview with the DON on 03/01/23 at 3:36 PM revealed the facility expected staff to perform hand hygiene as per the books as per the skill checks done with staff by her. When performing incontinence care, the DON stated staff were supposed to change gloves and perform hand hygiene when moving from dirty to clean. She stated she expected the staff who were wearing two pairs of gloves to doff both pairs of gloves and perform hand hygiene given that the resident had a bowel movement. She stated her expectation was the staff should use the non-contaminated hand to grab the wipes, and they should not leave the room without performing hand hygiene given that each room had a sink, water, and soap to prevent cross-contamination and the spread of infection. She stated she expected the staff to leave the remaining supplies in Resident #1's room and not to move them to a clean area. She stated she had done training with staff on hand washing infection control and peri care. <BR/>Observation on 03/01/23 at 4:30 PM revealed CNA C failed to perform hand hygiene before putting on gloves and after removing her gloves while she provided incontinence care for Resident #2. She was observed removing the gloves and putting on clean gloves without performing hand hygiene throughout the procedure.<BR/>Interview with CNA C on 03/01/23 at 5:37 PM revealed she knew she was supposed to perform hand hygiene before donning and after doffing her gloves. She stated she was supposed to change her gloves and perform hand hygiene when they were soiled and when moving from dirty to clean. She stated she did not know whether she was supposed to sanitize or wash hands during the care, and she was nervous. She stated she had been trained on incontinence care, handwashing, and infection control. She stated she knew the failure to perform hand hygiene could spread infection and contamination.<BR/>Interview with the DON on 03/01/23 at 5:45 PM revealed the facility expectation was staff were supposed to perform hand hygiene when changing their gloves and perform hand hygiene when moving from dirty to clean when performing incontinence care. She stated she expected the CNA to perform better since she had taken her through the process, and she was disappointed she forgot to perform hand hygiene.<BR/>Review of the facility's current policy for hand washing/hand hygiene, dated August 2019, reflected:<BR/> .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread the spread of infections to other personnel, residents, and visitors.<BR/> .7. Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following:-<BR/> .b. Before and after contact with residents. <BR/> .f. Before donning sterile gloves. <BR/> .m. After removing glove.<BR/>Review of the facility's current policy for peri-care, dated 05/11/22, reflected: .staff should perform hand hygiene and put on gloves and all other PPE per standard precautions. <BR/>.Doffing and discarding of gloves are required if visibly soiled. <BR/>.Always perform hand hygiene before and after glove use.<BR/>If heavy soiled use wipes to remove heavy soiling from front to back, prior to performing perineal care. Do not wipe more than once with the same surface of the tissue or wipes.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plans for 3 (Residents #1, #2, and #3) of 5 residents reviewed for comprehensive care plans in that:<BR/>The MDS Coordinators failed to individualize the care plans, to include interventions, for Residents #1, #2, and #3.<BR/>This failure could place the residents at risk of receiving the individualized care they required.<BR/>Findings included:<BR/>Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of right lower leg. morbid obesity, heart failure, and asthma.<BR/>Review of Resident #1's admission MDS assessment, dated 01/04/24, revealed a BIMS score of 10 indicating she had mild cognitive impairment. Her Functional Status indicated she required assistance with most of her ADLs. <BR/>Review of Resident #1's care plan, dated 01/01/24 revealed her care plan had not been individualized. Resident #1 has a rash (specify location, type, and extent) r/t; The resident is risk for falls r/t; and The resident has potential fluid deficit r/t. The majority of Resident #1's Focuses as well as Interventions had not been individualized. <BR/>Review of Resident #2's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included open wound to scalp post cancer surgery, heart disease, and high blood pressure. <BR/>Review of Resident #2's admission MDS assessment, dated 02/18/24, revealed a BIMS score of 13, indicating he was cognitively intact. His Functional Status indicated he was independent in most of his ADLs except eating and hygiene. <BR/>Review of Resident #2's care plan, dated 02/16/24, revealed his care plan had not been individualized. Resident #2 has a pacemaker (specify type) r/t; The resident is at risk for falls r/t; and The resident has hypertension r/t. The majority of Resident #2's Focuses and Interventions had not been individualized. <BR/>Review of Resident #3's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, diabetes, and alcoholic liver disease. <BR/>Review of Resident #3's admission MDS assessment, dated 02/15/24, revealed a BIMS score of 9 indicating he had moderate cognitive impairment. His Functional Status indicated he required minimal assistance with his ADLs. <BR/>Review of Resident #3's care plan, dated 02/09/24, revealed his care plan had not been individualized. Resident #3 is at risk for falls r/t; The resident has a communication problem r/t; and The resident has potential fluid deficit r/t. The rest of Resident #3's Focuses and Interventions had not been individualized. <BR/>Interview on 04/04/24 at 3:00 PM with the MDS Coordinator revealed she had been in her position since August 2023. She stated when she and the other Coordinator took over the roles the MDSs, care plans, and PASRR were all a mess. She stated the two of them had been trying to catch things up. The MDS Coordinator stated care plans should all be individualized to each resident. She stated the DON or the ADON enter the baseline care plan which triggers alerts in the comprehensive care plan. The MDS Coordinators were then responsible for completing the comprehensive care plan after they completed the MDS. The MDS Coordinators stated Residents #1, #2, and #3 were all being worked on, but had not been completed. <BR/>Interview on 04/04/24 at 3:11 PM with the DON revealed each department (Dietary, Rehabilitation, etc .) add their part of the care plan, and the MDS Coordinators were responsible for keeping them updated with information provided during the morning meetings. The DON stated the risk to residents to not have individualized care plans, staff might not know what care the resident needed. The DON stated she was ultimately responsible for everything in the facility including MDS and care plans, but she relied on everyone doing their job properly. There was no true oversight of each department. <BR/>Review of the facility's current, undated Comprehensive Care Planning policy reflected: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his preferences and goals.

**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 is unable to carry out activities of daily living, receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #1) of 3 residents reviewed for ADLs. <BR/>The facility failed to ensure Resident #1 was not left in a soiled brief for an extended period of time on 04/04/24.<BR/>This failure could place the resident at risk for skin breakdown.<BR/>Findings included:<BR/>Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of right lower leg, morbid obesity, heart failure, and asthma.<BR/>Review of Resident #1's admission MDS assessment, dated 01/04/24, revealed a BIMS score of 10 indicating she was mildly cognitively impaired. Her Functional Status indicated she required assistance with most of her ADLs, and assistance of 1-2 people for toileting. Her Bowel and Bladder Assessment indicated she was always incontinent of bowel.<BR/>Review of Resident #1's care plan, dated 01/01/24 revealed her care plan had not been individualized. Resident #1 was a risk for pressure ulcer development, the resident had a skin tear, laceration or abrasions to. The resident has a surgical site to:The resident has an ADL Self Care Performance Deficit. Resident #1 was not care planned for bowel and bladder incontinence. <BR/>Observation and interview on 04/04/24 at 9:05 AM Resident #1 stated she was currently soiled, and she had called for help at 8:40 AM. The resident had times and dates documented on her cell phone and showed them to the surveyor. Resident #1 stated CNA A had answered the call light within a few minutes and stated she was going to find help. CNA A was observed to have returned with the Staffing Coordinator at 9:26 AM to perform incontinence care. Resident #1 stated it was the second time that morning she had to wait and extended period of time to be changed. She stated she pushed the call light at 6:18 AM and CNA B answered at 6:59 AM, CNA B went for help, and she was finally changed at 7:18 AM. Resident #1 stated she has had to call her family at home to come help her get changed because staff had not responded or there was not enough help for two people to come in and help. Resident #1 stated she felt like she had developed skin breakdown because of lying in her waste for long periods of time. <BR/>Interview on 04/04/24 at 9:20 AM with Resident #1's family member revealed they had been called at home multiple times by the resident when she was not getting the help she needed. They stated often they would come in to help with incontinence care only to observe the nurse sitting at the nurse station not doing anything. and the CNA and he would change the resident. The family member stated they stay at the facility most of the day every day to assist with care because there is never enough staff to give prompt care. The CNAs always had to look for someone to help them, so he ended up assisting the CNA. The family member stated they knew they would be helping the resident when she went home, but he did not think he should have to be so involved while she was still at the facility. <BR/>Observation on 04/04/24 at 1:07 PM of incontinence care provided by CNA B and the family member revealed the resident had soft stool. CNA B provided the resident with perineal care, while the family member held the resident up. The resident had reddened areas in the skin folds on both sides of her perineal area, and barrier cream was applied, The resident had reddened areas to both buttocks, also treated with barrier cream. No skin breakdown was observed.<BR/>Interview on 04/04/24 at 1:35 PM with the ADON revealed stated his expectation for call light response was for it to be answered within 5-15 minutes. He stated anything longer than that would be unacceptable depending on what else was going on in the unit. The ADON stated a 45-minute response time was definitely excessive. The staff should answer the call light. If help was needed,they should be able to find someone to help within 5-10 minutes. If it was taking longer than that they needed to update the resident to let them know they had not been forgotten. <BR/>Interview on 04/04/24 at 1:40 PM with the DON revealed she expected call lights to be answered within 5-10 minutes depending on what was going on in the hall. The DON stated if a CNA needed help with a resident, they should be able to find someone within 10-20 minutes. She stated they had no staffing shortages, all open positions were covered by staff. The DON stated she was unaware that Resident #1's family was being called at home to come help with the resident. She stated the family needed to learn to care for the resident as she was due to be discharged in a few days, so it was good training.<BR/>Interview on 04/04/24 at 2:00 PM with CNA A revealed the incontinence care for Resident #1 at 9:30 AM was delayed because she could not find any help. CNA A stated the other CNA was out monitoring the smoking residents, she could not find the nurse, she asked for help on the 200 hall, and finally asked the Staffing Coordinator to help her. CNA A stated leaving the resident in soiled briefs for extended periods could cause skin breakdown. <BR/>Interview on 04/04/24 at 2:10 PM with CNA B revealed she had been out with the smokers from 9:00 AM-9:30 AM. CNA B stated they often used the help of Resident #1's family because they could not find the other CNA, and the nurses usually would not help because they had something else to do. CNA B stated the risk of leaving a resident in soiled briefs was that it could cause skin breakdown or urinary tract infections. <BR/>Interview on 04/04/24 at 2:15 PM with the Staffing Coordinator revealed CNA A came to her for help because she could not find any help for Resident #1. The Staffing Coordinator stated it was rare for the CNAs to have to come to her for help. <BR/>Review of the facility's current Perineal Care Female policy, dated 12/08/09, reflected the steps of providing care, but did not reference time frames for care or define what would be considered prolonged wait times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for one (Resident #3) of five resident rooms reviewed for accidents and hazards. <BR/>The facility failed to ensure the closet doors in Resident #3's room were maintained in a safe and functional manner.<BR/>This failure could place residents at risk of accidents or injury. <BR/>Findings included:<BR/>Record review of Resident #3's face sheet dated 01/17/24 indicated the resident was a [AGE] year-old male, initially admitted on [DATE], and readmitted on [DATE] with diagnoses that included weakness, reduced mobility, contracture (shortening of muscles) unspecified joint, contracture unspecified knee, muscle weakness, history of falling, age related nuclear cataract, bilateral (major cause of blindness), epilepsy (nerve cell activity in the brain is disturbed causing seizures). <BR/>Record review of Resident #3's MDS assessment dated [DATE] indicated Resident #3 had moderately impaired cognition with a BIMS score of 9. The resident's active diagnoses included cataracts, epilepsy, and anxiety disorder. Resident #3 had vision impairment and had behaviors with difficulty focusing attention and disorganized thinking. Resident #3 required extensive assistance with two people for toileting, bed mobility and transfers. He required set up assistance for eating, and limited assistance with one person for hygiene, and he used a wheelchair for mobility. <BR/>Record review of Resident #3's current, undated care plan revealed Resident #3 was at risk for frequent falls related to weakness and unsteady gait. The care plan reflected: Goal: Resident #3 will minimize risk and injury potential. Intervention: Resident #3 will receive assistance out of bed, educate and redirect resident about slouching in wheelchair, anticipate resident needs and wants, encourage resident not to transfer himself without assistance, and keep bed in low position during transfers.<BR/>Observation and interview on 01/17/24 at 10:17 AM revealed Resident #3 in his room, in his wheelchair. Resident #3 communicated that he recently had a fall out of bed and injured himself. Resident #3 stated he was blind and had a hard time seeing out of both eyes. During the interview, Resident #3 was observed attempting to wheel himself out of his room. Resident #3 was observed bumping his chair first into the wall and then heading towards his closet. Observation of the closet revealed one closet door leaning up against the back wall and another door hanging off the closet hinge. <BR/>Interview on 01/17/24 at 1:07 PM with Medication Aide F revealed she worked with Resident #3. She stated the resident would yell and scream when he wanted something, so she would hear him and assist him with his needs. Most of the time he was screaming because he wanted to get out of his room or wanted a snack or water. Medication Aide F stated she did not know if Resident #3 was blind, but she knew the resident's vision was impaired. She stated the resident continually repeated that he was. Since the resident was having a hard time with his vision, his door was always left open. She stated she was aware of the closet doors being damaged. Medication Aide F stated the doors often were damaged due to Resident #3's impaired vision. She stated Resident #3 became anxious when he attempted to leave his room and thought the closet doors were an exit. She stated Resident #3 would try to exit through the closet causing the doors to become damaged or come off the hinge. She stated once the closet doors were damaged, she would inform the nurse. According to Medication Aide F, having damaged closet doors or the doors hanging off the hinges could cause a risk to Resident #3 becoming injured if the door fell off the hinge and hit Resident #3 in the head or caused other injury. <BR/>Interview on 01/17/24 at 1:48 PM with ADON C revealed he began working at the facility in March 2023. He stated Resident #3 at that time was able to self-propel in his wheelchair without any issues. However, recently Resident #3 had become confused and stated he was having issues with his vision. ADON C stated within the last couple of weeks Resident #3 had been running into doors and walls while in the facility. ADON C stated Resident #3 had been stating he was blind. According to ADON C, Resident #3 had been running into his closet door thinking he was exiting his room, causing the doors to be torn down. ADON C stated he thought maintenance replaced the doors back on the hinges. According to ADON C, having the closet doors hanging off the hinges or leaning up against the wall in the resident room would cause a hazard to Resident #3 causing possible injuries. ADON C stated Resident #3's current condition of having impaired vision could cause Resident #3 to run into the closet door causing the doors to fall on him causing him to have head or bodily injury. <BR/>Interview and observation on 01/17/24 at 1:57 PM with the Maintenance Supervisor revealed one closet door leaning up against the back wall in Resident #3's room and a second door hanging off the closet hinges at the top of the closet entry way. According to the Maintenance Supervisor, he had replaced the closet doors in Resident #3's room on several occasions. The Maintenance Supervisor stated he was not sure how to secure the doors on the closet to prevent Resident #3 from bumping into the doors and tearing them down. He stated he thought about removing the doors; but he did not want to be out of compliance. According to the Maintenance Supervisor, not having the doors secured on the hinges would place Resident #3 at risk of injury, due to him having impaired vision. <BR/>Interview on 01/17/24 at 1:59 PM with ADON D revealed Resident #3 had recently become physically weaker and his vision had become impaired causing him to need more assistance from staff. ADON D stated Resident #3 had an eye appointment last week resulting with him not being a candidate for surgery. <BR/>Interview on 01/17/24 at 2:12 PM with CNA E revealed Resident #3 made his needs known by yelling help or screaming out. CNA E stated Resident #3 rarely used the call light for assistance because he was not able to see that well. According to CNA E, Resident #3's closet doors were broken for a while, but she was not sure how long. CNA E stated she had not seen Resident #3 run into the doors while in his wheelchair. According to CNA E, she was alerted that Resident #3 had a recent fall, crawled to the wall or the closet door causing injury to his eye. CNA E stated she had reported the doors off the hinge in Resident #3's room by alerting the nurse. CNA E stated not having the doors replaced could cause Resident #3 to injure himself. <BR/>Interview on 01/17/24 at 5:37 PM with the DON revealed Resident #3 did have a fall that resulted in an injury last week. Resident #3 had impaired vision which caused him to keep his eyes closed most of the time. The DON stated Resident #3 did have a history of scooting around on the floor until someone heard him yelling out for help. According to the DON, she was aware Resident #3's doors were off the closet and in a safe area. She was not aware they were in his room. The DON stated maintenance had placed the doors back on the door at this time and requested they be replaced in a manner they could not be easily removed by Resident #3. The DON stated she did not know how often the closet doors were checked by maintenance. The DON stated due to the closet door continually being damaged hanging off the hinges perhaps Resident #3's care plan should be updated, and the closet doors removed. The DON stated not having the closet doors secured could cause the doors to fall on his head. <BR/>On 01/17/24 at 5:00 PM, the Administrator was asked to provide the facility's policy; however, the policy was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, maintained medical records on each resident that were complate and accurately documented for one (Resident #1) of four residents reviewed for quality of care. <BR/>The facility failed to provide wound care to Resident #1's coccyx on 12/25/23, 12/26/23, 12/27/23, 12/30/23 and 01/01/24 through 01/04/24 and document when it was provided. <BR/>The facility failure placed residents at risk of continued pain, discomfort, infection and a worsening of their wounds. <BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 12/27/23 reflected she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses which included atherosclerosis (thickening and hardening of the arteries) of native arteries of left leg with ulceration (a long-lasting (chronic) sore that takes more than 2 weeks to heal) of other part of foot, paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days), acute kidney failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days), dysphagia (difficulty swallowing), dependence on renal dialysis (a treatment for people whose kidneys are failing), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problem), acute respiratory failure with hypoxia (loss of breath) and acquired absence of left leg below knee (amputation).<BR/>Record review of Resident #1's admission MDS assessment dated [DATE] reflected she had no hearing, vision or speech issues and her BIMS score was 13, which indicated her cognition was intact. Resident #1 had no signs or symptoms of delirium, no negative mood issues and no behavioral symptoms which included rejection of care. Resident #1 required limited assistance of staff for her ADLs and had range of motions limitation in her lower extremity on one side and used a wheelchair for mobility. Resident #1 was frequently incontinent of bowel. Resident #1 had a recent major surgery of a below knee amputation prior to admission which required active SNF care. Resident #1 was five foot four and weighed 115 pounds and was at risk of developing pressure ulcers. Resident #1 had one unhealed pressure ulcer that was unstageable and present upon admission and she required pressure ulcer care. Resident #1 received a high risk medication called antiplatelet therapy (medication that helps prevent blood clots), and she also received oxygen therapy and dialysis. <BR/>Record review of Resident #1's care plan dated 12/22/23 reflected, The resident has a pressure ulcer or potential for pressure ulcer development: Date Initiated: 12/22/2023; The resident requires a cushion to their wheel or Geri chair . Resident #1's care plan did not address her need for wound care treatment or that she admitted to the facility with an unstageable pressure ulcer. <BR/>Record review of Resident #1's physician order dated 12/23/23 reflected, Unstageable sacrum wound, cleanse with NS, pat dry, apply Santyl and Calcium Alginate, cover with adhesive foam dressing QD and PRN as needed. <BR/>Record review of Resident #1's wound treatment record [TAR] reflected she did not receive daily wound care treatment to her pressure ulcer on 12/25/23, 12/26/23, 12/27/23, 12/30/23 and 01/01/24 through 01/04/24. <BR/>Record review of nursing progress notes on the dates Resident #1 did not have documented pressure ulcer wound care provided [12/25/23, 12/26/23, 12/27/23, 12/30/23 and 01/01/24 through 01/04/24] did not indicate wound care was provided as ordered daily or PRN. <BR/>Record review of Resident #1's Weekly Ulcer assessment dated [DATE] reflected she had an unstageable pressure wound to her sacrum and measured 5.5cm x 2.5 cm with no infection. <BR/>Record review of Resident #1's weekly Ulcer assessment dated [DATE] reflected she continued to have an unstageable pressure wound to her sacrum and measured 3.8 x 2.8 and had decreased in size with no infection. <BR/>An interview with LVN C on 01/05/24 at 1:15 PM revealed she was the morning charge nurse for Resident #1. LVN C stated Resident #1's family was concerned about her wound care and repositioning herself on her own. LVN C stated Resident #1 was alert and oriented x3 and knew to keep the weight off her coccyx. LVN C stated the family stated Resident #1 obtained the pressure ulcer to her coccyx while in the hospital prior to admission, but LVN C did not know if it had gotten bigger since admission. She stated the wound care nurse [LVN D] did the wound care for Resident #1. <BR/>An interview with ADON A on 01/05/24 at 3:50 PM revealed she looked at the wound care TAR for Resident #1 and identified that she did not receive wound care for 12/25/23, 12/26/23, 12/27/23, 12/30/23 and 01/01/24 through 01/04/24. She stated that she remembered doing it on 01/01/24 because the wound care nurse [LVN D] was not at the facility. ADON A stated she remembered doing the dressing change and wound care because a CNA came to her and said they had showered Resident #1 and her dressing was wet, so ADON A did a PRN dressing change on it. ADON A stated she did not document that she changed the dressing or provided wound treatment on the TAR. ADON A could not locate any recent notes post-admission from the wound care doctor. ADON A stated when a resident admitted with a wound/pressure ulcer, the first thing that needed to occur was the wound needed to be assessed with initial measurements. If the wound was unstageable, that would be documented and then the admitting nurse would look for wound care in the admission orders from the hospital. If the orders were present, the admitting nurse would then enter them into the e-chart and initiate them. If the wound care orders were not present upon admission, then the admitting nurse would need to do a basic dry dressing until the resident could be seen by the wound care nurse who knew what all of the facility's standing orders were for pressure ulcers and had a protocol she went by. ADON A stated measurements on wound should be done every week and documented as an assessment and when she last saw the wound on 01/01/24, the wound did have dome slough but was not infected and looked good and the edges were clear. <BR/>An observation and interview with Resident #1 occurred on 01/05/23 at 5:15 PM. Resident #1 stated the facility was not consistent in treating the wound on her sacrum every day and when she went to dialysis, she had to sit on her bottom for four hours which hurt, no matter what position she tried to get into. She was frustrated at their slow response time to answer the call light and did not feel like her pain medication was sufficient at times to treat the discomfort she had on her bottom and newly amputated stump that had healing stitches. <BR/>An interview with LVN D on 01/08/23 at 10:50 AM revealed she was the wound care nurse for the facility. LVN D stated Resident #1's pressure ulcer was being debrided with Santyl every day and if LVN D was not working at the facility on a certain day, the charge nurses or weekend supervisor could do the wound. LVN D stated she usually would tell the 6 AM-2 PM charge nurses if she was going to be on leave ahead of time so they knew they would need to complete the residents' wound care that day. LVN D stated she remembered she worked on Christmas day (12/25/23) from 2pm-10pm as a charge nurse on the floor, so she would not have done any wound care that shift except for any residents assigned to her hall. Then on 12/26/23, LVN D stated she got sick and called in and came back on 12/27/23 through 12/29/23. Then Monday, 01/01/24 was New Year's Day and LVN D said she did not work that day but did work 01/02/24 through 01/04/23 as the wound care nurse. LVN D stated, What I can tell you, when I am here, they [wound care] are done, I may have forgotten to sign out [on the TAR] that week, so be it. But I did do it and if I didn't, there would be a documented reason. LVN D stated when she was unable to do wound care for residents and it fell on the charge nurses, she always made sure to stock her treatment cart with everything she used so the charge nurses had access to it and would not have to run around to find anything. LVN D stated, Sounds like we need a better communication system. LVN D stated there was a day she would not complete Resident #1's wound care because his dialysis chair time changed and she left at noon instead of at 2pm. LVN D stated she got to work around 5-5:30 AM to do wound care but Resident #1 was often sleeping, eating or in rehab therapy. LVN D stated Resident #1's wound on Friday 01/05/24 was looking better, thinner slough and We are making headway. LVN D stated Resident #1 had not been seen by the wound care doctor yet but LVN D had spoken with him and he gave her the new treatment orders post-admission and said the wound was not going to heal until the slough was off. LVN D stated slough is like a biofilm, a natural response and usually happened when air hits the wound and if it had been there for a bit, like Resident #1's, it was like rubber and was adherent to the granulating tissue. So as long as that was there, the wound could not close and there was a higher risk of bacteria getting into the slough and getting infected. <BR/>An interview with ADON B on 01/08/23 at 11:21 AM revealed when the wound care nurse was not available, ideally the charge nurse for Resident #1 would complete the wound care to her pressure ulcer, but if the charge nurse was busy, then either of the two ADONs could complete it. ADON B stated she remembered doing wound care to Resident #1 for a couple of days when wound care LVN D was out sick, But whether or not I did it in the TAR I can't say, that is a part of the chart I do not access that much. ADON B stated she remembered the orders were listed on Resident #1's wound care administration record, so she remembered Resident #1's was to clean with normal saline and apply Santyl and calcium alginate and cover. ADON B stated, Documentation I did not do. Bottom line is if it is not documented, it didn't get done. Her wound has gotten better though. <BR/>A follow up interview on 01/08/24 at 12:00 PM with wound care LVN D occurred where she stated, I am going to confess something, some [blanks on TAR for wound care] were mine that I forgot to document because I was looking at others [residents wounds] those days and I didn't document them either, so some of those days are my error. So I just went back in and clicked on the MAR/TAR today that I did it.<BR/>An interview with the DON on 01/08/24 at 12:35 PM revealed she had just learned that day (01/08/24) that Resident #1's wound care treatment was not being documented as completed. The DON stated an in-service would be started immediately and I want the nurses to understand the wound care gets done and it is documented and if it doesn't get done, then document why. The DON stated in the morning meeting, she was going to start pulling up wound care logs and treatment records and address any missing treatments daily in the morning meetings. The DON stated prior to investigator intervention, the facility nursing management ran audits once a week for nursing MAR and medication aide MAR, but not for the wound care TAR. The DON stated a potential negative outcome of was there was no proof that wound care was being provided, if it is not documented, it didn't get done and it is an education they know because we have had that education before.<BR/>Record review of the facility's policy titled, Pressure Injury: Prevention, Assessment and Treatment revised 08/12/16, reflected, Procedure: 1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection .10. Treatment Nurse/Designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet any treatment completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, maintained medical records on each resident that were complate and accurately documented for one (Resident #1) of four residents reviewed for quality of care. <BR/>The facility failed to provide wound care to Resident #1's coccyx on 12/25/23, 12/26/23, 12/27/23, 12/30/23 and 01/01/24 through 01/04/24 and document when it was provided. <BR/>The facility failure placed residents at risk of continued pain, discomfort, infection and a worsening of their wounds. <BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 12/27/23 reflected she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses which included atherosclerosis (thickening and hardening of the arteries) of native arteries of left leg with ulceration (a long-lasting (chronic) sore that takes more than 2 weeks to heal) of other part of foot, paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days), acute kidney failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days), dysphagia (difficulty swallowing), dependence on renal dialysis (a treatment for people whose kidneys are failing), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problem), acute respiratory failure with hypoxia (loss of breath) and acquired absence of left leg below knee (amputation).<BR/>Record review of Resident #1's admission MDS assessment dated [DATE] reflected she had no hearing, vision or speech issues and her BIMS score was 13, which indicated her cognition was intact. Resident #1 had no signs or symptoms of delirium, no negative mood issues and no behavioral symptoms which included rejection of care. Resident #1 required limited assistance of staff for her ADLs and had range of motions limitation in her lower extremity on one side and used a wheelchair for mobility. Resident #1 was frequently incontinent of bowel. Resident #1 had a recent major surgery of a below knee amputation prior to admission which required active SNF care. Resident #1 was five foot four and weighed 115 pounds and was at risk of developing pressure ulcers. Resident #1 had one unhealed pressure ulcer that was unstageable and present upon admission and she required pressure ulcer care. Resident #1 received a high risk medication called antiplatelet therapy (medication that helps prevent blood clots), and she also received oxygen therapy and dialysis. <BR/>Record review of Resident #1's care plan dated 12/22/23 reflected, The resident has a pressure ulcer or potential for pressure ulcer development: Date Initiated: 12/22/2023; The resident requires a cushion to their wheel or Geri chair . Resident #1's care plan did not address her need for wound care treatment or that she admitted to the facility with an unstageable pressure ulcer. <BR/>Record review of Resident #1's physician order dated 12/23/23 reflected, Unstageable sacrum wound, cleanse with NS, pat dry, apply Santyl and Calcium Alginate, cover with adhesive foam dressing QD and PRN as needed. <BR/>Record review of Resident #1's wound treatment record [TAR] reflected she did not receive daily wound care treatment to her pressure ulcer on 12/25/23, 12/26/23, 12/27/23, 12/30/23 and 01/01/24 through 01/04/24. <BR/>Record review of nursing progress notes on the dates Resident #1 did not have documented pressure ulcer wound care provided [12/25/23, 12/26/23, 12/27/23, 12/30/23 and 01/01/24 through 01/04/24] did not indicate wound care was provided as ordered daily or PRN. <BR/>Record review of Resident #1's Weekly Ulcer assessment dated [DATE] reflected she had an unstageable pressure wound to her sacrum and measured 5.5cm x 2.5 cm with no infection. <BR/>Record review of Resident #1's weekly Ulcer assessment dated [DATE] reflected she continued to have an unstageable pressure wound to her sacrum and measured 3.8 x 2.8 and had decreased in size with no infection. <BR/>An interview with LVN C on 01/05/24 at 1:15 PM revealed she was the morning charge nurse for Resident #1. LVN C stated Resident #1's family was concerned about her wound care and repositioning herself on her own. LVN C stated Resident #1 was alert and oriented x3 and knew to keep the weight off her coccyx. LVN C stated the family stated Resident #1 obtained the pressure ulcer to her coccyx while in the hospital prior to admission, but LVN C did not know if it had gotten bigger since admission. She stated the wound care nurse [LVN D] did the wound care for Resident #1. <BR/>An interview with ADON A on 01/05/24 at 3:50 PM revealed she looked at the wound care TAR for Resident #1 and identified that she did not receive wound care for 12/25/23, 12/26/23, 12/27/23, 12/30/23 and 01/01/24 through 01/04/24. She stated that she remembered doing it on 01/01/24 because the wound care nurse [LVN D] was not at the facility. ADON A stated she remembered doing the dressing change and wound care because a CNA came to her and said they had showered Resident #1 and her dressing was wet, so ADON A did a PRN dressing change on it. ADON A stated she did not document that she changed the dressing or provided wound treatment on the TAR. ADON A could not locate any recent notes post-admission from the wound care doctor. ADON A stated when a resident admitted with a wound/pressure ulcer, the first thing that needed to occur was the wound needed to be assessed with initial measurements. If the wound was unstageable, that would be documented and then the admitting nurse would look for wound care in the admission orders from the hospital. If the orders were present, the admitting nurse would then enter them into the e-chart and initiate them. If the wound care orders were not present upon admission, then the admitting nurse would need to do a basic dry dressing until the resident could be seen by the wound care nurse who knew what all of the facility's standing orders were for pressure ulcers and had a protocol she went by. ADON A stated measurements on wound should be done every week and documented as an assessment and when she last saw the wound on 01/01/24, the wound did have dome slough but was not infected and looked good and the edges were clear. <BR/>An observation and interview with Resident #1 occurred on 01/05/23 at 5:15 PM. Resident #1 stated the facility was not consistent in treating the wound on her sacrum every day and when she went to dialysis, she had to sit on her bottom for four hours which hurt, no matter what position she tried to get into. She was frustrated at their slow response time to answer the call light and did not feel like her pain medication was sufficient at times to treat the discomfort she had on her bottom and newly amputated stump that had healing stitches. <BR/>An interview with LVN D on 01/08/23 at 10:50 AM revealed she was the wound care nurse for the facility. LVN D stated Resident #1's pressure ulcer was being debrided with Santyl every day and if LVN D was not working at the facility on a certain day, the charge nurses or weekend supervisor could do the wound. LVN D stated she usually would tell the 6 AM-2 PM charge nurses if she was going to be on leave ahead of time so they knew they would need to complete the residents' wound care that day. LVN D stated she remembered she worked on Christmas day (12/25/23) from 2pm-10pm as a charge nurse on the floor, so she would not have done any wound care that shift except for any residents assigned to her hall. Then on 12/26/23, LVN D stated she got sick and called in and came back on 12/27/23 through 12/29/23. Then Monday, 01/01/24 was New Year's Day and LVN D said she did not work that day but did work 01/02/24 through 01/04/23 as the wound care nurse. LVN D stated, What I can tell you, when I am here, they [wound care] are done, I may have forgotten to sign out [on the TAR] that week, so be it. But I did do it and if I didn't, there would be a documented reason. LVN D stated when she was unable to do wound care for residents and it fell on the charge nurses, she always made sure to stock her treatment cart with everything she used so the charge nurses had access to it and would not have to run around to find anything. LVN D stated, Sounds like we need a better communication system. LVN D stated there was a day she would not complete Resident #1's wound care because his dialysis chair time changed and she left at noon instead of at 2pm. LVN D stated she got to work around 5-5:30 AM to do wound care but Resident #1 was often sleeping, eating or in rehab therapy. LVN D stated Resident #1's wound on Friday 01/05/24 was looking better, thinner slough and We are making headway. LVN D stated Resident #1 had not been seen by the wound care doctor yet but LVN D had spoken with him and he gave her the new treatment orders post-admission and said the wound was not going to heal until the slough was off. LVN D stated slough is like a biofilm, a natural response and usually happened when air hits the wound and if it had been there for a bit, like Resident #1's, it was like rubber and was adherent to the granulating tissue. So as long as that was there, the wound could not close and there was a higher risk of bacteria getting into the slough and getting infected. <BR/>An interview with ADON B on 01/08/23 at 11:21 AM revealed when the wound care nurse was not available, ideally the charge nurse for Resident #1 would complete the wound care to her pressure ulcer, but if the charge nurse was busy, then either of the two ADONs could complete it. ADON B stated she remembered doing wound care to Resident #1 for a couple of days when wound care LVN D was out sick, But whether or not I did it in the TAR I can't say, that is a part of the chart I do not access that much. ADON B stated she remembered the orders were listed on Resident #1's wound care administration record, so she remembered Resident #1's was to clean with normal saline and apply Santyl and calcium alginate and cover. ADON B stated, Documentation I did not do. Bottom line is if it is not documented, it didn't get done. Her wound has gotten better though. <BR/>A follow up interview on 01/08/24 at 12:00 PM with wound care LVN D occurred where she stated, I am going to confess something, some [blanks on TAR for wound care] were mine that I forgot to document because I was looking at others [residents wounds] those days and I didn't document them either, so some of those days are my error. So I just went back in and clicked on the MAR/TAR today that I did it.<BR/>An interview with the DON on 01/08/24 at 12:35 PM revealed she had just learned that day (01/08/24) that Resident #1's wound care treatment was not being documented as completed. The DON stated an in-service would be started immediately and I want the nurses to understand the wound care gets done and it is documented and if it doesn't get done, then document why. The DON stated in the morning meeting, she was going to start pulling up wound care logs and treatment records and address any missing treatments daily in the morning meetings. The DON stated prior to investigator intervention, the facility nursing management ran audits once a week for nursing MAR and medication aide MAR, but not for the wound care TAR. The DON stated a potential negative outcome of was there was no proof that wound care was being provided, if it is not documented, it didn't get done and it is an education they know because we have had that education before.<BR/>Record review of the facility's policy titled, Pressure Injury: Prevention, Assessment and Treatment revised 08/12/16, reflected, Procedure: 1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection .10. Treatment Nurse/Designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet any treatment completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs for 6 (Residents #8, #10, #34, #38, #40, and #76) of 8 residents reviewed for PASARR compliance. <BR/>The facility failed to follow up on Residents #8, #10, #34, #38, #40, and #76, who were PASARR Level I positive and refer them to the local authority for further evaluation to determine their need for specialized services.<BR/>This failure placed the residents at risk of not receiving the full extent of services available to them and/or alternative living accommodations. <BR/>Findings included:<BR/>Record review of residents triggered for PASARR review revealed six residents had not been referred to the local authority for PASARR II screening or had form 1012 filed verifying they had dementia and did not require PASARR II screening. <BR/>Review of Resident #8's admission Record revealed the resident was [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included depression and paranoid schizophrenia. A diagnosis of schizoaffective disorder was added on 9/10/20. <BR/>Review of Resident #8's quarterly MDS, dated [DATE], revealed a BIMS score of 12 indicating moderate cognitive impairment. <BR/>Review of Resident #8's care plan, dated 04/19/23, indicated he required the use of an anti-psychotic for his mental illness. <BR/>Review of Resident #8's PASRR Level I completed on 04/18/23 indicated he had no mental illness.<BR/>Review of Resident #8's physician orders revealed he had no orders for an anti-psychotic. <BR/>Review of Resident #10's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke, difficulty swallowing due to stroke, and bipolar disorder. A diagnosis of schizoaffective disorder was added on 8/31/20. <BR/>Review of Resident #10's quarterly MDS, dated [DATE], revealed a BIMS score of 10 indicating moderate cognitive impairment. <BR/>Review of Resident #10's care plan, dated 06/28/23, revealed he required the use of an anti-psychotic for his schizoaffective disorder. <BR/>Review of Resident #10's physician orders revealed he was prescribed Seroquel 200 mg once a day for schizoaffective disorder. <BR/>Review of Resident #10's PASRR Level I completed on 03/24/20 indicated he had no mental health issues.<BR/>Review of Resident #34's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included skin infection, depression, and bipolar disorder. <BR/>Review of Resident # 34's admission MDS, dated [DATE], revealed a BIMS score of 13 indicating he was cognitively intact. <BR/>Review of Resident #34's care plan, dated 07/17/23, revealed he required the use of an anti-psychotic for his bipolar disorder. <BR/>Review of Resident #34's physician orders revealed he was prescribed Quetiapine 50 mg twice a day for bipolar disorder. <BR/>Review of Resident #34's PASRR Level I completed on 07/13/23 indicated he had no mental illness.<BR/>Review of Resident #38's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included bipolar disorder, depression, and anxiety. <BR/>Review of Resident #38's annual MDS, dated [DATE], revealed a BIMS score of 8, indicating moderate cognitive impairment. <BR/>Review of Resident #38's care plan, dated 03/29/23, revealed she required the use of an antidepressant. <BR/>Review of Resident #38's PASRR Level I, completed on 05/11/22 indicated she had no mental illness. A second PASRR Level I was not completed after she was admitted to the facility. <BR/>Review of Resident #38's physician orders revealed she had no orders for treatment of her bipolar disorder. <BR/>Review of Resident #40's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included kidney disease, paralysis, depression. A diagnosis of bipolar disorder was added on 09/21/20. <BR/>Review of Resident #40's quarterly MDS, dated [DATE], revealed a BIMS score of 15 indicating he was cognitively intact. <BR/>Review of Resident #40's care plan, dated 03/05/23, revealed no mental health issues except depression for which he took an antidepressant. <BR/>Review of Resident #40's physician orders revealed he was prescribed Sertraline 100 mg once a day for depression. <BR/>Review of Resident #40's His PASRR Level I, completed on 07/17/20 indicated he had no mental illness. A second PASRR Level I was not completed after the new diagnosis was added on 09/21/20.<BR/>Review of Resident #76's admission Record revealed the residen twas a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included morbid obesity, muscle wasting, unsteadiness on her feet. A diagnosis of bipolar disorder was added on 03/31/22.<BR/>Review of Resident #76's quarterly MDS, dated [DATE], revealed a BIMS score of 15 indicating she was cognitively intact. <BR/>Review of Resident #76's care plan, dated 07/29/23, revealed she was at risk for depression and required an antidepressant. <BR/>Review of Resident #76's PASRR Level I, dated 04/19/23, indicated she had no mental illness. <BR/>Review of Resident #76's physician orders revealed she was prescribed Aripiprazole 5 mg once a day for bipolar disorder. <BR/>Interview on 08/21//23 at 2:25 PM with the Administrator revealed she had been without an MDS nurse for over a month but had hired one on 08/20/23 and a second one was due to start in a week. MDS Coordinators from sister facilities had been filling in while she was going through the hiring process. She stated she did not know why the resident's PASARR Level II was not completed.<BR/>Review of 1012 forms, Mental Illness/Dementia Review, provided by the Administrator on 08/22/23 for Residents #8, #10, #34, #38, #40, and #76 indicated Residents #10 and #38 had a diagnosis of dementia and did not require a new PASARR 1 to be submitted. Review of Resident #38's admission Record revealed no diagnosis of dementia is listed. Residents #8, #34, #40, and #76 did require a new PASARR 1 to be submitted, which were submitted on 08/21/23. <BR/>The was asked to provide a policy regarding PASSAR; however, a policy was not provided.

**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 is unable to carry out activities of daily living, receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #1) of 3 residents reviewed for ADLs. <BR/>The facility failed to ensure Resident #1 was not left in a soiled brief for an extended period of time on 04/04/24.<BR/>This failure could place the resident at risk for skin breakdown.<BR/>Findings included:<BR/>Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of right lower leg, morbid obesity, heart failure, and asthma.<BR/>Review of Resident #1's admission MDS assessment, dated 01/04/24, revealed a BIMS score of 10 indicating she was mildly cognitively impaired. Her Functional Status indicated she required assistance with most of her ADLs, and assistance of 1-2 people for toileting. Her Bowel and Bladder Assessment indicated she was always incontinent of bowel.<BR/>Review of Resident #1's care plan, dated 01/01/24 revealed her care plan had not been individualized. Resident #1 was a risk for pressure ulcer development, the resident had a skin tear, laceration or abrasions to. The resident has a surgical site to:The resident has an ADL Self Care Performance Deficit. Resident #1 was not care planned for bowel and bladder incontinence. <BR/>Observation and interview on 04/04/24 at 9:05 AM Resident #1 stated she was currently soiled, and she had called for help at 8:40 AM. The resident had times and dates documented on her cell phone and showed them to the surveyor. Resident #1 stated CNA A had answered the call light within a few minutes and stated she was going to find help. CNA A was observed to have returned with the Staffing Coordinator at 9:26 AM to perform incontinence care. Resident #1 stated it was the second time that morning she had to wait and extended period of time to be changed. She stated she pushed the call light at 6:18 AM and CNA B answered at 6:59 AM, CNA B went for help, and she was finally changed at 7:18 AM. Resident #1 stated she has had to call her family at home to come help her get changed because staff had not responded or there was not enough help for two people to come in and help. Resident #1 stated she felt like she had developed skin breakdown because of lying in her waste for long periods of time. <BR/>Interview on 04/04/24 at 9:20 AM with Resident #1's family member revealed they had been called at home multiple times by the resident when she was not getting the help she needed. They stated often they would come in to help with incontinence care only to observe the nurse sitting at the nurse station not doing anything. and the CNA and he would change the resident. The family member stated they stay at the facility most of the day every day to assist with care because there is never enough staff to give prompt care. The CNAs always had to look for someone to help them, so he ended up assisting the CNA. The family member stated they knew they would be helping the resident when she went home, but he did not think he should have to be so involved while she was still at the facility. <BR/>Observation on 04/04/24 at 1:07 PM of incontinence care provided by CNA B and the family member revealed the resident had soft stool. CNA B provided the resident with perineal care, while the family member held the resident up. The resident had reddened areas in the skin folds on both sides of her perineal area, and barrier cream was applied, The resident had reddened areas to both buttocks, also treated with barrier cream. No skin breakdown was observed.<BR/>Interview on 04/04/24 at 1:35 PM with the ADON revealed stated his expectation for call light response was for it to be answered within 5-15 minutes. He stated anything longer than that would be unacceptable depending on what else was going on in the unit. The ADON stated a 45-minute response time was definitely excessive. The staff should answer the call light. If help was needed,they should be able to find someone to help within 5-10 minutes. If it was taking longer than that they needed to update the resident to let them know they had not been forgotten. <BR/>Interview on 04/04/24 at 1:40 PM with the DON revealed she expected call lights to be answered within 5-10 minutes depending on what was going on in the hall. The DON stated if a CNA needed help with a resident, they should be able to find someone within 10-20 minutes. She stated they had no staffing shortages, all open positions were covered by staff. The DON stated she was unaware that Resident #1's family was being called at home to come help with the resident. She stated the family needed to learn to care for the resident as she was due to be discharged in a few days, so it was good training.<BR/>Interview on 04/04/24 at 2:00 PM with CNA A revealed the incontinence care for Resident #1 at 9:30 AM was delayed because she could not find any help. CNA A stated the other CNA was out monitoring the smoking residents, she could not find the nurse, she asked for help on the 200 hall, and finally asked the Staffing Coordinator to help her. CNA A stated leaving the resident in soiled briefs for extended periods could cause skin breakdown. <BR/>Interview on 04/04/24 at 2:10 PM with CNA B revealed she had been out with the smokers from 9:00 AM-9:30 AM. CNA B stated they often used the help of Resident #1's family because they could not find the other CNA, and the nurses usually would not help because they had something else to do. CNA B stated the risk of leaving a resident in soiled briefs was that it could cause skin breakdown or urinary tract infections. <BR/>Interview on 04/04/24 at 2:15 PM with the Staffing Coordinator revealed CNA A came to her for help because she could not find any help for Resident #1. The Staffing Coordinator stated it was rare for the CNAs to have to come to her for help. <BR/>Review of the facility's current Perineal Care Female policy, dated 12/08/09, reflected the steps of providing care, but did not reference time frames for care or define what would be considered prolonged wait times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #82) of 18 residents reviewed for quality of care. <BR/>The facility failed to ensure Resident #82 received dressing changes to his lower legs as scheduled.<BR/>This failure placed the resident at risk of infection and decreased feelings of self-worth. <BR/>Findings included:<BR/>Review of Resident #82's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included skin infection to both lower legs, heart failure, and reduced mobility.<BR/>Review of Resident # 82's admission MDS, dated [DATE], revealed a BIMS score of 13 indicating he was cognitively intact. His Functional Status indicated he required limited assistance with his ADLs. <BR/>Review of Resident #82's care plan, dated 07/17/23, revealed he had edema, putting him at risk for fluid imbalance; venous ulcers to both lower legs related to lymphedema (swelling caused by blockage in the lymphatic system), with interventions of wound care, and elevation of legs when in bed. <BR/>Review of Resident # 82's physician orders revealed an order to cleanse both lower legs with saline, pat dry, apply betadine, cover with abdominal pads, secure with kling wrap and ace bandages twice a day and as needed. <BR/>Interview and observation on 08/20/23 at 11:28 AM, Resident #82 stated he had been admitted to help reduce the swelling in his lower legs, and to receive proper wound care. Resident stated he lived alone on a fixed income and could not afford the proper wound care supplies. He would scrub his legs with half-strength peroxide and then wrap them with paper towels. This led to him being admitted to the hospital with pseudomonas (bacterial) sepsis. Resident #82 stated his wound care was scheduled daily, but it did not always happen on the weekends. Resident #82 stated his dressings had not been changed since 08/18/23 when the wound care nurse did them. Observation of Resident #82's dressings revealed they were saturated with serosanguinous (mixture of blood and body fluid) drainage. Resident was in his wheelchair with his feet resting on a towel that was very wet with the drainage that was dripping off the resident's heels. There was a strong earthy, yeast like odor in the room indicative of pseudomonas. <BR/>Interview and observation on 08/21/23 at 11:00 AM, Resident #82 stated the wound care nurse had changed his dressing that morning. Resident's dressings were clean, but there was serosanguinous fluid dripping from his heels onto a pad on the floor. <BR/>Interview and observation on 08/22/23 at 10:00 AM, the Wound Care Nurse changed Resident #82's dressing to his lower legs. The resident's right lower leg was larger than the left. The skin on the back of the resident's calf had split open in multiple places and had copious serosanguinous fluid dripping onto the floor. The resident's left lower leg had one open area to the back of the calf with moderate serosanguinous fluid draining. The Wound Care Nurse stated it required a minimum of two staff to perform the dressing change due to the location, the weight of the resident's legs, and the complicated dressings that were applied. She stated she performed wound care Monday through Friday, and the weekend care was to be done by the nurses. The Wound Care Nurse agreed that Resident #82's dressing on 08/21/23 did not appear to have been changed on 08/20/23 due to the condition of the dressing when she changed it on 08/21/23. She stated regular dressing changes were required to prevent infection. The Wound Care Nurse also stated the order for Resident #82's dressing to be changed twice a day had been an error on her part when she entered it, he only needed it changed once a day and she would amend the order. The Wound Care Nurse stated the resident's wounds did not appear to have deteriorated over the weekend, they appeared the same as when she last saw them. <BR/>Interview on 08/22/23 at 11:00 AM, the ADON stated he was unaware Resident #82's dressing had not been changed as scheduled. He stated the facility used to have a Weekend Supervisor, who would perform wound care on the weekends, but Weekend Supervisor had quit and had not been replaced yet. Wound care on the weekends was the responsibility of the floor nurse. <BR/>Interview on 08/22/23 at 1:49 PM with the Wound Care Nurse revealed when a new resident admits to the facility, the nurses are responsible to complete a head-to-toe assessment, skin assessment, take vitals, call physician, and review medications. <BR/>Interview on 08/22/23 at 3:11 PM with the Unit Manager revealed the process of any new admission the nurse who admits the resident is responsible to obtain and complete residents' vitals (blood pressure, pulse, respirator), head-to-toe assessment, skin assessment, and check if resident is alert and oriented. <BR/>Interview on 08/22/23 at 3:18 PM with LVN H revealed the process for a new admission, the nurses should obtain vitals, complete head to toe assessment, skin assessment, review medications and contact physician. <BR/>The facility did not have a policy regarding wound care specifically.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status based on the residents' comprehensive assessments for 4 (Residents #90, #91, #204, and #206) of 18 residents reviewed for nutrition. <BR/>The facility failed to obtain Resident #90, #91, #204, #206 weights at admission per facility policy. <BR/>This failure placed the resident at risk of infection and decreased feelings of self-worth. <BR/>Findings included:<BR/>Review of Resident #90's admission Record, dated 08/22/23, revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses that included end stage renal disease (kidney disease), and high blood pressure <BR/>Review of Resident # 90's quarterly MDS, dated [DATE], revealed a BIMS score of 14 indicating the resident was cognitively intact. <BR/>Review of Resident #90's care plan, dated 04/09/023, revealed Resident #90 had a potential risk of malnutrition, had an altered diet, renal regular diet. The care plan reflected the resident would maintain stable weights and nutritional paraments. The care plan interventions included monitoring the resident's weight. <BR/>Review of Resident #90's Nursing admission assessment, dated 03/28/23, revealed there was no weight documented, and the assessment was signed and completed on 03/29/23 by the Wound Care Nurse<BR/>Review of Resident #90 electronic weight revealed weight was completed on 04/05/23. <BR/>Review of Resident #91's admission Record, dated 08/22/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, Type 2 Diabetes, high blood pressure, and unspecified protein-calorie malnutrition. <BR/>Review of Resident # 91's quarterly MDS, dated [DATE], revealed a BIMS score of 08 indicating the resident's cognition was moderately impaired. <BR/>Review of Resident #91's care plan, dated 05/02/23, revealed Resident #91 had an ADL self-care<BR/>performance deficit. The care plan reflected the resident would maintain or improve current levels of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene; ADL Score) through the review date.<BR/>Review of Resident #91's Nursing admission Assessment, dated 05/01/23, revealed there was no weight documented, and the assessment was signed and completed on 05/01/23 by RN F. <BR/>Review of Resident #91's electronic weight revealed weight was completed on 05/03/23.<BR/>Review of Resident #204's admission Record, dated 08/22/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included surgical amputation, Type 2 diabetes, high blood pressure and anemia. <BR/>Review of Resident #204's admission MDS, dated [DATE], revealed a BIMS score of 14 indicating the resident was cognitively intact. <BR/>Review of Resident #204's care plan, dated 08/04/23, revealed Resident #204 had hypertension. The care plan reflected the resident would remain free of complications related to hypertension through review date. The care plan reflected the resident, family, caregiver would be educated about: the importance of maintaining a normal weight for height, the value of regular, exercise, limiting salt intake, the adverse effects of tobacco and alcohol, the importance of medication and diet compliance.<BR/>Review of Resident #204's Nursing admission assessment, dated 08/03/23, revealed no weight documented. Signed and completed on 08/04/23 by RN G. <BR/>Review of Resident #204's electronic weight revealed weight was completed on 08/07/23. <BR/>Review of Resident #206's admission Record, dated 08/22/23, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included encounter for surgical aftercare following surgery, high blood pressure, gastro-esophageal reflux disease and unspecified severe protein-calorie malnutrition. <BR/>Review of Resident #206's MDS, dated [DATE], revealed a BIMS score of 15 indicating she was cognitively intact. <BR/>Review of Resident #206's care plan, dated 08/18/23, revealed Resident #206 had a diet order other than regular diet and was at risk for unplanned weight loss or gain. The care plan reflected the resident would maintain an ideal weight and receive proper nutrition daily for 90 days. The care plan also reflected the resident's weight would be monitored per facility protocol. <BR/>Review of Resident #206's Nursing admission Assessment, dated 08/15/23, revealed weight was completed on 08/17/23, and it was signed and completed on 08/18/23 by the Unit Manager. <BR/>Review of Resident #90, #91, #204 and #206 weights revealed no concerns regarding weight loss.<BR/>Interview on 08/22/23 at 1:49 PM with the Wound Care Nurse revealed they took residents weight upon admission. The Wound Case Nurse stated she is not sure if she admitted Resident #90, she stated she recalls only assisting with his admission process. <BR/>Interview on 08/22/23 at 2:07 PM with the Wound Care Nurse revealed she had reviewed Resident #90 clinical records, and the records reflected she was the one who admitted Resident #90. She stated she was not sure why Resident #90's weight was not completed upon admission; however, it should had been completed within 24 hours. She stated initial weighs are important because it establish a baseline. <BR/>Interview on 08/22/23 at 3:11 PM with Unit Manager revealed the process of any new admission the nurse who admits the resident is responsible to obtain and complete residents' vitals (blood pressure, pulse, respirator), head-to-toe assessment, skin assessment, and check if resident is alert and oriented. The Unit Manager stated weights should be completed upon admission. She stated she does not recall admitting Resident #206; however, last week she noticed that Resident #206 initial assessments was not documented in PCC upon admission. She stated her weights were not obtained and is unsure why. She stated admission weights are needed to establish a baseline care and to determine if there is any weight loss or weight gain. <BR/>Interview on 08/22/23 at 3:18 PM with LVN H revealed weights should be completed upon admission. LVN H stated she admitted Resident #204, she stated she was unaware why his weights were not completed. She stated she believes she asked the upcoming nurse to complete Resident #204 assessments. LVN H stated initial weighs are important because it establish a baseline helps determine the services they would provide to the resident. <BR/>Interview on 08/22/23 at 3:56 PM with the DON revealed her expectations are for new admits weights to be completed within 48 hours of admission. She stated she was unaware until recently that weights were not being completed upon admission. She stated she reviewed Resident #206 and noticed her assessments were not completed/documented. She stated it is the unit manager and herself responsibility to ensure weights are being obtained. The DON stated weight are needed upon admission for staff to monitor any weight loss or weight gain. <BR/>Review of facility's current Resident Weight, policy and procedure, revised 02/13/07, reflected in part the following: .1. Weights shall be obtained and documented at admission, readmission, and monthly unless ordered otherwise by the physician, or unless dictated more frequently by the resident's condition 3. All new admissions and readmissions will have a height and weight obtained within 24 hours of admission then weighed at least weekly x4. This information shall be recorded on the nursing admission assessment and in PCC .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for one (Resident #37) of five residents reviewed for therapeutic diets. <BR/>The facility failed to provide Resident #37 a pureed diet as prescribed by the physician. <BR/>The failure placed residents at risk for aspiration and weight loss. <BR/>Findings included:<BR/>Review of Resident #37's MDS dated [DATE] revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, Alzheimer's disease, glaucoma, and dysphagia. Resident #37 had severely impaired cognition rarely/never understood others and never/rarely made self-understood.<BR/>Review of Resident #37's physicians order summary report for August 2023 revealed she was on a regular diet, puree texture with a start date of 05/15/23. <BR/>Review of Resident #37's hospital records dated 05/12/23 revealed the following:<BR/>Speech-Language Pathology Progress Notes<BR/> .Recommend:<BR/>.1. Pureed textures with thin/normal liquids. Careful hand feeding w/ focus on comfort/pleasure .<BR/>Observation and interview on 08/21/23 at 9:04 AM, of Resident #37 revealed she was in bed eating breakfast with her fingers. The resident was picking up what appeared to be pieces of cut up sausage and scrambled eggs. The resident was eating with her hands and had eaten about 75% of her breakfast. The resident had a bowl of uneaten oatmeal and the oats were whole and it was not in a puree form. CNA E was asked what type of diet Resident #37 was on and when she (CNA E) looked at the meal tray she said it was mechanical soft. The meal ticket was lying drawer next to the resident's bed and it read Regular/Puree. CNA E at that time took the tray from Resident #37 and stated she could not have it because it was not in puree form.<BR/>Interview on 08/22/23 at 10:51 AM, with LVN B revealed she had checked the resident meal trays before they were passed out and stated she did not think Resident #37 had been given a mechanical soft diet the day prior (08/21/23) for breakfast. LVN B said the meal appeared to be puree to her and when asked about the oatmeal she said, that (oatmeal) has always looked like that (whole oats) for residents that were on a puree diet. LVN B further stated the resident had never had any swallowing issues as a result. <BR/>Interview on 08/22/23 at 11:03 AM, with the Unit Manager revealed charge nurses were responsible for checking each meal ticket and comparing it to the meal to ensure each resident was getting the correct diet. The Unit Manager stated it was important to make sure each resident got the correct diet for safety reasons such as choking and swallowing issues. <BR/>Review of Resident #37's clinical record revealed the resident had not had any choking or difficulty swallowing issues after the resident had been put on a pureed diet. <BR/>Interview on 08/22/23 at 9:03 AM, with the [NAME] revealed the dietary aides were responsible to matching the meal ticket to the correct tray prior to send them out for delivery. The [NAME] said she ran the oatmeal through the food processor but it was not able to puree the oats to a puree form so she would make sure it was cooked until the oats were soft and easy to swallow. She stated she would be putting the oatmeal in the blender instead of the food processor to see if she could get it to a puree consistency. <BR/>Observation on 08/22/23 at 9:10 AM, of a bowl oatmeal brought by the [NAME] revealed she had put it in the blender, and it had been turned into a puree, pudding like consistency. The [NAME] stated she would begin to use the blender to make the oatmeal was at a puree consistency. <BR/>Interview on 08/22/23 at 11:22 AM, with the Dietary Manager revealed he was responsible for overlooking at special diets such as the purees and mechanical soft. The Dietary Manager would make sure the puree form was a smooth pudding like consistency. He stated prior to serving the oatmeal they would make sure oats were cooked long enough to ensure they were soggy enough to swallow. The Dietary Manager admitted the way they were serving the oatmeal was not technically in puree form because the oats were not broken down to a puree consistency. He further stated risks of not having a fully puree meal included choking or difficulty swallowing. The Dietary Manager said the dietary aides were responsible for matching each meal ticket with the appropriate tray before being sent out for delivery. The tray carts are then checked again by the charge nurses to make sure the residents have the correct diet. <BR/>Interview on 08/22/23 at 11:50 AM, with the Dietitian revealed oatmeal should be served in smooth pudding like consistency so resident with swallowing issues did not choke. <BR/>Review of the policy titled Pureed Diet dated 2019 reflected the following:<BR/>The Pureed Diet is texture modification of Regular or therapeutic diets, designed to provide adequate nutrition for those persons with choking tendencies or difficulty with swallowing due to facial paralysis or other illness .<BR/>Review of the recipe for Hot Cereal dated 08/22/23 reflected the following:<BR/> .Desired thickness should be mashed potato, pudding, or applesauce texture. There should be no large lumps or particles

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to inform the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in mental or physical condition of a resident who has mental illness or intellectual disability for one (Resident #1) of one resident reviewed. <BR/>The facility failed to notify Resident #1's state mental health agency or intellectual disability agency of a significant change for Resident #1 when he expired on [DATE].<BR/>This failure could affect residents in the facility that are PASRR positive for their mental health agency or state intellectual disability agency not being notified of a significant change for residents. <BR/>Findings included:<BR/>Review of Residents #1's discharged face sheet, dated [DATE], reflected the resident admitted to the facility on [DATE] and discharged from the facility on [DATE]. His diagnoses included acute respiratory failure with hypoxia (below normal level of oxygen in the blood), Dementia, Huntington's Disease, <BR/>Review of Resident #1's discharge MDS Assessment, dated [DATE], reflected the resident discharged on [DATE], and the resident was deceased . <BR/>Review of Resident #1's care plan, closed date [DATE], did reflect a positive PASRR status.<BR/>Review of Resident #1's PASRR Level One Screening, dated [DATE] reflected he had both an intellectual disability and developmental disability.<BR/>Review of Resident #1's progress notes dated [DATE] at 10:37 AM reflected the following: LATE ENTRY <BR/>Note Text : Hospice nurse in the facility at this time. Per family request (POA care, feedings to be stopped at this time and comfort measures initiated. Resident moved to room [ROOM NUMBER] to allow family to spend time with resident.<BR/>Interview on [DATE] at 2:54 PM with MDS Coordinator C revealed she was new to the facility and recently took certification for PASRR, prior to and the other new MDS Coordinator C the facility had travelers come in for MDS responsibilities. MDS Coordinator C stated Resident #1 had expired [DATE], and was PASRR positive. MDS Coordinator C stated Habilitation Coordinator was in the facility today and Resident #1 was not discussed. MDS Coordinator C stated she had not alerted anyone of his death. MDS Coordinator C stated she was not involved with Resident #1's PASSAR due to him being a long-term care Resident, her being new to the facility and recently talking the training. <BR/>Interview on [DATE] at 3:13 PM with MDS Coordinator D revealed she was new to the facility and also recently took certification for PASRR. MDS Coordinator D revealed Resident #1 was PASRR positive, she was present during a meeting at the end of [DATE], however, did not get to work much with him due to his death in [DATE]. MDS Coordinator D stated she was not aware who's responsibility it was to notify Habilitation Coordinator of Resident #1's death, and that she had not. MDS Coordinator D stated she was still in training with her corporate office on how some of her responsibilities are done at this facility. MDS Coordinator D stated Habilitation Coordinator was in the facility today, however Resident #1 was not discussed. <BR/>Interview on [DATE] at 3:26 PM with the Social Worker revealed she was not sure who would be responsible for notifying the Habilitation Coordinator of a resident's change in condition or expiration. The Social Worker said she had never had the responsibility of notifying Habilitation Coordinator at this facility. Social Worker stated she assumed it the MDS Coordinators who should make the notification. The Social Worker said she was aware Resident #1 had expired in [DATE].<BR/>Interview on [DATE] at 3:42 PM with The Administrator revealed Resident #1 was on Hospice and PASRR positive with services. Resident #1 had his quarterly meeting [DATE], Resident #1 passed away [DATE]. The Administrator stated both MDS Coordinators are new to the facility and new to working with PASRR. The Administrator stated in dealing with Resident #1's death, she was not sure if notifications of his death were sent out to the Habilitation Coordinator or uploaded to the portal. According to the Administrator there was meeting on [DATE]th, 2023, to alert Habilitation Coordinator of his decline and to remove him from services. Administrator later stated when Resident #1 passed away the facility did not send what they should have to notify Habilitation Coordinator of his death, and they just sent the notification today. The Administrator stated it was the responsibility of the MDS Coordinators to notify all parties of significant changes or deaths, not doing so would place residents at risk of not receiving proper services. <BR/>Interview by phone on [DATE] at 4:18 PM with the Habilitation Coordinator revealed she was in the facility working with both MDS Coordinators, however, did not speak about Resident #1. Habilitation Coordinator stated she was returning the next day ([DATE]) to visit with Resident #1 to prepare for his [DATE], meeting. Habilitation Coordinator stated she received a call from the facility informing her Resident #1 was not tolerating treatment, so a meeting was completed on [DATE], to remove services. Habilitation Coordinator stated she was not aware Resident #1 had passed away on [DATE]. According to Habilitation Coordinator the facility should have notified her of his death promptly and so that his case could be closed out. <BR/>Request on [DATE] at 3:42 PM to the Administrator of the facility's Coordination - Pre-admission Screening and Resident Review (PASRR) Program policy addressing significant changes and notification of death was requested however was not provided prior to exit.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program system for preventing and controlling infections for three (CNA A, CNA B, and CNA C) of three staff reviewed for hand hygiene. <BR/>1. CNA A and CNA B failed to perform hand hygiene and change gloves during incontinence care for Resident #1.<BR/>2. CNA C failed to perform hand hygiene before donning and after doffing gloves during the incontinence care of Resident #2.<BR/>These failures placed residents at risk for infections and cross-contamination.<BR/>Findings included: <BR/>Observation on 03/01/23 at 11:30 AM revealed CNA A and CNA B did not perform hand hygiene before entering Resident #1's room and before donning gloves to provide incontinence care for Resident #1, who had had a bowel movement. They were observed each donning two pairs of gloves. While wearing soiled gloves, CNA A was observed getting wipes from the wipes packet. After providing Resident #1 with incontinence care, CNA A removed one pair of gloves. Without performing hand hygiene, she touched the clean brief, the bedding, bed control and Resident#1. CNA A and CNA B then turned the resident, and CNA B cleansed Resident #1 on the right side. She doffed one pair of gloves. Without performing hand hygiene, CNA B then touched the clean brief and the draw sheet. CNA A was observed leaving Resident #1's room, carrying the clean linen in a plastic bag from Resident #1's room to the shower room, which was considered a clean area, without performing hand hygiene after doffing the second pair of gloves she had been wearing. CNA B was observed leaving Resident #1's room and going to the soiled linen closet without performing hand hygiene after doffing the second pair of gloves she had been wearing. CNA B then later walked to the nurses' station.<BR/> . <BR/>Interview with CNA B on 03/01/23 at 12:44 PM revealed she knew she was supposed to perform hand hygiene before entering the resident's room. She stated she thought she sanitized outside before she entered the room. She also stated she knew she was not supposed to wear two pairs of gloves. She stated if she did, she was supposed to change both pair of gloves and perform hand hygiene when they were soiled and when moving from dirty to clean. She stated she knew she was supposed to perform hand hygiene after incontinence care and before leaving Resident #1's room. CNA B stated she forgot because she was nervous. She also stated she had been trained on incontinence care, handwashing, and infection control. She stated she knew the failure to perform hand hygiene and not changing her gloves could cause cross-contamination and the spread of infection.<BR/>Interview with CNA A on 03/01/23 at 1:03 PM revealed she knew she was supposed to perform hand hygiene before entering the resident's room. She also stated she knew she was not supposed to wear two pairs of gloves. She revealed she was supposed to wear one pair of gloves and perform hand hygiene before putting on and after removing her gloves. She stated she was supposed to change her gloves and perform hand hygiene when they were soiled and when moving from dirty to clean. She stated she knew she was not supposed to remove supplies from the resident room to another room. If they were clean, they should remain in Resident #1's room. She stated she forgot because she was nervous. She also stated she had been trained on incontinence care, handwashing, and infection control. She stated she knew the failure to perform hand hygiene and not changing her gloves and moving supplies from one room to another would spread infection and contamination.<BR/>Interview with the DON on 03/01/23 at 3:36 PM revealed the facility expected staff to perform hand hygiene as per the books as per the skill checks done with staff by her. When performing incontinence care, the DON stated staff were supposed to change gloves and perform hand hygiene when moving from dirty to clean. She stated she expected the staff who were wearing two pairs of gloves to doff both pairs of gloves and perform hand hygiene given that the resident had a bowel movement. She stated her expectation was the staff should use the non-contaminated hand to grab the wipes, and they should not leave the room without performing hand hygiene given that each room had a sink, water, and soap to prevent cross-contamination and the spread of infection. She stated she expected the staff to leave the remaining supplies in Resident #1's room and not to move them to a clean area. She stated she had done training with staff on hand washing infection control and peri care. <BR/>Observation on 03/01/23 at 4:30 PM revealed CNA C failed to perform hand hygiene before putting on gloves and after removing her gloves while she provided incontinence care for Resident #2. She was observed removing the gloves and putting on clean gloves without performing hand hygiene throughout the procedure.<BR/>Interview with CNA C on 03/01/23 at 5:37 PM revealed she knew she was supposed to perform hand hygiene before donning and after doffing her gloves. She stated she was supposed to change her gloves and perform hand hygiene when they were soiled and when moving from dirty to clean. She stated she did not know whether she was supposed to sanitize or wash hands during the care, and she was nervous. She stated she had been trained on incontinence care, handwashing, and infection control. She stated she knew the failure to perform hand hygiene could spread infection and contamination.<BR/>Interview with the DON on 03/01/23 at 5:45 PM revealed the facility expectation was staff were supposed to perform hand hygiene when changing their gloves and perform hand hygiene when moving from dirty to clean when performing incontinence care. She stated she expected the CNA to perform better since she had taken her through the process, and she was disappointed she forgot to perform hand hygiene.<BR/>Review of the facility's current policy for hand washing/hand hygiene, dated August 2019, reflected:<BR/> .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread the spread of infections to other personnel, residents, and visitors.<BR/> .7. Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following:-<BR/> .b. Before and after contact with residents. <BR/> .f. Before donning sterile gloves. <BR/> .m. After removing glove.<BR/>Review of the facility's current policy for peri-care, dated 05/11/22, reflected: .staff should perform hand hygiene and put on gloves and all other PPE per standard precautions. <BR/>.Doffing and discarding of gloves are required if visibly soiled. <BR/>.Always perform hand hygiene before and after glove use.<BR/>If heavy soiled use wipes to remove heavy soiling from front to back, prior to performing perineal care. Do not wipe more than once with the same surface of the tissue or wipes.<BR/>

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program system for preventing and controlling infections for three (CNA A, CNA B, and CNA C) of three staff reviewed for hand hygiene. <BR/>1. CNA A and CNA B failed to perform hand hygiene and change gloves during incontinence care for Resident #1.<BR/>2. CNA C failed to perform hand hygiene before donning and after doffing gloves during the incontinence care of Resident #2.<BR/>These failures placed residents at risk for infections and cross-contamination.<BR/>Findings included: <BR/>Observation on 03/01/23 at 11:30 AM revealed CNA A and CNA B did not perform hand hygiene before entering Resident #1's room and before donning gloves to provide incontinence care for Resident #1, who had had a bowel movement. They were observed each donning two pairs of gloves. While wearing soiled gloves, CNA A was observed getting wipes from the wipes packet. After providing Resident #1 with incontinence care, CNA A removed one pair of gloves. Without performing hand hygiene, she touched the clean brief, the bedding, bed control and Resident#1. CNA A and CNA B then turned the resident, and CNA B cleansed Resident #1 on the right side. She doffed one pair of gloves. Without performing hand hygiene, CNA B then touched the clean brief and the draw sheet. CNA A was observed leaving Resident #1's room, carrying the clean linen in a plastic bag from Resident #1's room to the shower room, which was considered a clean area, without performing hand hygiene after doffing the second pair of gloves she had been wearing. CNA B was observed leaving Resident #1's room and going to the soiled linen closet without performing hand hygiene after doffing the second pair of gloves she had been wearing. CNA B then later walked to the nurses' station.<BR/> . <BR/>Interview with CNA B on 03/01/23 at 12:44 PM revealed she knew she was supposed to perform hand hygiene before entering the resident's room. She stated she thought she sanitized outside before she entered the room. She also stated she knew she was not supposed to wear two pairs of gloves. She stated if she did, she was supposed to change both pair of gloves and perform hand hygiene when they were soiled and when moving from dirty to clean. She stated she knew she was supposed to perform hand hygiene after incontinence care and before leaving Resident #1's room. CNA B stated she forgot because she was nervous. She also stated she had been trained on incontinence care, handwashing, and infection control. She stated she knew the failure to perform hand hygiene and not changing her gloves could cause cross-contamination and the spread of infection.<BR/>Interview with CNA A on 03/01/23 at 1:03 PM revealed she knew she was supposed to perform hand hygiene before entering the resident's room. She also stated she knew she was not supposed to wear two pairs of gloves. She revealed she was supposed to wear one pair of gloves and perform hand hygiene before putting on and after removing her gloves. She stated she was supposed to change her gloves and perform hand hygiene when they were soiled and when moving from dirty to clean. She stated she knew she was not supposed to remove supplies from the resident room to another room. If they were clean, they should remain in Resident #1's room. She stated she forgot because she was nervous. She also stated she had been trained on incontinence care, handwashing, and infection control. She stated she knew the failure to perform hand hygiene and not changing her gloves and moving supplies from one room to another would spread infection and contamination.<BR/>Interview with the DON on 03/01/23 at 3:36 PM revealed the facility expected staff to perform hand hygiene as per the books as per the skill checks done with staff by her. When performing incontinence care, the DON stated staff were supposed to change gloves and perform hand hygiene when moving from dirty to clean. She stated she expected the staff who were wearing two pairs of gloves to doff both pairs of gloves and perform hand hygiene given that the resident had a bowel movement. She stated her expectation was the staff should use the non-contaminated hand to grab the wipes, and they should not leave the room without performing hand hygiene given that each room had a sink, water, and soap to prevent cross-contamination and the spread of infection. She stated she expected the staff to leave the remaining supplies in Resident #1's room and not to move them to a clean area. She stated she had done training with staff on hand washing infection control and peri care. <BR/>Observation on 03/01/23 at 4:30 PM revealed CNA C failed to perform hand hygiene before putting on gloves and after removing her gloves while she provided incontinence care for Resident #2. She was observed removing the gloves and putting on clean gloves without performing hand hygiene throughout the procedure.<BR/>Interview with CNA C on 03/01/23 at 5:37 PM revealed she knew she was supposed to perform hand hygiene before donning and after doffing her gloves. She stated she was supposed to change her gloves and perform hand hygiene when they were soiled and when moving from dirty to clean. She stated she did not know whether she was supposed to sanitize or wash hands during the care, and she was nervous. She stated she had been trained on incontinence care, handwashing, and infection control. She stated she knew the failure to perform hand hygiene could spread infection and contamination.<BR/>Interview with the DON on 03/01/23 at 5:45 PM revealed the facility expectation was staff were supposed to perform hand hygiene when changing their gloves and perform hand hygiene when moving from dirty to clean when performing incontinence care. She stated she expected the CNA to perform better since she had taken her through the process, and she was disappointed she forgot to perform hand hygiene.<BR/>Review of the facility's current policy for hand washing/hand hygiene, dated August 2019, reflected:<BR/> .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread the spread of infections to other personnel, residents, and visitors.<BR/> .7. Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following:-<BR/> .b. Before and after contact with residents. <BR/> .f. Before donning sterile gloves. <BR/> .m. After removing glove.<BR/>Review of the facility's current policy for peri-care, dated 05/11/22, reflected: .staff should perform hand hygiene and put on gloves and all other PPE per standard precautions. <BR/>.Doffing and discarding of gloves are required if visibly soiled. <BR/>.Always perform hand hygiene before and after glove use.<BR/>If heavy soiled use wipes to remove heavy soiling from front to back, prior to performing perineal care. Do not wipe more than once with the same surface of the tissue or wipes.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident had the right to be free from involuntary seclusion not required to treat the resident's medical symptoms for one (Resident #86) of 30 residents reviewed for involuntary seclusion.<BR/>The facility failed to ensure Resident #86 was not placed in the facility's secured unit without justification for placement. <BR/>This failure could place residents at risk of feeling isolated, fearful, hopeless, decreased self-esteem, and diminished quality of life.<BR/>Findings included:<BR/>Record review of Resident #86's face sheet, dated 07/08/2022, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included essential hypertension, anxiety disorder, schizophrenia, cognitive communication deficit, unspecified psychosis not due to a substance or known physiological condition, restlessness and agitation. <BR/>Record review of Resident #86's MDS assessment, dated 06/09/2022, revealed the resident's cognition was moderately impaired with a BIMS score of 9. The MDS revealed the resident had no potential indicators of psychosis to include hallucinations or delusions, and he did not have behavioral symptoms directed toward others. <BR/>Record review of Resident #86 's care plan, dated 05/12/2022, reflected: Focus: [Resident #86] was an elopement risk/wanderer r/t dementia and encephalopathy (brain disease that alters brain function or structure). Interventions: Requires secure unit environment due to impaired safety awareness. <BR/>Record review of Resident #86 Elopement Risk Assessment, dated 04/14/2022, revealed there was no risk identified, and the resident had no verbal expressions to leave the facility. The Mental Status section of the assessment reflected the resident was alert and oriented, and he had no history of elopement within the past six months. <BR/>Record review of Resident #86 electronic physician's order, dated 11/04/2020, revealed Order Summary: Device: Secure Unit <BR/>Observation on 07/06/22 at 11:51 AM revealed Resident #86 was observed sleeping on his bed. Resident #86 resided in the locked unit.<BR/>Interview by phone on 07/07/22 at 9:24 AM with Resident #86's POA revealed the resident had been at the facility since 2020. The POA stated the Resident #86 had always been in the locked unit, and she thought the resident was in the locked unit due to a history of elopement at previous facilities. The POA stated at a previous facility the resident would try to elope, but it was due to his medications not being adjusted. She stated at this facility they were able to adjust the resident's medications, and the resident had improved in his health and behaviors. The POA stated the resident had never tried to elope or had had any behavioral problems since he admitted to the facility. The POA stated she did not recall ever giving the approval for Resident #86 to be in the locked unit and she was just informed that he was going to be admitted to the locked unit, she stated this happened back when he admitted in 2020. The POA stated she was never given an option to decide whether she wanted him to be in the locked unit or not. She stated she had never been provided with the opportunity to remove Resident #86 from the locked unit. She stated at first when the resident was admitted to the facility, she thought it was appropriate but now that he had improved, she would like for him to be moved or for them to reevaluate him. The POA stated she had not spoken to anyone regarding Resident #86 being in the locked unit because she did not think it was an option. <BR/>Observation and interview on 07/07/22 at 2:01 PM of Resident #86 revealed he was using the phone in the secure unit, and he was observed to be ambulating without assistance. Resident #86 stated he was doing well, and he had been in the locked unit since admission. Resident #86 could not recall an exact date. He stated he was not sure why he was in the locked unit, but he thought the facility was taking away my rights. Resident #86 stated he felt like a chicken in a chicken [NAME]. Resident #86 stated he could do things on his own, like walk and eat. Resident #86 stated he did not want to be in the locked unit. <BR/>Interview on 07/07/22 at 2:09 PM with CNA C revealed she mostly worked in the secure unit. She stated she had never seen Resident #86 have any behavioral problems. She stated the resident did walk around, but he had never tried to elope. She stated she had not seen any signs of depression. She stated Resident #86 stayed in his room most of the time. She stated she was not sure why Resident #86 was in the locked unit. <BR/>Interview on 07/07/22 at 2:11 PM with LVN A revealed a resident was admitted to the locked unit based on behaviors and elopement risk. She stated the decision was made by the Administrator, DON, and family. LVN A stated she had not witnessed Resident #86 have any behavioral problems, and the resident mostly stayed in his room. She stated she was not aware of any elopement attempts. LVN A stated she was not sure why he was in the locked unit. <BR/>Interview on 07/07/22 at 2:18 PM with LVN B revealed she mostly worked in the locked unit. She stated a resident was admitted to the locked unit based on behaviors and elopement risk. She stated the decision was made by the Administrator, DON, and family. She stated they should have a physician's order as well. LVN B stated she had not witnessed any behavioral concerns or elopement risk for Resident #86. She stated she was not sure why Resident #86 was admitted to the locked unit and stated the resident did not bother anyone. LVN B stated Resident #86 was not appropriate to be in the locked unit. <BR/>Interview on 07/07/22 at 2:34 PM with the DON revealed a resident was evaluated and admitted to the locked unit due to behaviors or being an elopement risk. She stated they conducted an IDT meeting with the resident's POA or guardian and they made the decision on what was best for the resident. The DON stated Resident #86 was admitted to the locked unit due to stimulation issues as he liked smaller type places. She stated Resident #86 had not had any behavioral episodes since being in the locked unit. She stated when he was admitted , Resident #86 did have behavioral incidents which made him appropriate for the locked unit. The DON stated the resident's behaviors were pacing up and down the hall, staying awake all night, and going into other residents' rooms. The DON stated they would remove a resident from the locked unit upon the resident's POA request, and they would evaluate the resident. <BR/>Interview on 07/08/22 at 12:30 PM with Physician F, who was Resident #86's physician, revealed Resident #86 had always been in the locked unit since admission. She stated it was up to the facility on whether a resident was admitted to the locked unit. She stated they did not have to have a physician's order. She stated Resident #86 had a diagnosis of schizophrenia; however, she did not know how he would behave outside the locked unit. She stated she had not been made aware of any elopement attempts or behavior problems. Physician F stated there was no harm having Resident #86 in the locked unit, but she was not sure why he was in the locked unit. <BR/>Interview on 07/08/22 at 4:28 PM with the Administrator revealed a resident was admitted to the locked unit after they conduct an IDT meeting with the resident's family. She stated Resident #86 was admitted to the facility from the hospital with a plan of being admitted to the locked unit. She stated Resident #86 had stimulation behaviors, he would go into other residents' rooms, pacing around the room and would be up all night . The Administrator stated she did not recall the resident having any elopement attempts. She stated the family was aware and the POA provided them with a verbal consent for Resident #86 to be in the locked unit. The Administrator stated she had not noticed any decline effects on Resident #86 for being in the locked unit. The Administrator stated she did not recall any conversation with the family regarding any attempts of removing the resident from the locked unit. The Administrator stated they need better communication with the family regarding what was best for the resident. A policy regarding the locked unit was requested; however, the Administrator stated they did not have one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plans for 3 (Residents #1, #2, and #3) of 5 residents reviewed for comprehensive care plans in that:<BR/>The MDS Coordinators failed to individualize the care plans, to include interventions, for Residents #1, #2, and #3.<BR/>This failure could place the residents at risk of receiving the individualized care they required.<BR/>Findings included:<BR/>Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of right lower leg. morbid obesity, heart failure, and asthma.<BR/>Review of Resident #1's admission MDS assessment, dated 01/04/24, revealed a BIMS score of 10 indicating she had mild cognitive impairment. Her Functional Status indicated she required assistance with most of her ADLs. <BR/>Review of Resident #1's care plan, dated 01/01/24 revealed her care plan had not been individualized. Resident #1 has a rash (specify location, type, and extent) r/t; The resident is risk for falls r/t; and The resident has potential fluid deficit r/t. The majority of Resident #1's Focuses as well as Interventions had not been individualized. <BR/>Review of Resident #2's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included open wound to scalp post cancer surgery, heart disease, and high blood pressure. <BR/>Review of Resident #2's admission MDS assessment, dated 02/18/24, revealed a BIMS score of 13, indicating he was cognitively intact. His Functional Status indicated he was independent in most of his ADLs except eating and hygiene. <BR/>Review of Resident #2's care plan, dated 02/16/24, revealed his care plan had not been individualized. Resident #2 has a pacemaker (specify type) r/t; The resident is at risk for falls r/t; and The resident has hypertension r/t. The majority of Resident #2's Focuses and Interventions had not been individualized. <BR/>Review of Resident #3's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, diabetes, and alcoholic liver disease. <BR/>Review of Resident #3's admission MDS assessment, dated 02/15/24, revealed a BIMS score of 9 indicating he had moderate cognitive impairment. His Functional Status indicated he required minimal assistance with his ADLs. <BR/>Review of Resident #3's care plan, dated 02/09/24, revealed his care plan had not been individualized. Resident #3 is at risk for falls r/t; The resident has a communication problem r/t; and The resident has potential fluid deficit r/t. The rest of Resident #3's Focuses and Interventions had not been individualized. <BR/>Interview on 04/04/24 at 3:00 PM with the MDS Coordinator revealed she had been in her position since August 2023. She stated when she and the other Coordinator took over the roles the MDSs, care plans, and PASRR were all a mess. She stated the two of them had been trying to catch things up. The MDS Coordinator stated care plans should all be individualized to each resident. She stated the DON or the ADON enter the baseline care plan which triggers alerts in the comprehensive care plan. The MDS Coordinators were then responsible for completing the comprehensive care plan after they completed the MDS. The MDS Coordinators stated Residents #1, #2, and #3 were all being worked on, but had not been completed. <BR/>Interview on 04/04/24 at 3:11 PM with the DON revealed each department (Dietary, Rehabilitation, etc .) add their part of the care plan, and the MDS Coordinators were responsible for keeping them updated with information provided during the morning meetings. The DON stated the risk to residents to not have individualized care plans, staff might not know what care the resident needed. The DON stated she was ultimately responsible for everything in the facility including MDS and care plans, but she relied on everyone doing their job properly. There was no true oversight of each department. <BR/>Review of the facility's current, undated Comprehensive Care Planning policy reflected: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his preferences and goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for three (Residents #20, #79, and #150) of four residents reviewed for bed rails.<BR/>The facility failed to obtain informed consent for bed rails for Residents #20, #79, and #150. <BR/>This deficient practice could place all residents at risk for unintended entrapment of the head, neck or limb, physical restraint, and injuries.<BR/>Findings included:<BR/>Review on 07/06/2022 of Resident #150's EHR revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included persistent vegetative state, respiratory failure requiring placement of tracheotomy (breathing tube in the neck), diabetes, and feeding tube placement. <BR/>Review of Resident #150's Bed Rail Safety Review, dated 06/01/2022, reflected: Continued current alternative measures.<BR/>Further review of Resident #150's EHR and hard copy clinical records revealed no documented evidence of consent by the resident and/or the resident's responsible party for the use of bed rails.<BR/>Review of Resident #150's physician orders revealed no order for bed rail use. <BR/>Review of Resident #150's MDS, dated [DATE], revealed her BIMS score was not calculated related to her medical condition. Her functional status indicated she required total care for all ADLs. <BR/>Review of Resident #150's care plan, dated 06/16/2022, revealed she was not care planned for bed rails. <BR/>Observation on 07/06/2022 at 11:25 AM of Resident #150 revealed she was in bed, bed rails up on both sides. The bed rails were 1/2 bed rails. <BR/>Interview on 07/06/2022 at 11:25 AM with Resident #150 was unsuccessful. The resident was in a vegetative state and non-responsive.<BR/>Interview on 07/07/2022 1:45 PM with LVN D, she stated Resident #150 was a total care resident, meaning she was unable to do anything for herself. She was turned every two hours by the staff, and needed total assistance with her cares. She sated she was unaware the resident's bed rails were up. LVN D stated the resident had not had any falls from bed that she was aware of. She was unable to locate an order for bed rails, nor the consent for bed rails. She went to the bedside immediately to lower the bed rails. <BR/>Interview on 07/07/2022 at 1:50 PM with CNA E, she stated Resident #150 did not reposition herself, she had only seen the resident perform minor spastic movements of her arms. She stated that the bed rails had been up for as long as she could remember. <BR/>Review on 07/06/2022 of Resident #79's EHR revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included anemia, osteoarthritis, asthma, and reflux. She had a Bed Rail Safety Review, dated 06/03/2022 indicating 1/4 bedrail for mobility. Consent for bed rails was not found in EHR or paper chart. <BR/>Review of Resident #79's physician orders revealed an order dated 04/07/2022 for 1/2 side rail to promote mobility. <BR/>Review of Resident #79's MDS, dated [DATE], revealed a BIMS score of 14 indicating she was cognitively intact. Her functional status indicated extensive assistance needed for bed mobility. No Restraints or alarms were in use.<BR/>Review of Resident #79's care plan, dated 06/20/2022, revealed she was care planned for independence for meeting physical needs, but ADL self-care deficit related to activity intolerance. She was not care planned for bed rails. <BR/>Observation on 07/06/2022 at 11:45 AM of Resident #79 revealed she was in bed, bed rails up on both sides, and were 1/2 bed rails. <BR/>Interview on 07/06/2022 at 11:45 AM of Resident #79 she stated she did not use the bed rails to reposition herself. She stated she required the assistance of two people to turn and reposition her. She stated the bed rails were on the bed when she arrived and she assumed they were part of the bed. <BR/>Review on 07/06/2022 of Resident #20's EHR revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included quadriplegia, above the knee amputation of right leg, and infection of unknown origin. She had Bed Rail Safety Review dated 04/20/2022 recommending 1/4 bed rail for mobility. Consent for bed rails was not present in EHR or paper chart. <BR/>Review of Resident #20's physician orders revealed no order for bed rails. <BR/>Review of Resident #20's MDS, dated [DATE], revealed a BIMS score of 15 indicating she was cognitively intact. Her functional status indicated she required total assistance with her ADLs, including bed mobility. No restraints or alarms were in use.<BR/>Review of Resident #20's care plan, dated 04/29/2022, she was care planned for ADL self-care deficit, active range of motion therapy, low risk for falls, and multiple pressure ulcers related to quadriplegia. She was not care planned for bed rails.<BR/>Observation on 07/06/2022 at 11:34 AM of Resident #20 revealed she was in bed, and the bed rails were up on both sides, and were 1/2 bed rails <BR/>Interview on 07/06/2022 at 11:34 AM of Resident #20 she stated she had gross movement of her arms and she used the bed rails to help reposition herself some, but required assistance to turn for cares. She is unable to raise or lower the bed rails by herself. <BR/>Interview on 07/08/2022 at 3:20 PM with the DON, she stated that before bed rails could be used there needed to be an assessment for them, then a physician's order, and then a consent signed by the resident or their representative. She stated she did not know why residents had bed rails in use without all the above. She stated failing to follow the protocol could place residents at risk of entrapment or misuse of the bed rails. The DON stated each unit manager was responsible for keeping track of bed rail use, but they had been without unit managers for a couple of months now, so she was ultimately responsible but was overloaded with having to perform their duties as well as her own. She stated some of the resident might have a consent in their paper charts that had not been scanned into their EHR, and she would try to produce them. She was unable to produce the needed consents by the time of exit from the facility. <BR/>Review of facility's policy Bed Rail Management System, dated September 2021, reflected:<BR/>The center ensures that the resident was provided with a bed that was appropriate for their height and weight, prior to the installation of bed rails, attempts to provide the resident with alternative measures to meet their need for positioning, mobility, or transfer ability while in bed. When alternatives are deemed ineffective or not adequate to meet the resident's needs, the resident will be assessed for the use of bed rails, including the risk of entrapment, and informed consent was obtained from the resident or resident's representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 3 (rooms [ROOM NUMBER]) of 10 rooms observed.<BR/>The facility failed to maintain rooms [ROOM NUMBER] in a safe and sanitary condition.<BR/>This failure could place residents at risk for decreased quality of life.<BR/>Findings included:<BR/>Observation on 08/03/23 during the following hours revealed:<BR/>9:45 AM - room [ROOM NUMBER] - The window screen was bent at the bottom and detached from the window leaving a gap between the window and the screen. <BR/>10:01 AM - room [ROOM NUMBER] - There were three ceiling tiles that were slightly bulging out and had water stains on them right above the window. The window screen was bent at the bottom leaving a gap between the screen and the window. <BR/>10:01 AM - room [ROOM NUMBER] - The bottom half of the window screen was ripped. <BR/>Interview on 08/03/23 at 12:04 PM with the Maintenance Director revealed he was aware of the ripped and dented screens. He stated they were working on getting proposals to find a good price. The Maintenance Director said he did not recall seeing the bulging and stained ceiling tiles in room [ROOM NUMBER] but stated that would be an easy fix, and he would replace them as soon as possible. He further stated there were no risks associated with the bent/ripped screens, and they were just an eye sore. <BR/>Interview on 08/03/23 at 1:45 PM with the Administrator revealed they were aware of the bent/ripped screens, and they had been calling places to get quotes but none of the quotes had been approved yet. The Administrator stated she was not aware of the ceiling tiles being in disrepair but said environmental risks included ants and bugs getting into the building. <BR/>Interview on 08/03/23 at 3:08 PM with the Administrator revealed they did have not a policy on ceiling tiles and window screens, but they followed the Texas Administrative Code.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for one (Resident #1) of three reviewed for quality of care.<BR/>The facility failed to maintain ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for Residents #1. <BR/>The failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. <BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 12/27/23 reflected she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses which included atherosclerosis (thickening and hardening of the arteries) of native arteries of left leg with ulceration (a long-lasting (chronic) sore that takes more than 2 weeks to heal) of other part of foot, paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days), acute kidney failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days), dysphagia (difficulty swallowing), dependence on renal dialysis (a treatment for people whose kidneys are failing), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problem), acute respiratory failure with hypoxia (loss of breath) and acquired absence of left leg below knee (amputation).<BR/>Record review of Resident #1's admission MDS assessment dated [DATE] reflected she had no hearing, vision or speech issues and her BIMS score was 13, which indicated her cognition was intact. Resident #1 had no signs or symptoms of delirium, no negative mood issues and no behavioral symptoms which included no rejection of care. Resident #1 required limited assistance of staff for her ADLs and had range of motion limitation in her lower extremity on one side and used a wheelchair for mobility Resident #1 received a high risk medication called antiplatelet therapy (medication to help prevent blood clots), and she also received oxygen therapy and dialysis. <BR/>Record review of Resident #1's care plan dated 12/22/23 did not reflect any discussion of her dialysis care, goals and interventions. <BR/>Record review of Resident #1's physician order dated 12/28/23 reflected, Dialysis Every Mon-Wed-Fri at [company]-Chair time is 12pm; Weight from Dialysis center every evening shift every Mon, Wed, Fri.<BR/>Record review of Resident #1's e-chart reflected no Dialysis Communication Forms available since her admission. <BR/>An interview with the DON on 01/05/23 at 1:31 PM occurred where she was asked to provide the pre/post dialysis communication forms for Resident #1 since her admission. The DON stated they were in a binder at the nurses' station and would provide them.<BR/>Review of the dialysis communication binder from Resident #1's nurses' station provided by the DON on 01/05/24 reflected there were no communication forms in the binder for her. <BR/>Record review of a blank Dialysis Communication Form reflected the following information needed to be completed:<BR/>1. Pre-Dialysis (responsibility of the nursing facility): date, name, temperature heart rate, respirations, blood pressure, CBG [capillary blood glucose], access site, any medications changes, presence of thrill/bruit shunt site condition, and the licensed nurse's signature verifying the information, <BR/>2. During the dialysis visit (responsibility of the center): weight before, weight after, temperature, heart rate, respirations, blood pressure, seen by the doctor, new orders, any medications given at Center, route of administration if yes, dressing change needed, labs drawn, and the nurse from the dialysis center's signature verifying the information.<BR/>3. Post-Dialysis (responsibility of the nursing facility): temperature, heart rate, respirations, blood pressure, CBG, access site, thrill and bruit, dressing, and the facility charge nurse's signature verifying the information. <BR/>An interview with LVN C on 01/05/24 at 1:50 PM reflected she did complete the pre-dialysis forms and sometimes the dialysis center did not send them back, or the resident did not have them, or the nurses would forget to ask the resident and/or van driver for them. LVN C stated she did not know if medical records had any of the dialysis communication forms, but she did not know where they were and thought they may have been misplaced for Resident #1. LVN C stated the importance of completed dialysis communication forms was so the charge nurse knew what the resident's vitals were before he/she left for dialysis; they needed to see the vitals were good before that resident left the facility. LVN C stated the middle part of the form was to be completed by the dialysis center and was important information for the facility to know if the resident was stable coming back from their dialyzing. LVN C stated the post-dialysis section of the form was the third part to be completed and was done by the charge nurse when the resident returned from their dialysis visit and it was done to double check the resident's vitals. LVN C reviewed a blank dialysis communication form and stated there was also a section on the form for the dialysis center to indicate if they ran any labs for the resident while they were there and there was also a section for the facility charge nurse to assess the access site to make sure it was working and had a thrill and bruit. LVN C stated she usually asked the dialysis resident for the form that was sent back with them when they returned from their appointment. When the form was completed in its entirety, it was placed in the binder at the nurses' station and the ADON/Unit Manager oversaw that those forms were completed. LVN C stated her supervisor (ADON B) was out sick presently but there was another supervisor (ADON A) who worked the other halls but knew the process as well. <BR/>An interview with ADON A on 01/05/24 at 2:13 PM revealed the dialysis communication forms were important because the dialysis center needed to know what Resident #1's vitals were prior to coming to their chair time to know if she was stable enough to dialyze. ADON A stated the post-dialysis section of the form needed to be completed by the facility charge nurse after dialysis to assess if Resident #1 had a change in vitals due to the fact she just depleted a lot of fluid out of her system. ADON A stated the charge nurses did not always document on the dialysis communication form and would document the information instead in the e-charting system, It specifically says post dialysis vital signs for 24 hours. ADON A stated if the charge nurse did not get the dialysis communication form, then the charge nurse needed to contact the center and ask them to fax it to the facility. ADON A stated she did not know if there was a specific person in management designated to oversee the dialysis residents and the dialysis communication forms. She stated, We spot check it because when they come back from dialysis, we put the communication forms in the medical records box so that [MR E] can scan them into the chart. <BR/>Review of Resident #1's December 2023 and January 2024 TAR reflected no entry for post-dialysis vital signs. The MAR/TAR only reflected the following dialysis related orders, Weight from Dialysis center every evening shift every Mon-Wed-Fri. However, no weights were recorded on the MAR/TAR post-dialysis on 12/22/23, 12/25/23, 12/27/23, and 01/01/24. <BR/>An interview with MR E on 01/05/24 at 2:44 PM reflected she was in charge of medical records and she did not have any pre-post dialysis communication forms for Resident #1 and had not seen any turned in recently. MR E stated she only uploaded what dialysis communication sheets the staff put in her box to upload and she did not have any records outstanding. <BR/>An interview with the ADM on 01/05/24 at 4:32 PM revealed the facility could contact Resident #1's dialysis center to get the communication forms but it would not serve its purpose since the information was supposed to be reviewed by the charge nurse in real time on Resident #1's dialysis days. <BR/>An interview with Transportation Aide F on 01/05/24 at 4:45 PM revealed he had just returned with Resident #1 from dialysis. He stated the dialysis nurse typically gave the dialysis residents the communication forms when they were finished with their chair time and he usually put them in the pack of their wheelchair when he picked them up. <BR/>An observation and interview with Resident #1 on 01/05/24 at 5:15 PM revealed she discussed the incident where she was sent to dialysis the week prior [no date given] where they did not provide her portable oxygen tank. Resident #1 did not know if the dialysis center gave her any paperwork and stated no one from the facility had come and asked her about it for the appointment she just got back from. <BR/>An interview with LVN G on 01/05/24 at 5:32 PM revealed Resident #1 did not return from dialysis that afternoon with any dialysis communication forms. She said the transportation aide did not give her anything. <BR/>A follow up observation of Resident #1 occurred on 01/05/24 at 5:35 PM and the back of her wheelchair bag was looked at with her consent. Observed in the bag hanging on the back of her wheelchair were two dialysis communication forms, one from 01/03/24 that did not have the post-dialysis information completed (which was to be done by the facility), and one for 01/05/24 that was completed, including the post-dialysis section by the dialysis center. <BR/>A follow up interview with LVN G on 01/05/24 at 5:38 PM revealed she was given the two missing dialysis communication forms by the investigator. She stated she did not check for them when Resident #1 came back from dialysis and did not know they were in her wheelchair bag. LVN G accepted the communication forms and did not appear to review the information and put the forms to the side. She stated one of the ADONs was going to make a binder for the nurses to keep the forms in. <BR/>An interview with ADON B on 01/08/23 at 11:21 AM revealed the dialysis communication forms were done by the charge nurse because the charge nurse was seeing the resident out to dialysis and in from dialysis and they should have done the assessments before the visit and they should be expecting the form back to do the follow up. ADON B stated, For one, we are looking at their condition pre-dialysis because it is a pretty extensive thing, they weigh them before and after at dialysis. We are supposed to weigh them too. Honestly, they [dialysis center] do post dialysis vitals sometimes. If it comes back incomplete, I expect the charge nurse to do it, even if dialysis has done it, we still do it. ADON B stated if the charge nurse did not get the dialysis communication form, they were supposed to call the center and ask for a copy to be faxed to the facility. ADON B stated on the communication form, there were three opportunities to monitor the resident and those times were important because the facility and dialysis center were looking for changes in the resident's blood pressure, vitals, decrease in oxygen saturation levels and also to check the shunt and access site to make sure everything was working. <BR/>An interview with the DON on 01/08/24 at 12:35 PM revealed the purpose of the dialysis communication forms were for the facility to know what was going on with the resident. The DON stated, First the dialysis center needs to know what happened in the morning prior to the resident's chair time, then the dialysis center tells us what is going on while the resident is at dialysis and we need to do the post [section]now they are finished with dialysis so there are no complications and if there are, we may need to address meds. The DON stated LVN G just moved over to station 3 where Resident #1 resides and last week was her first week over there so she was still learning how to obtain and complete the dialysis forms.<BR/>The facility's policy titled, Dialysis, revised November 2013 reflected, .Procedure: .2. The facility will establish baseline information from the dialysis center with [sic] will monitor changes from the baseline .7. The site will be assessed for bleeding, bruising, lack of pulsation, and aneurysm as ordered by the physician .Conduct this procedure every shift. Record the results of the examination. Report nonfunctioning access to the dialysis center immediately .14. Strict intake and output will be maintained on the resident according to physician order. Daily weights will be maintained unless otherwise specified by physician order .All documentation will be maintained in the resident's clinical record .19. The facility will monitor departures and returns from the dialysis center. The facility will document the resident's vital signs, general appearance, orientation, and additional baseline data as needed. The resident's clinical record will be documented with this information .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two (Resident #1 and Resident #2) of four residents reviewed for and pharmacy services.<BR/>1. The facility failed to follow physician orders and provide Resident #1's treatment to her newly amputated leg sutures and incision site on 12/25/23, 12/27/23, 01/01/24 and 01/03/24.<BR/>2. The facility failed to follow physician orders and provide Resident #2 her analgesic topical pain medications of Diclofenac Sodium External Gel on 01/05/23 and a Lidocaine Patch on 01/02/24, 01/03/24 and 01/05/23.<BR/>The failure could place residents at risk for increased pain, infection and physical discomfort. <BR/>Findings included:<BR/>1. Record review of Resident #1's Face Sheet dated 12/27/23 reflected she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses which included atherosclerosis (thickening and hardening of the arteries) of native arteries of left leg with ulceration (a long-lasting (chronic) sore that takes more than 2 weeks to heal) of other part of foot, paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days), acute kidney failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days), dysphagia (difficulty swallowing), dependence on renal dialysis (a treatment for people whose kidneys are failing), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problem), acute respiratory failure with hypoxia (loss of breath) and acquired absence of left leg below knee (amputation).<BR/>Record review of Resident #1's admission MDS assessment dated [DATE] reflected she had no hearing, vision or speech issues and her BIMS score was 13, which indicated her cognition was intact. Resident #1 had no signs or symptoms of delirium, no negative mood issues and no behavioral symptoms which included rejection of care. Resident #1 required limited assistance of staff for her ADLs and had range of motions limitation in her lower extremity on one side and used a wheelchair for mobility. Resident #1 was frequently incontinent of bowel. Resident #1 had a recent major surgery of a below knee amputation prior to admission which required active SNF care. Resident #1 was five foot four and weighed 115 pounds and was at risk of developing pressure ulcers. Resident #1 had one unhealed pressure ulcer that was unstageable and present upon admission and she required pressure ulcer care. Resident #1 received a high risk medication called antiplatelet therapy, and she also received oxygen therapy and dialysis. <BR/>Record review of Resident #1's care plan dated 12/22/23 did not address her amputation or need for amputation care. <BR/>Record review of Resident #1's physician order dated 12/23/23 reflected, LBKA incision cleanse with NS, pat dry, apply Bacitracin ointment, cover with island dressing Q MWF and PRN as needed every Mon, Wed, Fri.<BR/>Record review of Resident #1's December 2023 TAR reflected no documentation the incision was treated per physician's orders on 12/25/23, 12/27/23, 01/01/24 and 01/03/24.<BR/>Record review of nursing progress notes on the dates Resident #1 did not have documented wound care to her incision site for 12/25/23, 12/27/23, 01/01/24 and 01/03/24 ordered.<BR/>An interview with ADON A on 01/05/23 at 3:50 PM revealed she remembered doing treatment to Resident #1's pressure ulcer on her sacrum on 01/01/24 when the wound care nurse was not working, but she did not treat her amputation suture site. ADON A stated when a resident admits with a new amputation, they generally came into the facility with orders for wound care and wound care nurse [LVN D] did the stump incision treatment orders and they were usually communicated to management in the morning meetings. ADON A stated the facility usually knew ahead of time that there was a new admission coming with recent amputation and talk about the pending admission before that resident arrived. ADON A stated if LVN D was not working, on leave or sick, then the treatments were the responsibility for the unit managers/ADONs. <BR/>An observation and interview with Resident #1 occurred on 01/05/23 at 5:15 PM. Resident #1 was interviewable and had just arrived back to the facility from dialysis. She was sitting upright in her wheelchair eating a hamburger. Resident #1 stated the facility was not consistent in treating the incision site/sutures on her newly amputated leg/stump. She was frustrated at their slow response time to answer the call light and did not feel like her pain medication was sufficient at times to treat the discomfort she had on her bottom and newly amputated stump that had healing stitches. <BR/>An interview with LVN D on 01/08/23 at 10:50 AM revealed Resident #1 had incisions where her fresh amputation was and LVN D did treatment to that site to make sure the sutures did not get pulled out. LVN D stated if she was not at the facility, the charge nurses or weekend supervisors were supposed to continue the treatment orders and she always stocked her treatment cart with all the necessary supplies. LVN D stated the main thing with Resident #1's stump was to clean it with normal saline and put a dry dressing on it to protect the sutures. LVN D stated if the treatment to the stump did not occur there would be no negative outcome. She stated the hospital did not order any type of treatment at discharge, But they don't understand this environment, she is getting up and down. I don't think anything would happen but I am scared that with her moving around in the bed that the sutures don't get hung, that's all I am doing, is protecting those sutures. <BR/>An interview with ADON B on 01/08/23 at 11:21 AM revealed when the wound care nurse was not available, ideally the charge nurse would complete treatment orders for Resident #1, unless the charge nurse was busy, then it would be the ADON/Unit managers. ADON B remembered doing wound care for a couple of days in December 2023 and January 2024 when LVN D was not at work, but whether or not I did in the TAR I can't day, that is a part of the chart I do not access that much. ADON B stated Resident #1 needed to have her stump clean with normal saline and to put some type of ointment on it and keep it dry. ADON B stated, Documentation, I did not do. Bottom line is if it is not documented, it didn't get done.<BR/>2. Record review of Resident #2's Face Sheet dated 01/05/24 reflected she was a [AGE] year old female admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness), cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting right dominant side, idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions) and unspecified osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time).<BR/>Record review of Resident #2's admission MDS dated [DATE] reflected she had unclear speech and was sometimes understood and sometimes understood by others. Resident #2's BIMS score was a 12, which indicated moderate cognitive impairment. Resident #2 had fluctuating signs and symptoms of delirium to include inattention and disorganized thinking and she had a high mood score of 15, which showed issues with depression and fatigue. Resident #2 had no rejection of care issues. She had range of motion impairments on both sides of her upper and lower extremities and used a wheelchair for mobility. Resident #2 was on pain management and indicated she had no pain presence during the admission MDS. <BR/>Record review of Resident #2's care plan dated 11/24/23 reflected the was at risk for alteration in level of comfort related to osteoarthritis and was prescribed routine diclofenac PRN, tizanidine and ibuprofen. Goals included to anticipate Resident #2's need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions. <BR/>Record review of Resident #2's physician order dated 09/29/23 reflected, Diclofenac Sodium External Gel 1 % Sodium (Topical)- Apply to Effected areas topically four times a day for Arthritis and an order dated 01/03/24, Lidocaine External Patch 4 % Apply to right shoulder topically one time a day for pain right arm 12 hours on, 12 hours off and remove per schedule.<BR/>Record review of Resident #2's January 2024 MAR reflected Lidocaine External Patch 4 % Apply to right shoulder topically one time a day for pain right arm 12 hours on, 12 hours off and remove per schedule-Apply 0800/Remove 1959. (8:00 AM/5:59PM) The MAR reflected MA I administer the patch on the morning of 01/05/23. <BR/>Record review of Resident #2's January 2024 nursing MAR reflected Diclofenac Sodium External Gel was not provided on 01/02/24, 01/03/24 and 01/05/23 during the morning shifts. <BR/>Review of Resident #2's eMAR-Administration Notes reflected the following: <BR/>-01/02/2024 11:50 Note Text : Diclofenac Sodium External Gel 1 % Apply to Effected areas topically four times a day for Arthritis--waiting on medication [documented by LVN K]<BR/>-01/03/2024 09:33 Note Text : Diclofenac Sodium External Gel 1 % Apply to Effected areas topically four times a day for Arthritis--waiting for medication [documented by LVN K]<BR/>-01/05/2024 09:03 Note Text : Diclofenac Sodium External Gel 1 % Apply to Effected areas topically four times a day for Arthritis--waiting on medication [documented by LVN K]<BR/>-01/05/2024 11:31 Note Text : Diclofenac Sodium External Gel 1 % Apply to Effected areas topically four times a day for Arthritis--waiting on medication [documented by LVN K]<BR/>An interview with Resident #2 on 01/05/24 at 3:15 PM revealed she had not been provided topical medication, a gel and a patch, for her arthritis consistently and had not received it so far that day (01/05/23). Resident #1 stated the nurse/medication aide on applied the medication in the evening and they were supposed to put it on her right shoulder and both knees four times a day but they were doing it. Resident #1 also stated she had not been provided a lidocaine patch either and did not have one placed on her body. She stated at night, a female staff (name unknown) took off her lidocaine patch and put a new one on and it was supposed to stay on for 12 hours. She stated someone came into her room that morning (name unknown) and took the lidocaine patch off but did not put a new one on. Resident #2 stated the charge nurse had not come to her room that day (01/05/23), only the medication aide [MA I], but he did not apply the patch or gel. Resident #2 stated the lidocaine patch had been ordered and started the day prior (01/04/24) and was supposed to help with pain and the gel medication stopped the arthritis from hurting. <BR/>An interview with ADON A on 01/05/24 at 3:50 PM revealed she thought the topical pain gel was not on the nurses' cart so the morning charge nurse [LVN K] did not have it to apply, but the facility had gotten in a supply of items that were now stocked in central supply, so it should have been available at that time. <BR/>An observation of ADON A and Resident #2 occurred on 01/05/24 at 3:55 PM where ADON A looked at Resident #2's skin under her clothing and verified she did not have a lidocaine patch on her body. ADON A stated the lidocaine patch had been ordered the day prior (01/04/24) by the physician because Resident #2 had chronic pain and muscle spasms. ADON A stated she would talk to the morning charge nurse [LVN K] because she should have asked ADON A where the medication was if she could not locate it. ADON A stated LVN K was fairly new licensed nurse of six months but she still knew to come and ask the unit managers/ADONs when they have any questions. <BR/>An interview with LVN J on 01/05/24 at 3:50 PM revealed she applied the gel to both of Resident #2's shoulders and both knees twice a day on the 2pm-10pm shift. LVN J stated the lidocaine patch would have been applied by MA I. LVN J stated the gel- Diclofenac Sodium External Gel was always available, it was that the morning charge nurse [LVN K] did not recognize the medication was in a new tubing and she probably did not know what it was. LVN J stated there were two tubes of Diclofenac Sodium External Gel on the nursing cart. LVN J stated if the gel was ordered four times a day by the physician, it needed to be applied four times a day and the nurse could not change the order. <BR/>An interview with ADON B on 01/08/23 at 11:21 AM revealed she looked at Resident #1's MAR/TAR and confirmed MA I documented that he applied Resident #1's lidocaine patch on 01/05/23 but it was not on her body. ADON B stated as unit managers, she was responsible to check the e-charting system to see if medications/treatments were administered to the residents and the nurses and medication aides knew they had to document when they provided a medication or treatment. ADON B stated, If it was Christmas Day, god knows what happened, it can be awful with the holidays. ADON B stated if no medication/treatment was given to Resident #2 for pain, the possible negative outcome would be that she would be in pain and discomfort. ADON B stated documentation was the proof that a medication/treatment administration was done. If the nurse or medication aide forgot to document the administration for whatever reason but they knew they gave it, that nurse/medication aide was supposed to document a late entry in the progress notes to explain why. <BR/>An interview with MA I on 01/08/24 at 12:05 PM revealed it was an accident that he documented he provided Resident #2 with her lidocaine patch on 01/05/23 in the morning, when he in fact, did not apply it. MA I stated Resident #2 was still sleeping and he let the CNA do her morning routine with the resident and gave her some time to wake up, but when he went back to apply the patch, she did not want it. He stated he did not know why she refused the lidocaine patch and he stated he did not know why she needed it because he had never heard her complain of pain. MA I stated when he went to complete his charting, he did not know what happened, but he documented he placed the lidocaine patch on the resident but he did not actually do it. MA I stated if a resident refused a medication/treatment, the medication aide was supposed to notify the charge nurse because they may have better rapport with the resident. MA I stated he had never had Resident #2 refuse a medication/treatment before. MA I stated on 01/08/24, Resident #2 was provided her lidocaine patch and was able to indicate to him where she wanted it to be placed on her right shoulder. <BR/>An interview with the DON on 01/08/24 at 12:35 PM revealed she contacted MA I on 01/05/24 and asked him why he documented he provided a topical medication to Resident #2 when he did not actually do it. The DON stated there was no lidocaine patch applied to Resident #2 on 01/05/24 and the resident had made a previous complaint a few weeks ago that she was not receiving all of her medications and the DON told MA I to start taking a witness with him when he did the med pass. MA I told her that he did but after a few days there were no issues so he did not take a witness in anymore. The DON stated with LVN K, she was going to have to figure out how she missed applying the gel and she had not answered the DON's calls over the past few days to follow up. The DON stated the pharmacy was getting to where nursing facilities could purchase the same gel over the counter and it was called Voltran and there was some in central supply, but it was not the generic name that was on the physician's order/MAR/TAR. The DON stated she would have to talk with LVN K to make sure she knew what the medication looked like and would in-service and educate her on her next working day. The DON stated the gel was for arthritic pain. <BR/>Review of the facility's policy titled, Medication Administration Procedures revised 10/25/17, reflected, .20. The 10 rights of medication should always be adhered to: 1. Right patient, 2. Right medication, 3. Right dose, 4. Right route, 5. Right time, 6. Right patient edification, 7. Right documentation, 8. Right to refuse, 9. Right assessment, 10. Right evaluation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for one (Residents #10) of five residents reviewed for medication regimen.<BR/>The facility failed to communicate the Pharmacist Consultant's recommendations to the physician for Residents #10 for April, May, and June 2022.<BR/>These failures could place all residents receiving medication, who required monthly MRR at risk for medication errors, unnecessary medications, and incorrect medication administration.<BR/>Findings included:<BR/>Record review of Resident #10's face sheet, dated 07/08/2022, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included acute intermittent (hepatic) porphyria (metabolic disorder), essential hypertension (high blood pressure), restlessness and agitation, dementia in other diseases classified elsewhere with behavioral disturbance. <BR/>Record review of Resident #10's MDS assessment, dated 03/31/2022, reflected the resident's BIMS score was not completed due to resident was rarely/never understood.<BR/>Record review of Resident #10's electronic physician's order, dated 02/23/2022, revealed Order Summary: Ativan Tablet 0.5 MG (Lorazepam) 'Controlled Drug' Give 1 tablet by mouth every 6 hours PRN for Agitation.<BR/>Record review of the Pharmacist Consultation Report dated 04/11/2022 through 04/13/2022 revealed a comment: Resident #10 has a PRN order for an anxiolytic, without a stop date: Lorazepam. Recommendation: Please discontinue PRN Lorazepam, tapering as necessary (e.g., decreasing the dose by no more than 25%, or 10-12% in high-risk resident, every 2 weeks). If the medication cannot be discontinued at this time, current regulation requires that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period. <BR/>Record review of Pharmacist Consultation Report dated 05/09/2022 through 05/10/2022 revealed a comment: Please follow up on last month's recommendation regarding stop date for Ativan PRN. Recommendation: Thank you!<BR/>Record review of Pharmacist Consultation Report dated 06/08/2022 through 06/09/2022 revealed a comment: Resident #10 has a PRN order for an anxiolytic, without a stop date: Lorazepam. Recommendation: Please discontinue PRN Lorazepam, tapering as necessary (e.g., decreasing the dose by no more than 25%, or 10-12% in high-risk resident, every 2 weeks). If the medication cannot be discontinued at this time, current regulation requires that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Physician's Response: No response was noted on the form and the physician's signature was blank.<BR/>Record review of Resident #10's Psychiatric Follow up notes, dated 03/2/2022, 0204/25/22 and 05/30/2022, revealed psychiatric medication noted: Ativan 0.5 mg every six hours as needed, PRN. <BR/>Interview on 07/08/22 at 1:26 PM with Physician F revealed the ADON passed the Consultant Pharmacist's recommendations to them, and they reviewed them. She stated she did not recall seeing the pharmacist's recommendation for the past month. She stated she might had missed it or did not receive them. Physician F stated they did not have to follow pharmacist's recommendations. She stated Resident #10 was frequently agitated and needed her medication. Physician F stated the medication was appropriate for the resident due to her behaviors.<BR/>Interview on 07/08/22 at 2:43 PM with the ADON revealed she was responsible for following up with the pharmacist's recommendations. She stated once she receiveds the consultation report she will fax over the recommendations to the physician. The ADON stated she was not able to locate the faxed consultation reports for the month of April, May or June for Resident #10. The ADON stated she cannot confirm or deny if they were ever sent to the physician. She stated she could have missed it. The ADON stated Resident #10's sees a psychiatrist who recommembed resident to be on Avitan; however, she is not sure if she followed up with the pharmasict regarding the recommendations. <BR/>Interview on 07/08/22 at 4:10 PM with the DON revealed the ADON was responsible to follow up with the pharmacist recommendations and faxing over the consultation reports to the physician. The DON stated she contacted the pharmacist and stated she only made one recommendation however she was not sure if they followed up with the recommendation. The DON stated the resident has been receiving psych services and their recommendation was for resident to continue to be on the medication. <BR/>Interview on 07/08/22 at 4:45 PM with the DON revealed her expectation was for all pharmacy recommendations to be immediately communicated to the appropriate discipline/MD for review. The DON stated it was the responsibility of the entire clinical team to check pharmacy recommendations monthly. She stated the risk of not immediately communicating pharmacy recommendations was that the resident could continue receiving unnecessary medications/treatments. <BR/>Attempted to interview by phone on 07/08/22 at 4:50 PM with Resident #10's Psychiatrist; however, there was no answer. <BR/>Record review of the facility policy titled: 9.1 Medication Regimen Review, revision date 03/03/20, revealed the following: Applicability: This policy 9.1 sets forth procedures relating to the medication regimen review (MRR).<BR/>Procedure:<BR/>6. The pharmacist will address copies of the residents' MRRs to the director of nursing and/or the attending physician and to the medical director. Facility staff should ensure that the attending physician, medical director, and director of nursing are provided with copies of the MRRs. <BR/>7. Facility Should encourage physicians/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. <BR/>7.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescribers to either accept or act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. <BR/>7.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. <BR/>7.2.1 If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residence health record. <BR/>8. Facility should alert the medical director where MMRs are not addressed by the attending physician in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and assure only authorized personnel had access to the keys for 1 (Resident #2) of 1 resident reviewed for pharmacy services, in that: <BR/>The facility failed to ensure that Resident #2's albuterol inhaler, one bottle of levocetirizine (allergy medication) 5 mg, eleven pills Slow Fe (iron) tablets, and two yeast plus tablets were stored in a secured place.<BR/>This failure could place all residents on the 300 Hall North at risk of drug diversion or misuse of medications.<BR/>Findings included:<BR/>Record review of Resident #2's face sheet, dated 01/17/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: allergic rhinitis (inflammation of the inside of the nose caused by an allergen, such as pollen, dust, mold, or flakes of skin from certain animals), acute respiratory failure (serious condition that makes it difficult to breathe), and asthma (narrow and inflamed airways).<BR/>Record review of Resident #2's care plan, revised 01/01/24, revealed the resident was allergic. Interventions included do not administer or come into contact with allergen. Inform MD if allergen is ordered, make note on chart of all allergies.<BR/>Record review of Resident #2's admission MDS assessment, dated 01/04/23, revealed Resident #2 had moderate cognitive impairment with a BIMS score of 10. Section G revealed Resident #2 needed assistance with planning regular task, such as remembering to take medication prior to the current illness, exacerbation, or injury.<BR/>Record review of Resident #1's clinical record revealed she did not have a self-administration of medication assessment done.<BR/>Record review of Resident #2's January 2024 physician orders revealed there was an order for levocetirizine 5 mg and no orders for albuterol inhaler, Slow Fe (iron) tablets, and yeast plus pills.<BR/>Record review of Resident #2's January 2024 MAR revealed the Resident #2 was being administered levocetirizine 5 mg one tablet by mouth daily, other medications were not documented on her MAR.<BR/>Observation and interview on 01/17/24 at 12:08 PM with Resident #2 revealed she was on her bed watching television and on the side of her bed were personal items and one bottle of levocetirizine 5 mg tablets (used to relieve the symptoms of hay fever and hives of the skin), Slow Fe 11 tablets (used to treat or prevent low blood levels of iron), 2 tablets of yeast plus, and an albuterol inhaler (used to prevent and treat wheezing) in a Ziploc bag. Resident #2 stated she had not been told by staff that her medication had to be locked or put in a secure place. Resident #2 stated she had been using the albuterol and levocetirizine as needed and mostly at night. She stated she took the iron tablets every other day and the yeast tablet when she suspected she had a yeast infection. <BR/>Interview on 01/17/24 at 12:15 PM with LVN B revealed she was not aware Resident #2 had possession of her albuterol inhaler, slow Fe, yeast plus and levocetirizine. She stated she knew a staff member had seen the levocetirizine, so the doctor was called, and they got an order for it. LVN B stated she did not know Resident #2 was still in possession of the levocetirizine and other medications. She stated she knew the risk was overdose and other residents getting the medications. She stated Resident #2 was not assessed for self-administration of medication.<BR/>Interview on 01/17/24 at 2:41 PM with the DON revealed she was unaware Resident #2 had possession of an albuterol inhaler and other medications. The DON stated Resident #2 was supposed to be assessed for self-administration and educated on how to use and when to administer her medications. The DON stated the risk of a resident having possession of medication and self-administering without being assessed could be inappropriate consumption, interaction with other medications, and the wrong resident getting ahold of the medication. <BR/>The facility's Self-Administration of Medication policy was requested on 01/17/24 at 2:45 PM, but it was not provided. <BR/>Review of the facility's Recommended Medication Storage policy, dated July 2012, revealed it did not address medication storage/security.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders and the comprehenxive person-centered care plan for 1 (Resident #97) of 1 resident reviewed for parenteral fluids. <BR/>The facility failed to ensure Resident #97's PICC line dressing remained intact. <BR/>This failure placed the resident at risk of infection.<BR/>Findings included:<BR/>Review of Resident #97's admission Record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of bone infection of the right foot and ankle with right 4th toe amputation. <BR/>Review of Resident #97's admission MDS, dated [DATE], revealed a BIMS score of 12 indicating moderate cognitive impairment. His Functional Status indicated he required limited assistance with his ADLs. <BR/>Review of Resident #97's care plan revealed he had a surgical site to his right foot requiring wound care and dressing changes; IV access required daily monitoring for signs of infection and dressing change every 7 days or as needed. <BR/>Review of Resident #97's physician orders revealed an order to change the dressing to PICC line every 7 days on Mondays and as needed. <BR/>Interview and observation on 08/20/23 at 11:34 AM, Resident #97 stated he had been admitted after having the wound on his right foot repaired surgically after it became infected and re-opened. He stated he was at the facility for antibiotic therapy and some physical therapy to regain his strength. Resident stated he was worried his IV access would get infected because the dressing was coming off and had not been changed since it was inserted on 08/17/23. Observation of Resident #97 revealed his dressing to his right foot was clean, dry, and intact. Resident #97 had a PICC line to his right upper arm that was barely hanging on, the dressing was peeling off on three sides and was being held in place by a wrap around his arm. <BR/>Interview and observation on 08/21/23 at 11:05 AM, Resident #97 stated his dressing to his foot had been changed by the wound care nurse. Dressing to his PICC line had not been changed and was still peeling off.<BR/>Interview and observation on 08/22/23 at 10:00 AM, the Wound Care Nurse stated PICC line dressings were done by the nurses, but she would change Resident #97's dressing when she did his dressing change for his foot. <BR/>Review of the facility's currente, undated Central Venous Catheters policy reflected: Peripherally inserted central catheters (PICC's) are generally indicated when therapy is expected to last for weeks to a few months. The policy reflected PICC line maintenance procedures included changing the transparent dressing every 7 days and as needed and monitoring for infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders and the comprehenxive person-centered care plan for 1 (Resident #97) of 1 resident reviewed for parenteral fluids. <BR/>The facility failed to ensure Resident #97's PICC line dressing remained intact. <BR/>This failure placed the resident at risk of infection.<BR/>Findings included:<BR/>Review of Resident #97's admission Record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of bone infection of the right foot and ankle with right 4th toe amputation. <BR/>Review of Resident #97's admission MDS, dated [DATE], revealed a BIMS score of 12 indicating moderate cognitive impairment. His Functional Status indicated he required limited assistance with his ADLs. <BR/>Review of Resident #97's care plan revealed he had a surgical site to his right foot requiring wound care and dressing changes; IV access required daily monitoring for signs of infection and dressing change every 7 days or as needed. <BR/>Review of Resident #97's physician orders revealed an order to change the dressing to PICC line every 7 days on Mondays and as needed. <BR/>Interview and observation on 08/20/23 at 11:34 AM, Resident #97 stated he had been admitted after having the wound on his right foot repaired surgically after it became infected and re-opened. He stated he was at the facility for antibiotic therapy and some physical therapy to regain his strength. Resident stated he was worried his IV access would get infected because the dressing was coming off and had not been changed since it was inserted on 08/17/23. Observation of Resident #97 revealed his dressing to his right foot was clean, dry, and intact. Resident #97 had a PICC line to his right upper arm that was barely hanging on, the dressing was peeling off on three sides and was being held in place by a wrap around his arm. <BR/>Interview and observation on 08/21/23 at 11:05 AM, Resident #97 stated his dressing to his foot had been changed by the wound care nurse. Dressing to his PICC line had not been changed and was still peeling off.<BR/>Interview and observation on 08/22/23 at 10:00 AM, the Wound Care Nurse stated PICC line dressings were done by the nurses, but she would change Resident #97's dressing when she did his dressing change for his foot. <BR/>Review of the facility's currente, undated Central Venous Catheters policy reflected: Peripherally inserted central catheters (PICC's) are generally indicated when therapy is expected to last for weeks to a few months. The policy reflected PICC line maintenance procedures included changing the transparent dressing every 7 days and as needed and monitoring for infection.