Vista Hills Health Care Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #4 & #3) of three residents reviewed for quality of care. <BR/>The facility failed to ensure treatment nurse transcribed the physician treatment order to treat Resident #4's rash on groin area. <BR/>The facility failed to identify and treat Resident #3's rash and behavior of scratching. <BR/>This failure placed residents at risk for delays in treatment, developing infections and deterioration of skin condition. <BR/>Findings included: <BR/>Resident #4<BR/>Record review of Resident #4's admission record dated 02/12/2024 revealed Resident #4 was an [AGE] year-old woman admitted to the facility on [DATE]. <BR/>Record review of Resident #4's History & Physical dated 09/27/23 revealed Resident #4 was an [AGE] year-old female transferred from foster home. Past Medical History; dementia, depression, and insomnia. Skin: No rash. No skin breakdown. <BR/>Record review of Resident #4's MDS assessment dated [DATE] revealed she rarely made herself understood; had short-term memory problems. Her cognitive skills for Daily Decision Making were severely impaired. She required extensive assistance of one person with bed mobility, transfer, and eating. She received skin treatment including pressure reducing device for chair; pressure reduction device for bed, and to receive application of ointments other than to her feet. <BR/>Record review of Resident #4's undated care plan revealed she had an ADL Self-Care Deficit and was at risk for not having her needs met in a timely manner. Interventions were to include Substantial/Maximum assistance with bed mobility, transfers, toileting, and personal hygiene. Interventions for Incontinence were to include Check frequently for wetness and soiling and change as needed, apply barrier cream to skin after incontinent episodes. She was to receive weekly skin checks to monitor for redness, breakdown, or other skin concerns. Any new skin conditions were to be reported to the physician. <BR/>Review of Physician Order Recap dated 02/15/24 for Resident #4 revealed an order to perform a head to toe skin assessment every Saturday for wound prevention/early identification. Staff were to notify the physician of any changes in skin integrity. An order dated 02/12/24 said that Nystatin External Powder 100000 Unit/GM was to be applied to bilateral groin topically every shift for redness to bilateral groin area. The medication recap did not document an order for Hydrogel. <BR/>Record review of Resident #4's Physician Progress Note dated 01/23/24 revealed the resident's chief complaint was for a Comprehensive Monthly Visit. Patient required assistance with all ADLs including feeding. Patient ambulated with wheelchair. History of Present Illness indicated she was alert and oriented x 1. She had diagnoses including dementia, depression, cognitive communication deficits, abnormalities of gait and mobility, and dysphagia. She had no skin breakdown and no skin rash. The assessment/plan included that nursing would manage bowel and bladder. They were to turn the patient every 2 hours while in bed. They were to provide heel protectors while in bed, and wound care was to valuate and treat. <BR/>Review of Resident #4's Nurses Progress Notes revealed 02/09/24 07:39 Skin/Wound Note Text: Head to toe skin assessment performed, no discoloration, no open skin noted, call light within reach. <BR/>Review of Resident #4's Nurses Progress Notes on 02/09/24 revealed that Treatment Nurse had not documented that she reported to physician and/or NP that Resident #4 had a pink rash on groin area. <BR/>Review of Resident #4's Nurses Progress Notes dated 02/12/24 12:53 revealed a new order for Nystatin powder to apply topically Q shift to bilateral groin area for redness. RP notified. <BR/>Record Review Resident #4's Physician Order dated 02/12/24 at 12:38 PM, for Resident #4 written by ADON, documented Nystatin External Powder 100000 units/GM apply to bilateral groin every shift for redness to bilateral groin area. <BR/>Review of Resident #4's Skin Observation Worksheet provided by Treatment Nurse on 02/09/24 revealed [Resident #4] did not have any issues. <BR/>Interview on 02/09/24 at 3:33 PM, the Treatment Nurse stated charge nurses completed weekly skin assessments on all residents and were responsible for immediately reporting any changes in skin integrity to the attending physician and/or Nurse Practitioner. Treatment Nurses were responsible for completing the initial skin assessments on all admissions and for completing weekly skin assessments on all residents that had pressure ulcers, skin rashes, surgical wounds, or skin tears. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately reported any changes in skin integrity to the charge nurses and charge nurses would report to the treatment nurse. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately report any changes in skin integrity to the charge nurses. She reported that the new company would take over the last week of February 2024 and corporate staff had requested that she complete a skin sweep for all residents at the facility. She started the skin sweep in the South Side today [02/09/2024] at 4:00 AM. The Treatment Nurse did not know how often she would be expected to conduct skin sweeps on the residents. <BR/>Observation and interview on 02/09/24 at 4:32 PM with the DON and the Treatment Nurse revealed Resident #4 was lying in bed on her back, awake, and had a pressure relieving mattress. It was reported the resident was confused, incoherent speech, required total assistance of two persons with ADLs, and was incontinent of bowel & bladder. The DON pulled sheets down, noted that the resident was wearing double disposable briefs . The DON stated, CNAs have been trained not to put two briefs on the residents. The DON demonstrated to surveyor disposable briefs were clean and dry. Resident #4 had a light pink rash on the groin area. There was no urine smell, the bed sheets were clean and dry. The Treatment Nurse reported she called the physician today [02/09/2024] to report skin integrity change and was pending return call. <BR/>Interview on 02/12/24 at 11:30 AM, Treatment Nurse reported she got a telephone order on 02/09/24 for Resident #4 to apply Hydrogel to the perineal area every shift. When the surveyor asked the nurse if treatment had been started as ordered, The Treatment Nurse stated No, because I did not enter the new order in the resident's electronic record. The Treatment Nurse stated she had been trained to immediately enter new orders on the computer to ensure treatments were done as ordered. <BR/>Observation and interview 02/12/24 at 12:35 PM, with Treatment Nurse revealed Resident #4's brief was slightly wet with urine. It was noted resident had a pink rash on the groin area. The Treatment Nurse reported that she still had not added the new order for Hydrogel that was given by the physician on 02/09/24 to the resident's electronic record received on 02/09/24 to treat the rash on the pelvic area with Hydrogel because she was busy making rounds with the surveyors. <BR/>Interview 02/12/24 at 11:38 AM, with the DON, in the presence of the Administrator, reported licensed staff had been trained to immediately report changes in condition to the attending physician and/or nurse practitioner and to immediately enter the new physician's order in the resident's electronic record as soon as the order was given. <BR/>Review of the facility's policy on Notification of Changes in condition reviewed/revised 02/10/2021 revealed Policy: To provide guidance on when to communicate acute change in status to MD, NP and responsible party. The facility will immediately consult with the resident's physician of the following: A significant change in the physical status of residents. Policy Explanation and Compliance Guidelines: The facility must document resident assessment(s), interventions, physician and family notification(s) on SBAR, Nurse Progress Note or Telephone Order Form as appropriate. Immediate Physician Notification - the physician is notified immediately and should respond timely (within minutes). Non-Immediate Notification - the physician is notified and there should be a return call within the same day. <BR/>Resident #3<BR/>Record review of Resident #3's face sheet dated 02/15/2024 revealed she was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. <BR/>Record review of Resident #3's History and Physical (H&P) dated 1/10/2024 revealed she was nonverbal and had diagnoses including Type 2 Diabetes mellitus, high blood pressure, and cerebral infarction (stroke). She was bed-bound and was non-verbal. She had no issues with her skin. The History and Physical stated right ulcer but did not specify the type or where the ulcer was located. The plan included to turn patient every 2 hours while in bed and that wound care was to evaluate and treat. <BR/>Record review of Resident #3's discharge MDS assessment dated [DATE] revealed she was nonverbal and was assessed by staff regarding her mental status. She had moderately impaired skills for daily decision making and had poor short- term memory. She was dependent on staff for toileting hygiene. She had behavioral symptoms not directed toward others. The MDS did not specify what these behaviors were. She was always incontinent of bladder and bowel. <BR/>Record review of Resident #3's Care Plan dated 06/19/2023 revealed she was incontinent of bowel and bladder. The goal was that she was to remain free from skin breakdown due to incontinence and brief use through the next review date (revised 01/26/2024). Interventions included weekly skin checks to monitor for redness, circulatory problems, breakdown, or other skin concerns and to report any new skin conditions to the physician. There was no care plan that addressed her behavior of scratching her inguinal area (where the thigh meets the front of the lower body) and abdominal fold. <BR/>Record review of Resident #3's Progress note dated 02/14/2024 revealed that a skin assessment revealed an inguinal rash (a rash where the thigh meets the front of the lower body). <BR/>Record review of progress notes for Resident #3 dated 01/15/2024 through 2/14/2024 revealed a Skin/Wound note dated 02/09/2024 that the resident had an inguinal rash. There were no notes regarding scratches. <BR/>Record review of Resident #3's physician's orders dated 2/12/2024 revealed an order to apply Nystatin power (a treatment for a yeast or fungal infection of the skin) 100000 unit/gm to her inguinal folds for a rash. <BR/>In an interview on 02/14/2024 at 12:27 PM, CNA B revealed that she provided help with ADLs to Resident #3 on 02/14/2024 and that Resident #3 had a rash in her inguinal area. The CNA said the rash was because the resident would scratch her inguinal area and her abdominal fold (the area under the stomach above the pelvis). <BR/>In an interview on 02/14/2024 at 3:10 PM, CNA C revealed that she was assigned to provide help with ADLs to Resident #3 about one week a month and had provided help to the resident on 02/14/2024. The CNA said the resident had flaky skin and scratched her inner thighs to the point she would bleed a little. The CNA stated she applied a cream that the resident's family provided and would put zinc oxide on the areas where she scratched. <BR/>In an interview on 02/14/2024 at 3:27 PM, CNA D revealed that she had provided help with ADLs to Resident #3 since the resident returned from the hospital. The CNA stated the resident had a rash between her legs and under her stomach. The CNA had no idea why the resident had a rash but said that resident did tend to scratch herself under her stomach and would also scratch her bottom. , <BR/>In an interview on 02/14/2024 at 4:13 PM, RN E revealed she was not aware that Resident #3 had a behavior of scratching her legs and under the abdomen. She stated that the CNAs should have told her if the resident had this behavior. She said that if she was aware that resident had behavior of scratching herself, she would get an order from the nurse practitioner to treat it. She said the CNAs had not indicated the resident had scratches or rashes on the shower sheets. <BR/>In an Interview on 2/14/24 at 4:25 PM, ADON G revealed she had become aware last week that Resident #3 was scratching. She said residents' skin condition was assessed weekly and the charge nurse should have been aware that the resident scratches. She stated that Resident #3's behavior of scratching should be on the care plan. The purpose of the care plan was for all nursing and management to be aware of the care the resident needed and pass along to take better care of her. The ADON said that if there was no care plan for scratching, the result was that the resident could be at risk to not accomplish goal of protecting skin. <BR/>In an interview on 02/15/2024 at 8:29 AM, CNA F revealed that had provided help with ADLs to Resident #3 two week before and the resident had a rash in her abdominal fold. The CNA said that the resident had a behavior of scratching herself was not new and had been occurring over the past six months. The CNA stated she had reported it to the charge nurse (unnamed) a while back (date unknown). The CNA said she told the resident not to scratch herself and would apply a diaper rash ointment to the scratched areas. <BR/>In an interview on 02/15/2024 at 11:14 PM, MDS Nurse H LVN revealed that Resident #3's behavior of scratching would be on care plan which had been brought to his attention a couple of days ago (date not remembered). He said the care plan's purpose was to paint a picture of the resident for staff members not familiar with the patient so they would know what to expect and how to care for them. The care plan might let someone familiar with the resident know what interventions are being used for a particular issue which was important because although a staff member might be familiar with a resident, they may not know everything about them. <BR/>In an interview on 02/15/2024 at 11:34 AM, the DON revealed she was aware of Resident #3's excoriation (raw or scraped skin) to the skin fold under abdomen and stated this should be on the resident's care plan. She stated the CNAs should have reported the excoriation and the resident's scratching behavior to the nurses. The resident's scratching behaviors and the possible causes for it should have been put on care plan. The DON said if the behavior was not on care plan, staff would not be aware of it which could lead to further skin breakdown and possible infection. <BR/>Record review of the facility policy Comprehensive Care Plans dated 02/10/2021 revealed the facility would develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical needs that are identified in the resident comprehensive assessment. The care plan process includes an assessment of the resident's needs and concerns identified by the interdisciplinary team. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 1 of 7 residents (Residents #4) reviewed for resident rights, in that: <BR/>The facility failed to ensure the treatment nurse notified the physician when Resident #4 had a change in skin integrity. <BR/>This deficient practice could place residents at risk of a delay of medical treatment. <BR/>Findings included: <BR/>Record review of Resident #4's admission record dated 02/12/2024 revealed Resident #4 was an [AGE] year-old woman admitted to the facility on [DATE]. <BR/>Record review of Resident #4's History & Physical dated 09/27/23 revealed Resident #4 was an [AGE] year-old female transferred from foster home. Past Medical History; dementia, depression, and insomnia. Skin: No rash. No skin breakdown. <BR/>Record review of Resident #4's MDS assessment dated [DATE] revealed she rarely made herself understood; had short-term memory problems. Her cognitive skills for Daily Decision Making were severely impaired. She required extensive assistance of one person with bed mobility, transfer, and eating. She received skin treatment including pressure reducing device for chair; pressure reduction device for bed, and to receive application of ointments other than to her feet. <BR/>Record review of Resident #4's undated care plan revealed she had an ADL Self-Care Deficit and was at risk for not having her needs met in a timely manner. Interventions were to include Substantial/Maximum assistance with bed mobility, transfers, toileting, and personal hygiene. Interventions for Incontinence were to include Check frequently for wetness and soiling and change as needed, apply barrier cream to skin after incontinent episodes. She was to receive weekly skin checks to monitor for redness, breakdown, or other skin concerns. Any new skin conditions were to be reported to the physician. <BR/>Review of Physician Order Recap dated 02/15/24 for Resident #4 revealed an order to perform a head to toe skin assessment every Saturday for wound prevention/early identification. Staff were to notify the physician of any changes in skin integrity. An order dated 02/12/24 said that Nystatin External Powder 100000 Unit/GM was to be applied to bilateral groin topically every shift for redness to bilateral groin area. The medication recap did not document an order for Hydrogel. <BR/>Record review of Resident #4's Physician Progress Note dated 01/23/24 revealed the resident's chief complaint was for a Comprehensive Monthly Visit. Patient required assistance with all ADLs including feeding. Patient ambulated with wheelchair. History of Present Illness indicated she was alert and oriented x 1. She had diagnoses including dementia, depression, cognitive communication deficits, abnormalities of gait and mobility, and dysphagia. She had no skin breakdown and no skin rash. The assessment/plan included that nursing would manage bowel and bladder. They were to turn the patient every 2 hours while in bed. They were to provide heel protectors while in bed, and wound care was to valuate and treat. <BR/>Review of Resident #4's Nurses Progress Notes revealed 02/09/24 07:39 Skin/Wound Note Text: Head to toe skin assessment performed, no discoloration, no open skin noted, call light within reach. <BR/>Review of Resident #4's Nurses Progress Notes on 02/09/24 revealed that Treatment Nurse had not documented that she reported to physician and/or NP that Resident #4 had a pink rash on groin area. <BR/>Review of Resident #4's Nurses Progress Notes dated 02/12/24 12:53 revealed a new order for Nystatin powder to apply topically Q shift to bilateral groin area for redness. RP notified. <BR/>Record Review Resident #4's Physician Order dated 02/12/24 at 12:38 PM, for Resident #4 written by ADON, documented Nystatin External Powder 100000 units/GM apply to bilateral groin every shift for redness to bilateral groin area. <BR/>Review of Resident #4's Skin Observation Worksheet provided by Treatment Nurse on 02/09/24 revealed [Resident #4] did not have any issues. <BR/>Interview on 02/09/24 at 3:33 PM, the Treatment Nurse stated charge nurses completed weekly skin assessments on all residents and were responsible for immediately reporting any changes in skin integrity to the attending physician and/or Nurse Practitioner. Treatment Nurses were responsible for completing the initial skin assessments on all admissions and for completing weekly skin assessments on all residents that had pressure ulcers, skin rashes, surgical wounds, or skin tears. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately reported any changes in skin integrity to the charge nurses and charge nurses would report to the treatment nurse. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately report any changes in skin integrity to the charge nurses. She reported that the new company would take over the last week of February 2024 and corporate staff had requested that she complete a skin sweep for all residents at the facility. She started the skin sweep in the South Side today [02/09/2024] at 4:00 AM. The Treatment Nurse did not know how often she would be expected to conduct skin sweeps on the residents. <BR/>Observation and interview on 02/09/24 at 4:32 PM with the DON and the Treatment Nurse revealed Resident #4 was lying in bed on her back, awake, and had a pressure relieving mattress. It was reported the resident was confused, incoherent speech, required total assistance of two persons with ADLs, and was incontinent of bowel & bladder. The DON pulled sheets down, noted that the resident was wearing double disposable briefs . The DON stated, CNAs have been trained not to put two briefs on the residents. The DON demonstrated to surveyor disposable briefs were clean and dry. Resident #4 had a light pink rash on the groin area. There was no urine smell, the bed sheets were clean and dry. The Treatment Nurse reported she called the physician today [02/09/2024] to report skin integrity change and was pending return call. <BR/>Interview on 02/12/24 at 11:30 AM, Treatment Nurse reported she got a telephone order on 02/09/24 for Resident #4 to apply Hydrogel to the perineal area every shift. When the surveyor asked the nurse if treatment had been started as ordered, The Treatment Nurse stated No, because I did not enter the new order in the resident's electronic record. The Treatment Nurse stated she had been trained to immediately enter new orders on the computer to ensure treatments were done as ordered. <BR/>Observation and interview 02/12/24 at 12:35 PM, with Treatment Nurse revealed Resident #4's brief was slightly wet with urine. It was noted resident had a pink rash on the groin area. The Treatment Nurse reported that she still had not added the new order for Hydrogel that was given by the physician on 02/09/24 to the resident's electronic record received on 02/09/24 to treat the rash on the pelvic area with Hydrogel because she was busy making rounds with the surveyors. <BR/>Interview 02/12/24 at 11:38 AM, with the DON, in the presence of the Administrator, reported licensed staff had been trained to immediately report changes in condition to the attending physician and/or nurse practitioner and to immediately enter the new physician's order in the resident's electronic record as soon as the order was given. <BR/>Review of the facility's policy on Notification of Changes in condition reviewed/revised 02/10/2021 revealed Policy: To provide guidance on when to communicate acute change in status to MD, NP and responsible party. The facility will immediately consult with the resident's physician of the following: A significant change in the physical status of residents. Policy Explanation and Compliance Guidelines: The facility must document resident assessment(s), interventions, physician and family notification(s) on SBAR, Nurse Progress Note or Telephone Order Form as appropriate. Immediate Physician Notification - the physician is notified immediately and should respond timely (within minutes). Non-Immediate Notification - the physician is notified and there should be a return call within the same day. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #8) of 3 residents reviewed for catheter care. <BR/>The facility failed to ensure Residents #8s catheter leg strap was in place to secure the catheter. <BR/>This failure could place residents with foley catheters at risk of catheter pulling causing pain. <BR/>Findings included:<BR/>Record review of Resident #8's face sheet dated 1/14/25 revealed a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of retention of urine and neuromuscular dysfunction of bladder. <BR/>Record review of Resident #8's significant change MDS assessment dated [DATE] revealed a BIMS score of 15, her cognition was intact and had and had indwelling catheter. <BR/>Record review of Resident #8's physician order dated 10/16/24 revealed ensure catheter strap in place and holding, every shift change as needed. <BR/>Record review of Resident #8's care plan dated 11/19/24 revealed a focus area for [Resident #8] has a Indwelling Catheter with goal of will remain free from catheter-related trauma through review date and interventions that included ensure tubing is anchored to the residents leg or linens so that tubing is not pulling on the urethra. <BR/>In an observation and interview on 1/14/25 at 11:26 am, Resident # 8 was alert and oriented to place, time, and event. While in bed, it was observed that Resident # 8's urinary catheter was positioned below the bladder and hanging over the bed, with no leg strap secured. Resident # 8 stated that the catheter strap had not been in place for two days and that she had reported the issue, though she could not recall to whom or when. Resident # 8 stated that the lack of a secured strap caused discomfort when moving, as it allowed the catheter to shift.<BR/>In an interview on 1/14/25 at 11:35 am, RN B stated that it was the responsibility of nursing aides and nurses to ensure urinary catheters were secured with leg straps and checked at least every two hours or as needed. RN B stated she had not received any communication indicating that Resident #8's catheter strap was not secured. RN B stated that she had spoken to Resident #8 that morning and asked how she was doing, but the resident had not mentioned the issue. RN B stated that during her check that morning, she only ensured the urinary catheter bag was off the floor and in a privacy bag, and she did not verify if the leg strap was in place. RN B stated that checking for the leg strap was part of her assessment, but she had forgotten to do so. RN B stated that the risk of not securing the leg strap included the catheter being tugged or pulled, potentially causing injury or trauma to the urethra. RN B stated she had received training on urinary catheter to include ensuring catheter strap was secured upon hire. <BR/>In an interview on 1/14/25 at 11:49 am, CNA A stated that she had received training on urinary catheter care upon hire and at least twice a year. CNA A explained that it was the CNA's responsibility to ensure the leg strap was secured at all times, with checks performed at least every two hours or as needed. CNA A noted that Resident #8 was verbal and able to communicate her needs. CNA A clarified that she was not the CNA assigned to the resident but had assisted with perineal care. CNA A stated that the risk of an unsecured catheter included possible discomfort, as she had been told that catheter movement when not secured could cause residents some pain.<BR/>In an interview on 1/14/25 at 3:00 pm, the DON stated that all staff, including CNAs, nurses, and nurse managers, were required to conduct rounds regularly. The DON stated nurse managers were expected to perform daily rounds, while CNAs and nurses were required to check on residents constantly and as needed throughout the day. The DON stated that nurses were expected to check catheter placement during their rounds, not just the privacy bags. The DON stated that nurses oversee the CNAs, while nurse managers oversee the nurses. The DON stated that failing to secure the catheter properly increases the risk of it being pulled out accidentally.<BR/>In an interview on 1/14/25 at 4:01 pm, the Administrator referred the question to the DON.<BR/>Record review of the facility's Cather Care policy dated 02/13/2007 read in part hold catheter tubing to one side and support against leg to avoid traction or unnecessary movement of the catheter while washing perineum.

Based on interviews and record review, the facility failed to consider the views of the residents and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. The facility failed to demonstrate their responses and rational's for such response for 1 of 1 resident council. <BR/>The facility failed to ensure concerns expressed in the resident council meetings for (the past 7 months) were reported to the administrator and designated department heads. <BR/>This failure could lead to residents feeling unheard and unvalued in their place of residence.<BR/>Findings included:<BR/>In a confidential interview during the Resident Group revealed stated they felt the administrator did not make any efforts to address their concerns and grievances discussed in previous months at the resident council meetings. The residents stated they had requested copies of the Resident Council minutes from the previous meetings so that they could see what efforts had been made to resolve the grievances expressed by the residents but were denied a copy of the minutes by the administrator. It was reported the Administrator retaliates against the Resident Council President and [NAME] President for reporting concerns about her interference with Resident Council Elections, concerns with cold food temperatures and request to review Resident Council Minutes to see what the facility was doing to address those concerns voiced at the Resident Council Meetings. It was reported that they had reported these concerns to the local ombudsman. <BR/>In an interview with the Activities Director on 11/19/2024 at 2:33 PM, she stated the residents had voiced concerns regarding food served cold during meals. She stated once the resident council meeting was over, she would complete the grievance form for all the concerns voiced during the meeting and give them to the administrator. The activities director said the administrator would review the Grievance Reports and Grievances Resolution at the morning meetings and the DON or administrator would provide in-services to address the concerns voiced at the Resident Council. She said Meal Test Tray checks were done by the Administrator on a quarterly basis to address concerns voiced regarding food. She said these concerns were also addressed at the Monthly QAPI Meeting where they reviewed the in-service training to verify if it was effective and to retrain staff as needed until the area of concern had been resolved.<BR/>In an interview and record review with the Administrator on 11/19/2024 at 2:56 PM, revealed the Activities Director and her assistant were responsible for writing the Resident Council Meeting Minutes and for turning them in to the Administrator for review. The Administrator stated, I was not aware they were not writing down all of the concerns voiced by the residents during the Resident Council Meetings. After the Resident Council Meeting, I will follow up with the Resident Council President on any concerns voiced at the Resident Council Meeting. The Resident Council President sometimes becomes very defensive because I will be asking questions about what was reported at the meeting so I can address his concerns. That is why I always have a witness with me when I talk to him. The Administrator stated the Activities Director had not documented any concerns in the Resident Council Minutes regarding concerns voiced by the resident regarding serving cold during meals. <BR/>In an interview on 11/20/24 at 9:44 AM, with the Administrator revealed their corporate staff would not permit the residents to review the Resident Council Minutes and were only allowed to provide the Resident Council President a list of residents who had attended the Resident Council Minutes. The Administrator stated the Activities Director wrote the minutes for the Resident Council Meetings and that is what she acted on. <BR/>In an interview on 11/20/24 at 9:51 AM, with the Director of Food and Nutrition stated, I get concerns from the residents regarding cold food temperatures sporadically or occasionally. I did not write a Grievance Form for the concerns voiced regarding cold food temperatures. I do not remember when was the last time that we checked food temperatures on a test tray. The meal carts are not insulated and the staff needed to keep the door closed while they were passing trays to keep the food warm in the meal cart. <BR/>Interview on 11/20/24 at 12:00 PM, with Administer reported they conduct monthly QAPI meetings. She said that as of now only the Dietary Manager, Maintenance Supervisor, Medical Director, Administrator and Director of Nursing. Topics discussed: Infection Control, Pharmacy Services, Incidents, PIPs, Immunizations and Staffing.<BR/>Interview on 11/20/24 at 12:11 PM, with Director of Food and Nutrition reported they conduct monthly QAPI meetings. He said Administrator, Director of Nursing, Human Resource Coordinator, Medical Director, Maintenance Supervisor, and Admissions Marketer. Topics discussed: Weight Loss, Incident Reports, Safety, and Immunizations. <BR/>Interview on 11/20/24 at 3:50 PM, Director of Nursing reported they conduct monthly QAPI meetings. Most of the department managers attend including the wound care nurses and one direct care staff. Medical Director attends all of the meeting. Topics discussed: Decline in ADLS, psychotropic drugs. <BR/>Interview on 11/21/24 at 10:36 AM, Director of Rehab Services occasionally attend QAPI meetings. I do not remember when was the last time I attended a QAPI meeting. It has been a while since a attended a meeting.<BR/>Interview on 11/21/24 at 10:43 AM, Maintenance Director Dietary new equipment, Cold Food, Falls, Admissions, Medications delivered on times, medical supplies ensure we have enough briefs; Who attends Medical Director, Dietary Supervisor, and DON.<BR/>Review of Resident Council Minutes dated 05/31/24 through 10/01/24 did not document documents any concerns related to cold food temperatures. <BR/>Record Review revealed QAA Committee members were Director of Nursing, Administrator,Medical Director, Maintenance Director, Director of Rehabilitation Services, and Director of Food and Nutrition.<BR/>Record Review of the QAPI Sign in sheets revealed: <BR/>-10/19/24 Continue to work with Care Planning concerns of clustering & individualizing the plan of care.<BR/>-09/19/24 CS focus is to keep an accurate inventory count. MDS focus on documentation accuracy. <BR/>-08/22/24 Medical Records continuing to compile the accuracy of rental inventory. MDS focus is to work on MDS assessments to submit on time. <BR/>-07/28/24 Care Plans over due<BR/>-06/11/24 Care Plans over-due<BR/>-05/16/24 MDS focus is to do a follow-up on all care plans to update any areas identified on audit log e.g. clustering and individualize plans.<BR/>Record review of the Grievance Policy Revised 11/19/2016 read: Residents and their families have the right to file a grievance without fear of reprisal. The designated grievance officer is the Administrator. Fundamental Information: Resident concerns should be taken seriously and that the ability to voice a grievance is an important right and protection of residents. Procedure: Social service, under the guidance of the Administrator is responsible for the following: Maintain a system to keep records (file, log, copy of grievance registration forms, etc.) of all complaints reported which contains the date of report, circumstances, specifics of investigation, action taken, and follow up with the complainant. Conduct/designate routine interviews with residents and families related to specific areas of facility life and resident care. Document negative findings on the grievance form. The Administrator (grievance officer) is responsible for the following: Review grievances to validate the investigation of the facts and circumstances of the grievance. Written findings of fact, conclusion and recommendations and validated with person issuing the grievance timely. Establish a mechanism for all associates to communicate resident or family grievances to the designated staff so that all grievances will be documented and timely response developed and implemented. Coordinate orientation and in-service training to ensure that all facility associates are knowledgeable of the facilities grievance procedure and their role in providing responsive customer service to residents and families and grievance resolution. Validates designee follow up with resident family regarding resolution or explanation. A reasonable expected time frame for completing the review of the grievance. The right to obtain a written decision regarding his or her agreements. Provide a copy of the grievance policy to the resident upon request. Coordinate to validate residence or notice of rights and services, including the right to file the grievance prior to or upon admission and during the resident stay.

Based on interview and record review, the facility failed to ensure the prompt resolution of all grievances to include all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 5 of 13 confidential residents reviewed for resident rights. <BR/>1. - The Activities Director failed to initiate grievance reports on behalf of the residents regarding grievances and concerns voiced during the Resident Council Meetings.<BR/>2. - The facility Administrator failed to document, resolve, and follow-up on grievances related to quality of care voiced by the residents during the Resident Council Meetings. <BR/>3. - The facility failed to ensure residents received responses to grievances and concerns voiced during the Resident Council Meetings.<BR/>These failures placed residents at risk of having their rights violated, not receiving responses to their grievances, a decrease in self-worth and a decline in quality of life. <BR/>Findings included:<BR/>In a confidential interview with 13 of 13 residents revealed the meals were being delivered cold. Residents reported that this was an on-going problem, and nothing was being done to address their concerns. <BR/>Interview and record review 11/20/24 at 9:44 AM, with the Administrator revealed she was not aware of resident grievances regarding food being served cold. She said no concerns had been reported during the monthly QAPI meetings regarding cold food served to the residents. <BR/>Interview on 11/20/24 at 9:51 AM, with the Director of Food and Nutrition reflected he occasionally got concerns from the residents regarding cold food temperatures. He said he could not recall when they had checked food temperatures on a test tray at the facility. He said the facility did not have insulated meal carts and they did not have a system in place to check meal trays were promptly served to the residents who ate their meals in the rooms. He stated he was not aware CNAs were leaving the meal carts open when they were passing trays in the resident halls. He stated, Leaving the meal carts opened could affect the food temperatures. <BR/>Record Review of the Grievance Forms dated May 2024 through November 2024 revealed Residents reported food was served cold.<BR/>Record Review of the monthly QAPI attendance records dated May 06,2024 - 11/20/24 did not document any concerns regarding cold food served to the residents.<BR/>In an interview with the Local Ombudsman on 11/19/24 at 11:15 AM, stated said residents had reported to him that the facility was not addressing grievances or concerns voiced at the Resident Council Meetings. <BR/>In an interview with the Activities Director on 11/19/2024 at 2:33 PM, she said that the residents had voiced concerns regarding food served cold during meals. She stated once the resident council meeting was over, she would complete the grievance form for all the concerns voiced during the meeting and give them to the administrator. The activities director said the administrator would review the Grievance Reports and Grievances Resolution at the morning meetings and the DON or administrator would provide in-services to address the concerns voiced at the Resident Council. She said Meal Test Tray checks were done by the Administrator on a quarterly basis to address concerns voiced regarding food. She said these concerns are also addressed at the Monthly QAPI Meeting where they reviewed the in-service training to verify if it was effective and to retrain staff as needed until the area of concern had been resolved.<BR/>In an interview on 11/19/24 at 2:55 PM with Administrator revealed she would go and talk to the residents after the Resident Council Meetings to discuss the concerns that were voiced during the Resident Council Meeting and would not complete a Grievance if she felt that there was not a problem. The Administrator stated the facility policy on Grievances states that facility will complete a Grievance for all concerns voiced to ensure that resident concerns are investigated and resolved. The administrator stated that she does not write a grievance for every concern expressed by the residents during the resident council meetings. <BR/>Review of facility's Grievance policy (not dated) revealed in part: all adverse events are investigated each time they occur, using action plan process and root cause analysis methods. The facility will identify and prioritize quality deficiencies and will utilize all opportunities to identify areas with the potential for improving resident outcomes to include but not limited to resident interview, family interview and staff interviews, observation and reviews. Resident and family council minutes, grievance review process, reportable incidents. The self-assessment tool will be utilized at least quarterly as a means of measuring the progress of the QAPI program until the program is 100% in all areas. The facility will use the QA action plan as a method of documenting identification of concerns identified from the review of data at all weekly meetings (standards of care, champion rounds etc.) and any other time that an issue should present a potential negative outcome. Root cause will be used in determining why a situation occurred. Performance improvement project areas will be developed through the action plan process, after gathering all the information in a systematic manner to clarify issues and problems from the above areas. The action plan will be used to intervene in improving identified areas of concern. The PIP committee is a team effort for improvement and will consider each event a learning experience. Potential topics for PIPs can be identified through reviewing monthly/quarterly data that is not showing expected outcomes that are being measured against thresholds/benchmarks. Establishing a timeline and communicate it to the QAPI committee. The action plan process will be used to improve identified areas of concern. Root cause analysis will be used to determine when in-depth analysis is needed to fully understand a problem/event, its causes, and implications of a change. The committee will review all involved systems to prevent future events and promote sustained improvement. The facility will focus on continued training, learning and continuous improvement. A means whereby all negative outcomes relative to resident care and services are identified and resolved using root cause analysis with an interdisciplinary approach. Positive outcomes will be established through education and monitoring as well as development of a PIP committee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Residents #1) reviewed for assistance with ADLs in that: <BR/>-Resident #1 had long fingernails that were dirty and had a black substance underneath them.<BR/>This failure could place residents who required assistance with showering and maintaining good personal hygiene at risk for not receiving care and services to meet their needs and avoid ADL decline.<BR/>Findings include: <BR/>Record review of Resident #1's face sheet dated 09/08/2023, revealed a [AGE] year-old male, with a readmission date of 05/03/2023 and initially admitted to the facility on [DATE]. Resident #1's diagnoses included: anoxic brain damage (a process that begins with the cessation of cerebral blood flow to brain tissue), tracheostomy status (surgically created hole in windpipe that provides an alternative airway for breathing), hypertension (high blood pressure), dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), seizures (a sudden uncontrolled burst of electrical activity in the brain), and pain (physical suffering or discomfort caused by illness or injury).<BR/>Record review of Resident #1's MDS quarterly assessment dated [DATE] revealed BIMS score of 0, indicating he was severely cognitively impaired. Section G. revealed Resident #1 required total dependence with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing.<BR/>Record review of Resident #1's care plan dated 09/08/2023, revealed Resident #1 had focus area that included: ADLs: Resident #1 has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Part of the interventions included: Provide .nail care per schedule and when needed.<BR/>Record review of Resident #1's Order Summary dated 09/08/2023, revealed Resident #1 had an order with start date of 05/10/2023 that read Licensed nurse to perform nail care, every day shift, every Wednesday for diabetic care.<BR/>Record review of Resident 1's MAR for the month of September 2023, revealed on 09/06/2023, staff initialed that licensed nurse performed nail care.<BR/>Observation and interview on 09/08/2023 at 3:00 p.m., Resident #1 was lying on a bed. Resident #1's fingernails on both hands were long (approximately 1 &frac12; cm long) with sharp edges and his index finger of left hand with black substance under the nail. Resident #1 did not respond to questions about who cuts/files his nails or when the last time his nails were trimmed/filed. <BR/>During an interview on 09/08/2023 at 3:02 p.m., the ADON looked at Resident #1's fingernails and said his nails were long and will have nurse check nails. The ADON said she did not know the order for when nurse was supposed to groom nails. The ADON said the nurses were responsible for cutting/trimming/filing Resident #1's fingernails. The ADON said the risk of not providing nail care was the resident could scratch himself. <BR/>Record review of the facility's Nail Care policy dated 02/10/2020, reads in part Purpose: to provide for personal hygiene needs and prevent infection. Note: Precautions should be used when trimming nails of a resident with diabetes and should be done by a Licensed Nurse or Physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 1 of 18 residents (Resident #27) reviewed for foot care. <BR/>The facility failed to provide access to podiatrist for Resident #27. <BR/>This failure placed residents at risk of poor foot hygiene and decline in residents' physical condition. <BR/>Findings include:<BR/>Record review of Resident #27's admission Record, dated 11/18/24, reflected 61-year-female who was admitted on [DATE].<BR/>Record review of Resident #27's History and Physical dated 10/13/24, revealed diagnoses: intracerebral hemorrhage and was non-verbal with limited range of motion and strength with hemiparesis (weakness on one side of the body), cerebrovascular disease (a problem with the blood vessels in the brain that carry oxygen and nutrients). Diabetes, seizures, muscle wasting and atrophy (when muscles start to shrink and get weaker), muscle weakness, cognitive communication deficit (trouble understanding or using language due to brain damage).<BR/>Record review of Resident #27's admission MDS dated [DATE], revealed she had a BIMS score of 3 demonstrating she was severely impaired. Resident required maximal assistance with shower/bathe and personal hygiene. <BR/>Record review of Resident #27's Care Plan dated 10/11/24, revealed she needed assistance with personal hygiene and bathing. It stated that if the resident was diabetic, the nurse would provide toenail care.<BR/>Observation and interview on 11/18/24 at 3:24 PM with the DON, revealed Resident #27 was lying in bed. The DON said there was no in-house podiatrist at that time. It was observed that Resident #27 had long toenails and this was confirmed by the DON during observation. Resident #27's toenails were brown and yellow in color. The DON said Resident #27 had not been seen by a podiatrist since she was admitted because due to her tracheotomy, she would not be able to go out of the facility. The DON said they would need a podiatrist to provide care for Resident #27 in the facility.<BR/>During an interview on 11/20/24 at 3:48 PM with LVN C, he said he had known Resident # 27 for about a week. LVN C stated he had not been trained in toenail care. LVN C said Resident #27 was at risk of getting cut because of her long toenails. LVN C said that Resident #27's toenails need to be trimmed at least once a week. He said he did not know who was responsible for trimming her toenails.<BR/>During an observation and interview on 11/21/24 at 11:11 AM with Treatment Nurse confirmed Resident #27's toenails were long and needed to be trimmed to prevent injuries.<BR/>During an observation and interview on 11/21/24 at 11:27 AM with CNA H, said she had been working at the facility for 1 year. CNA H said Resident #27 toenails should be trimmed . CNA H stated that a nurse would be responsible for cutting a resident's toenails. CNA H said the risk of Resident #27 having long toenails had the potential for her to get cut or injured while moving in her bed or when she gets assistance with transfers.<BR/>Record review of the facility's nursing policy and procedure manual dated 2003 titled Nail Care reads in part: Nail management is regular care of toenails to promote cleanliness and skin integrity of tissues, to prevent infection, injury or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle area and is usually done during the bath. Ingrown toenails are also common in elderly. Fungal infections of the toenails, dry, brittle ridges and thickening of the toenails all occur in the elderly with some frequency. Nail care, especially trimming, is performed by a podiatrist in those with diabetes and peripheral vascular disease.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation.<BR/>1. <BR/>Facility Staff and Dietary Staff were not wearing hair nets or beard guards when entering or working in the kitchen. <BR/>This failure could affect residents by placing them at risk of food borne illness.<BR/>Findings include:<BR/>Observation and interview on 01/30/24 at 11:00 AM, the Maintenance Director was observed going into the kitchen without a hair net or beard guard. The Maintenance Director stated it was okay to go into the kitchen without a hair net or beard guard. In the back in the kitchen Dietary [NAME] did not have his hair net or beard guard on. The Maintenance Director stated the Dietary Manager had in-serviced all of the facility staff of what should be worn when in the kitchen. <BR/>During an interview on 01/30/24 at 11:20 AM with Dietary Cook, he stated a hair net and beard guard had to be worn. The Dietary [NAME] stated he had received training on what to wear while in the kitchen. The Dietary [NAME] stated not having a hair net or beard guard on could have hair falling into the food and contaminate it. The Dietary [NAME] stated the resident could get sick if eaten. <BR/>During an interview on 01/31/24 at 9:36 AM with the Dietary Manager, he stated everything passing the doors in the dining room was to be considered the kitchen. The Dietary Manager stated all dietary staff are to be wearing hairnets and the males would be beard guards if they have a beard. The Dietary Manager stated he had not in-serviced facility staff that were not dietary staff. The Dietary Manager stated there was a sign posted outside of the kitchen door revealing staff had to be wearing a hair net and beard guard. The Dietary Manager stated if they catch facility staff without a hairnet or beard guard, they do tell them to put one on. The Dietary Manager stated all staff have to follow the facility policy to wear hair nets and beard net and the sign posted says the something. The Dietary Manager stated the negative outcome of not wearing a hair net or beard guard would be not following facility policy of personal hygiene in which staff should be kept at all times for the safety of the residents. <BR/>During an interview on 02/01/24 at 11:18 AM with the DON, she stated she considered the kitchen area to be a clean location and sterile. The DON stated once the facility staff breach the kitchen doors in the dining area it was considered the kitchen. The DON stated facility and dietary staff have been trained and in-serviced on what the correct clothing was when entering the kitchen. The DON stated hair nets and beard guards for the males need to be warn. The DON stated the Maintenance Director stated that it was okay to enter the kitchen without hair net nor beard guard was inappropriate response and not okay. The DON stated the purpose of a hair net or beard guard was to prevent hair from falling into the food, floor, and dishes. The DON stated the risk to the residents would be infection. The DON stated it would not be appealing if she found hair in her food. <BR/>During an interview on 02/01/24 at 4:18 PM with the Administrator, she stated once facility staff cross the kitchen door in the dining room into the kitchen was consider being in the kitchen. The Administrator stated all facility staff to include dietary staff have to be wearing a hair net and for the males with facial hair a beard guard. The Administrative stated dietary staff are trained on the proper wear when being in the kitchen. The Administrator stated facility staff were trained on what to wear when entering the kitchen including the hair net and beard guard for males with facial hair. The Administrator stated the regulation says anybody working in the kitchen has to cover their hair. The Administrator stated not wearing a hair net or beard guard could be a risk of contamination. The Administrator stated she would not be okay finding hair in her food, it would be gross. <BR/>Record review of the facility Dietary Personal Hygiene policy dated 11/06 with no year revealed, Dietary employees will maintain proper food safety practices through proper personal hygiene.<BR/>- <BR/>Dietary employees shall wear, hair covering, beard restraint, and clothing that covers body hair.<BR/>- <BR/>All staff entering the kitchen must comply with hair restraints. <BR/>- <BR/>All personnel entering the kitchen to perform job functions shall follow all pertinent rules. <BR/>Record review of the facility Dietary Notice/Aviso Sign not dated revealed, Notice - Hairnets and beard covers required in this area. (Spanish) Aviso - Redecillas para el [NAME] y coberturas para la [NAME] son requeridas en areas de produccion. <BR/>Record review of facility Dietary [NAME] certification dated 08/06/21 revealed, Completion of food safety for handlers.

Based on observations, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 1 of 1 laundry room, 2 of 2 linen closets and residents' rooms reviewed for environmental conditions. <BR/>1. - The facility failed to maintain wood linen closet shelves in clean linen closets and ensure the shelves were free from splintered edges.<BR/>2. -The facility failed to replace missing floor baseboards in the laundry room.<BR/>3. - The facility failed to maintain walls in the laundry room and ensure they remained free of holes and chipped paint.<BR/>4. -The facility failed to replace broken or missing tiles in the shower room. <BR/>5. -The facility failed to keep water drains in the shower room free of rust. <BR/>This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment. <BR/>Findings included:<BR/>Clean Linen Closets:<BR/>In an observation on 11/20/24 at 3:14 PM with the Housekeeping Supervisor revealed multiple wood shelves edges in the clean linen closet were splintered in Resident Halls A-C.<BR/>In an observation on 11/20/24 at 3:16 PM with the Housekeeping Supervisor revealed multiple wood shelves edges in the clean linen closet were splintered in Resident Halls D-F. The Housekeeping Supervisor stated that she had not seen the splintered wood shelves in the clean linen closets. She said that the wood splinters could get in the linen and/or injure the staff when they pulled the linen from the shelves. <BR/>Laundry Room:<BR/>Observation on 11/20/24 at 3:05 PM with Housekeeping Supervisor revealed the floor baseboards in the laundry room by the washers were missing and the paint on the wall was chipped and had multiple holes on the wall. <BR/>Shower Room:<BR/>In an observation on 11/19/24 at 4:05 PM the Maintenance Supervisor revealed multiple tiles were missing and/or broken in the shower stalls . The Maintenance Supervisor stated that he was new, and he was doing the best he could to address environmental issues because he did not have anyone else to help him in his department. <BR/>In an interview and observation on 11/21/24 at 9:50 AM the Administrator stated, the broken tiles in the shower stalls and rusted water drains put the residents at risk injury because they can get cut. She said facility staff had been trained to report any issues with the building and equipment that needed to be repaired or replaced by scanning the QR code, which created a work order for maintenance to address as soon as possible. She said, I think these two items need to be repaired as soon as possible because they can possibly harm the residents. The Administrator stated she did not know why the staff had not reported the broken and/or missing tiles in the shower stalls, and the rusted water drains in the shower room. She stated, I need to do another in-service training with all staff to remind them how to report needed repairs by using the QR code application. <BR/>In an interview on 11/21/24 at 9:56 AM the Maintenance Director revealed he received the work orders and fixed whatever the issue was and makes notes of what he did to fix it. He said he will check for work orders daily at the start of the day and go and fix the issues. Once he completes whatever he needed to repair, he enters a note into the system alerting the staff that it has been taken care of. The Maintenance Director stated he has not received work orders regarding the rusted drain covers and the missing or broken tiles in the shower room in Resident Halls A-C. <BR/>In an interview on 11/21/24 1at 0:29 AM LVN D stated, I believe that the broken tiles and the rusted drain covers are not acceptable. This could place the resident at risk of being cut with the edges of those broken tiles. We have been trained in how to report to maintenance where there's an issue with the environment by scanning the QR code and reporting to the Maintenance Supervisor .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 (Resident #5) of 7 residents whose records were reviewed for assessments. <BR/>Resident #5 was not listed as having behaviors on her annual MDS assessment. <BR/>This failure to ensure comprehensive and accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. <BR/>Findings included: <BR/>Record review of Resident #5's face sheet dated 9/17/24 revealed a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses of generalized anxiety, major depressive disorder, and mild cognitive impairment. <BR/>Record review of Resident #5's annual MDS assessment dated [DATE] revealed BIMS score of 15, indicating her cognitive was intact and the behaviors section revealed no history of any behavior. <BR/>Record review of Resident #5's comprehensive care plan dated 8/27/24 revealed a focus area for frequently requesting HIPPA information on other residents; wants to put staff in trouble with state and get them fired; tends to be going into other residents' rooms asking for information and making notes on her notepad with interventions that included Give a clear explanation of daily care activities prior to and as they occur during each contact. Encourage as much participation and interaction by the resident as possible and redirect and remind resident of certain information is HIPPA protected. <BR/>Record review of Resident #5's progress notes dated 7/30/24 read in part This Nurse was notified by ADON that there was someone at the front looking for this resident to deliver some medication that she instructed no Nurse or staff from this facility can received except her. Resident tends to get prescriptions without letting this Nurse Know, due to resident voiced to other staff members that is not an 'RN which does not make her feel safe. DON and administrator notify. No prescription was delivered or notified from any DR's office.<BR/>During an interview on 9/17/24 at 2:39 pm, the MDS Nurse stated she was familiar with Resident #5 and knew about her behavior. The MDS Nurse stated her behavior consisted of asking questions about other residents, their medications, their doctor appointments, and at time their family members information. The MDS Nurse stated Resident #5 required a lot of redirection and education on HIPPA. The MDS Nurse stated she had not thought of including her behavior on her MDS assessment due to the examples provided were more on the verbal aggressive side. The MDS Nurse stated the behaviors that were addressed in MDS as behaviors that would warrant a medical diagnosis with medication. <BR/>During an interview on 9/17/24 at 3:04 pm, the DON stated Resident #5 had history of fabricating stories, false allegations, she does not like the ADON and LVN A and would try to find anything she thought they might do wrong to try and get them terminated. The DON stated Resident #5 also had history of asking for HIPPA information for other residents. The DON stated Resident #5 required a lot of education on HIPAA rules. The DON stated Resident #5's type of behavior were hard to capture in MDS due to the wording of the assessment, they were more on the aggressive, combative, and insulting side. <BR/>During an interview on 9/17/24 at 3:36 pm, the Administrator stated she was familiar with Resident #5 history of behavior which included meddling in residents care, false accusations against staff to attempt to get them fired and asking for residents HIPPA information. The Administrator stated since Resident #5 became [NAME] President of resident council she has gone around and been asking residents for HIPPA information i.e., their doctor appointments, health issues, and family member information. The Administrator stated Resident #5 was questioned on those behaviors and her response was she wanted to ensure they were receiving the proper care. The administrator stated Resident #5 required a lot of redirection and education. The Administrator stated she was not well versed on MDS assessment, but her basic understating of behaviors accounted for on the MDS assessment were to bill for. <BR/>Record review of CMS's RAI version 3.0 manual dated October 2016 page E-10 read in part E0600: Impact on others: health related quality of life- behaviors identified in item E0200 put others at risk for significant injury, intrude on their privacy or activities and/or disrupt their care or living environments. The impact on others code here in item E0600. Steps for assessment: 2- to code E0600, determine if the behaviors identified put others at significant risk of physical illness or injury, intruded on their privacy or activities, and/or interfered with their care of living arrangements. Coding instructions for E0600B. Did any of the identified symptoms significantly intrude on the privacy or activities of others? Code 1, yes if any of the identified behavioral symptoms kept other residents from enjoying privacy or engaging in informal activities. Includes coming in uninvited, invading, or forcing oneself on other's private activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 1 of 7 residents (Residents #4) reviewed for resident rights, in that: <BR/>The facility failed to ensure the treatment nurse notified the physician when Resident #4 had a change in skin integrity. <BR/>This deficient practice could place residents at risk of a delay of medical treatment. <BR/>Findings included: <BR/>Record review of Resident #4's admission record dated 02/12/2024 revealed Resident #4 was an [AGE] year-old woman admitted to the facility on [DATE]. <BR/>Record review of Resident #4's History & Physical dated 09/27/23 revealed Resident #4 was an [AGE] year-old female transferred from foster home. Past Medical History; dementia, depression, and insomnia. Skin: No rash. No skin breakdown. <BR/>Record review of Resident #4's MDS assessment dated [DATE] revealed she rarely made herself understood; had short-term memory problems. Her cognitive skills for Daily Decision Making were severely impaired. She required extensive assistance of one person with bed mobility, transfer, and eating. She received skin treatment including pressure reducing device for chair; pressure reduction device for bed, and to receive application of ointments other than to her feet. <BR/>Record review of Resident #4's undated care plan revealed she had an ADL Self-Care Deficit and was at risk for not having her needs met in a timely manner. Interventions were to include Substantial/Maximum assistance with bed mobility, transfers, toileting, and personal hygiene. Interventions for Incontinence were to include Check frequently for wetness and soiling and change as needed, apply barrier cream to skin after incontinent episodes. She was to receive weekly skin checks to monitor for redness, breakdown, or other skin concerns. Any new skin conditions were to be reported to the physician. <BR/>Review of Physician Order Recap dated 02/15/24 for Resident #4 revealed an order to perform a head to toe skin assessment every Saturday for wound prevention/early identification. Staff were to notify the physician of any changes in skin integrity. An order dated 02/12/24 said that Nystatin External Powder 100000 Unit/GM was to be applied to bilateral groin topically every shift for redness to bilateral groin area. The medication recap did not document an order for Hydrogel. <BR/>Record review of Resident #4's Physician Progress Note dated 01/23/24 revealed the resident's chief complaint was for a Comprehensive Monthly Visit. Patient required assistance with all ADLs including feeding. Patient ambulated with wheelchair. History of Present Illness indicated she was alert and oriented x 1. She had diagnoses including dementia, depression, cognitive communication deficits, abnormalities of gait and mobility, and dysphagia. She had no skin breakdown and no skin rash. The assessment/plan included that nursing would manage bowel and bladder. They were to turn the patient every 2 hours while in bed. They were to provide heel protectors while in bed, and wound care was to valuate and treat. <BR/>Review of Resident #4's Nurses Progress Notes revealed 02/09/24 07:39 Skin/Wound Note Text: Head to toe skin assessment performed, no discoloration, no open skin noted, call light within reach. <BR/>Review of Resident #4's Nurses Progress Notes on 02/09/24 revealed that Treatment Nurse had not documented that she reported to physician and/or NP that Resident #4 had a pink rash on groin area. <BR/>Review of Resident #4's Nurses Progress Notes dated 02/12/24 12:53 revealed a new order for Nystatin powder to apply topically Q shift to bilateral groin area for redness. RP notified. <BR/>Record Review Resident #4's Physician Order dated 02/12/24 at 12:38 PM, for Resident #4 written by ADON, documented Nystatin External Powder 100000 units/GM apply to bilateral groin every shift for redness to bilateral groin area. <BR/>Review of Resident #4's Skin Observation Worksheet provided by Treatment Nurse on 02/09/24 revealed [Resident #4] did not have any issues. <BR/>Interview on 02/09/24 at 3:33 PM, the Treatment Nurse stated charge nurses completed weekly skin assessments on all residents and were responsible for immediately reporting any changes in skin integrity to the attending physician and/or Nurse Practitioner. Treatment Nurses were responsible for completing the initial skin assessments on all admissions and for completing weekly skin assessments on all residents that had pressure ulcers, skin rashes, surgical wounds, or skin tears. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately reported any changes in skin integrity to the charge nurses and charge nurses would report to the treatment nurse. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately report any changes in skin integrity to the charge nurses. She reported that the new company would take over the last week of February 2024 and corporate staff had requested that she complete a skin sweep for all residents at the facility. She started the skin sweep in the South Side today [02/09/2024] at 4:00 AM. The Treatment Nurse did not know how often she would be expected to conduct skin sweeps on the residents. <BR/>Observation and interview on 02/09/24 at 4:32 PM with the DON and the Treatment Nurse revealed Resident #4 was lying in bed on her back, awake, and had a pressure relieving mattress. It was reported the resident was confused, incoherent speech, required total assistance of two persons with ADLs, and was incontinent of bowel & bladder. The DON pulled sheets down, noted that the resident was wearing double disposable briefs . The DON stated, CNAs have been trained not to put two briefs on the residents. The DON demonstrated to surveyor disposable briefs were clean and dry. Resident #4 had a light pink rash on the groin area. There was no urine smell, the bed sheets were clean and dry. The Treatment Nurse reported she called the physician today [02/09/2024] to report skin integrity change and was pending return call. <BR/>Interview on 02/12/24 at 11:30 AM, Treatment Nurse reported she got a telephone order on 02/09/24 for Resident #4 to apply Hydrogel to the perineal area every shift. When the surveyor asked the nurse if treatment had been started as ordered, The Treatment Nurse stated No, because I did not enter the new order in the resident's electronic record. The Treatment Nurse stated she had been trained to immediately enter new orders on the computer to ensure treatments were done as ordered. <BR/>Observation and interview 02/12/24 at 12:35 PM, with Treatment Nurse revealed Resident #4's brief was slightly wet with urine. It was noted resident had a pink rash on the groin area. The Treatment Nurse reported that she still had not added the new order for Hydrogel that was given by the physician on 02/09/24 to the resident's electronic record received on 02/09/24 to treat the rash on the pelvic area with Hydrogel because she was busy making rounds with the surveyors. <BR/>Interview 02/12/24 at 11:38 AM, with the DON, in the presence of the Administrator, reported licensed staff had been trained to immediately report changes in condition to the attending physician and/or nurse practitioner and to immediately enter the new physician's order in the resident's electronic record as soon as the order was given. <BR/>Review of the facility's policy on Notification of Changes in condition reviewed/revised 02/10/2021 revealed Policy: To provide guidance on when to communicate acute change in status to MD, NP and responsible party. The facility will immediately consult with the resident's physician of the following: A significant change in the physical status of residents. Policy Explanation and Compliance Guidelines: The facility must document resident assessment(s), interventions, physician and family notification(s) on SBAR, Nurse Progress Note or Telephone Order Form as appropriate. Immediate Physician Notification - the physician is notified immediately and should respond timely (within minutes). Non-Immediate Notification - the physician is notified and there should be a return call within the same day. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #4 & #3) of three residents reviewed for quality of care. <BR/>The facility failed to ensure treatment nurse transcribed the physician treatment order to treat Resident #4's rash on groin area. <BR/>The facility failed to identify and treat Resident #3's rash and behavior of scratching. <BR/>This failure placed residents at risk for delays in treatment, developing infections and deterioration of skin condition. <BR/>Findings included: <BR/>Resident #4<BR/>Record review of Resident #4's admission record dated 02/12/2024 revealed Resident #4 was an [AGE] year-old woman admitted to the facility on [DATE]. <BR/>Record review of Resident #4's History & Physical dated 09/27/23 revealed Resident #4 was an [AGE] year-old female transferred from foster home. Past Medical History; dementia, depression, and insomnia. Skin: No rash. No skin breakdown. <BR/>Record review of Resident #4's MDS assessment dated [DATE] revealed she rarely made herself understood; had short-term memory problems. Her cognitive skills for Daily Decision Making were severely impaired. She required extensive assistance of one person with bed mobility, transfer, and eating. She received skin treatment including pressure reducing device for chair; pressure reduction device for bed, and to receive application of ointments other than to her feet. <BR/>Record review of Resident #4's undated care plan revealed she had an ADL Self-Care Deficit and was at risk for not having her needs met in a timely manner. Interventions were to include Substantial/Maximum assistance with bed mobility, transfers, toileting, and personal hygiene. Interventions for Incontinence were to include Check frequently for wetness and soiling and change as needed, apply barrier cream to skin after incontinent episodes. She was to receive weekly skin checks to monitor for redness, breakdown, or other skin concerns. Any new skin conditions were to be reported to the physician. <BR/>Review of Physician Order Recap dated 02/15/24 for Resident #4 revealed an order to perform a head to toe skin assessment every Saturday for wound prevention/early identification. Staff were to notify the physician of any changes in skin integrity. An order dated 02/12/24 said that Nystatin External Powder 100000 Unit/GM was to be applied to bilateral groin topically every shift for redness to bilateral groin area. The medication recap did not document an order for Hydrogel. <BR/>Record review of Resident #4's Physician Progress Note dated 01/23/24 revealed the resident's chief complaint was for a Comprehensive Monthly Visit. Patient required assistance with all ADLs including feeding. Patient ambulated with wheelchair. History of Present Illness indicated she was alert and oriented x 1. She had diagnoses including dementia, depression, cognitive communication deficits, abnormalities of gait and mobility, and dysphagia. She had no skin breakdown and no skin rash. The assessment/plan included that nursing would manage bowel and bladder. They were to turn the patient every 2 hours while in bed. They were to provide heel protectors while in bed, and wound care was to valuate and treat. <BR/>Review of Resident #4's Nurses Progress Notes revealed 02/09/24 07:39 Skin/Wound Note Text: Head to toe skin assessment performed, no discoloration, no open skin noted, call light within reach. <BR/>Review of Resident #4's Nurses Progress Notes on 02/09/24 revealed that Treatment Nurse had not documented that she reported to physician and/or NP that Resident #4 had a pink rash on groin area. <BR/>Review of Resident #4's Nurses Progress Notes dated 02/12/24 12:53 revealed a new order for Nystatin powder to apply topically Q shift to bilateral groin area for redness. RP notified. <BR/>Record Review Resident #4's Physician Order dated 02/12/24 at 12:38 PM, for Resident #4 written by ADON, documented Nystatin External Powder 100000 units/GM apply to bilateral groin every shift for redness to bilateral groin area. <BR/>Review of Resident #4's Skin Observation Worksheet provided by Treatment Nurse on 02/09/24 revealed [Resident #4] did not have any issues. <BR/>Interview on 02/09/24 at 3:33 PM, the Treatment Nurse stated charge nurses completed weekly skin assessments on all residents and were responsible for immediately reporting any changes in skin integrity to the attending physician and/or Nurse Practitioner. Treatment Nurses were responsible for completing the initial skin assessments on all admissions and for completing weekly skin assessments on all residents that had pressure ulcers, skin rashes, surgical wounds, or skin tears. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately reported any changes in skin integrity to the charge nurses and charge nurses would report to the treatment nurse. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately report any changes in skin integrity to the charge nurses. She reported that the new company would take over the last week of February 2024 and corporate staff had requested that she complete a skin sweep for all residents at the facility. She started the skin sweep in the South Side today [02/09/2024] at 4:00 AM. The Treatment Nurse did not know how often she would be expected to conduct skin sweeps on the residents. <BR/>Observation and interview on 02/09/24 at 4:32 PM with the DON and the Treatment Nurse revealed Resident #4 was lying in bed on her back, awake, and had a pressure relieving mattress. It was reported the resident was confused, incoherent speech, required total assistance of two persons with ADLs, and was incontinent of bowel & bladder. The DON pulled sheets down, noted that the resident was wearing double disposable briefs . The DON stated, CNAs have been trained not to put two briefs on the residents. The DON demonstrated to surveyor disposable briefs were clean and dry. Resident #4 had a light pink rash on the groin area. There was no urine smell, the bed sheets were clean and dry. The Treatment Nurse reported she called the physician today [02/09/2024] to report skin integrity change and was pending return call. <BR/>Interview on 02/12/24 at 11:30 AM, Treatment Nurse reported she got a telephone order on 02/09/24 for Resident #4 to apply Hydrogel to the perineal area every shift. When the surveyor asked the nurse if treatment had been started as ordered, The Treatment Nurse stated No, because I did not enter the new order in the resident's electronic record. The Treatment Nurse stated she had been trained to immediately enter new orders on the computer to ensure treatments were done as ordered. <BR/>Observation and interview 02/12/24 at 12:35 PM, with Treatment Nurse revealed Resident #4's brief was slightly wet with urine. It was noted resident had a pink rash on the groin area. The Treatment Nurse reported that she still had not added the new order for Hydrogel that was given by the physician on 02/09/24 to the resident's electronic record received on 02/09/24 to treat the rash on the pelvic area with Hydrogel because she was busy making rounds with the surveyors. <BR/>Interview 02/12/24 at 11:38 AM, with the DON, in the presence of the Administrator, reported licensed staff had been trained to immediately report changes in condition to the attending physician and/or nurse practitioner and to immediately enter the new physician's order in the resident's electronic record as soon as the order was given. <BR/>Review of the facility's policy on Notification of Changes in condition reviewed/revised 02/10/2021 revealed Policy: To provide guidance on when to communicate acute change in status to MD, NP and responsible party. The facility will immediately consult with the resident's physician of the following: A significant change in the physical status of residents. Policy Explanation and Compliance Guidelines: The facility must document resident assessment(s), interventions, physician and family notification(s) on SBAR, Nurse Progress Note or Telephone Order Form as appropriate. Immediate Physician Notification - the physician is notified immediately and should respond timely (within minutes). Non-Immediate Notification - the physician is notified and there should be a return call within the same day. <BR/>Resident #3<BR/>Record review of Resident #3's face sheet dated 02/15/2024 revealed she was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. <BR/>Record review of Resident #3's History and Physical (H&P) dated 1/10/2024 revealed she was nonverbal and had diagnoses including Type 2 Diabetes mellitus, high blood pressure, and cerebral infarction (stroke). She was bed-bound and was non-verbal. She had no issues with her skin. The History and Physical stated right ulcer but did not specify the type or where the ulcer was located. The plan included to turn patient every 2 hours while in bed and that wound care was to evaluate and treat. <BR/>Record review of Resident #3's discharge MDS assessment dated [DATE] revealed she was nonverbal and was assessed by staff regarding her mental status. She had moderately impaired skills for daily decision making and had poor short- term memory. She was dependent on staff for toileting hygiene. She had behavioral symptoms not directed toward others. The MDS did not specify what these behaviors were. She was always incontinent of bladder and bowel. <BR/>Record review of Resident #3's Care Plan dated 06/19/2023 revealed she was incontinent of bowel and bladder. The goal was that she was to remain free from skin breakdown due to incontinence and brief use through the next review date (revised 01/26/2024). Interventions included weekly skin checks to monitor for redness, circulatory problems, breakdown, or other skin concerns and to report any new skin conditions to the physician. There was no care plan that addressed her behavior of scratching her inguinal area (where the thigh meets the front of the lower body) and abdominal fold. <BR/>Record review of Resident #3's Progress note dated 02/14/2024 revealed that a skin assessment revealed an inguinal rash (a rash where the thigh meets the front of the lower body). <BR/>Record review of progress notes for Resident #3 dated 01/15/2024 through 2/14/2024 revealed a Skin/Wound note dated 02/09/2024 that the resident had an inguinal rash. There were no notes regarding scratches. <BR/>Record review of Resident #3's physician's orders dated 2/12/2024 revealed an order to apply Nystatin power (a treatment for a yeast or fungal infection of the skin) 100000 unit/gm to her inguinal folds for a rash. <BR/>In an interview on 02/14/2024 at 12:27 PM, CNA B revealed that she provided help with ADLs to Resident #3 on 02/14/2024 and that Resident #3 had a rash in her inguinal area. The CNA said the rash was because the resident would scratch her inguinal area and her abdominal fold (the area under the stomach above the pelvis). <BR/>In an interview on 02/14/2024 at 3:10 PM, CNA C revealed that she was assigned to provide help with ADLs to Resident #3 about one week a month and had provided help to the resident on 02/14/2024. The CNA said the resident had flaky skin and scratched her inner thighs to the point she would bleed a little. The CNA stated she applied a cream that the resident's family provided and would put zinc oxide on the areas where she scratched. <BR/>In an interview on 02/14/2024 at 3:27 PM, CNA D revealed that she had provided help with ADLs to Resident #3 since the resident returned from the hospital. The CNA stated the resident had a rash between her legs and under her stomach. The CNA had no idea why the resident had a rash but said that resident did tend to scratch herself under her stomach and would also scratch her bottom. , <BR/>In an interview on 02/14/2024 at 4:13 PM, RN E revealed she was not aware that Resident #3 had a behavior of scratching her legs and under the abdomen. She stated that the CNAs should have told her if the resident had this behavior. She said that if she was aware that resident had behavior of scratching herself, she would get an order from the nurse practitioner to treat it. She said the CNAs had not indicated the resident had scratches or rashes on the shower sheets. <BR/>In an Interview on 2/14/24 at 4:25 PM, ADON G revealed she had become aware last week that Resident #3 was scratching. She said residents' skin condition was assessed weekly and the charge nurse should have been aware that the resident scratches. She stated that Resident #3's behavior of scratching should be on the care plan. The purpose of the care plan was for all nursing and management to be aware of the care the resident needed and pass along to take better care of her. The ADON said that if there was no care plan for scratching, the result was that the resident could be at risk to not accomplish goal of protecting skin. <BR/>In an interview on 02/15/2024 at 8:29 AM, CNA F revealed that had provided help with ADLs to Resident #3 two week before and the resident had a rash in her abdominal fold. The CNA said that the resident had a behavior of scratching herself was not new and had been occurring over the past six months. The CNA stated she had reported it to the charge nurse (unnamed) a while back (date unknown). The CNA said she told the resident not to scratch herself and would apply a diaper rash ointment to the scratched areas. <BR/>In an interview on 02/15/2024 at 11:14 PM, MDS Nurse H LVN revealed that Resident #3's behavior of scratching would be on care plan which had been brought to his attention a couple of days ago (date not remembered). He said the care plan's purpose was to paint a picture of the resident for staff members not familiar with the patient so they would know what to expect and how to care for them. The care plan might let someone familiar with the resident know what interventions are being used for a particular issue which was important because although a staff member might be familiar with a resident, they may not know everything about them. <BR/>In an interview on 02/15/2024 at 11:34 AM, the DON revealed she was aware of Resident #3's excoriation (raw or scraped skin) to the skin fold under abdomen and stated this should be on the resident's care plan. She stated the CNAs should have reported the excoriation and the resident's scratching behavior to the nurses. The resident's scratching behaviors and the possible causes for it should have been put on care plan. The DON said if the behavior was not on care plan, staff would not be aware of it which could lead to further skin breakdown and possible infection. <BR/>Record review of the facility policy Comprehensive Care Plans dated 02/10/2021 revealed the facility would develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical needs that are identified in the resident comprehensive assessment. The care plan process includes an assessment of the resident's needs and concerns identified by the interdisciplinary team. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that residents receive care, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 (Resident #2 and #5) of 7 residents reviewed for quality of care. <BR/>1. The facility failed on 02/12/2024 to ensure the pressure ulcer on Resident #2's sacrum was covered with a dressing as ordered. <BR/>2. The facility failed to ensure there were orders in place to provide treatment to Resident #2's right lateral great toe although treatment was being provided. <BR/>3. The facility failed to ensure Resident #5 had a pressure relieving mattress to prevent development of pressure ulcers. <BR/>These failures could result in increased pain, infections, development of new pressure ulcers, and decline in quality of life for residents. <BR/>Findings include: <BR/>Resident #2 <BR/>Record review of Resident #2's face sheet dated 02/14/2024 revealed he was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #2's History and Physical dated 01/30/2024 revealed he had diagnoses including diabetes mellitus Type II, dementia, left BKA (left leg below the knee amputation), stage 2 pressure ulcer to the sacrum (lower back), and an unstageable ulcer right sole of the foot. The plan included turning the patient every 2 hours while in bed, providing heel protectors while in bed, and wound care to evaluate and treat. <BR/> Record review of Resident #2's five-day MDS assessment dated [DATE] revealed he had a BIMS score of 10 (moderate cognitive impairment). He was dependent on staff to move around in bed, to dress, bathe and for toileting hygiene. He required a mechanical lift to transfer from the bed to other surfaces. He was always incontinent of bladder and bowel. Active Diagnoses: Diabetes Mellitus, non-Alzheimer's dementia, cirrhosis of liver. The MDS documented no pressure ulcers or other skin conditions. <BR/>Record review of Resident #2's care plan revised 02/13/2024 revealed he was frequently incontinent because he took lactulose (a laxative). His care plan revised 02/07/24 revealed he had the potential for the development of a pressure ulcer because of his limited mobility. Interventions included repositioning and bathing per schedule. Resident #2's care plan initiated 02/12/2024 revealed he had a pressure ulcer and was at risk for infection, pain, and a decline in functional abilities. Interventions included providing wound care per physician's order, keeping the dressing intact, replacing the dressing as needed for soiling, monitoring the dressing to ensure it is intact and adhering and reporting loose or soiled dressings to treatment or charge nurse. <BR/>Record review of Resident #2's physician's order initiated on 02/08/2024 for Wound care to sacral ulcer (a wound on lower back), cleanse area with NS/WC, pat dry, apply Medi honey, border island gauze. every day shift every other day for wound. <BR/>Review of physician order dated 02/12/24 for Resident #2 revealed wound care to right plantar foot, cleanse area with normal saline, pat dry, apply betadine solution for discoloration. <BR/>Record review of Resident #2's physician's orders dated 02/13/24 revealed arterial wound right lateral foot, cleanse with normal saline, pat dry, apply calcium ag, with border island gauze dressing, every day. <BR/>Record review of Resident #2's MAR/TAR for January 2024 revealed wound care was provided to the lateral great toe blister on 01/11/24 through 01/15/2024 and on 01/17/2024. <BR/>Record review of Resident #2's MAR/TAR for February 2024 revealed wound care was provided every day beginning on 02/14/2024 to an arterial wound on his right, lateral foot (outer edge of the foot from the heel to the little toe) by cleansing the area with NS/WC, patting dry, applying calcium alginate (a special wound treatment) with border island gauze dressing shift for wound starting. The MAR/TAR for February 2024 revealed wound care was provided on 2/9/2024, 2/11/2024, and 2/13/2024 to the resident's sacral ulcer, cleanse area with NS/WC, pat dry, apply Medi honey, border island gauze. <BR/>Record review of Resident #2's Daily Skilled Note dated 01/29/2024 revealed he required daily skilled observation for open wounds and pressure injury. The type or location of the wounds or injury were not identified. Skin/Wound Note dated 1/31/2024 revealed discoloration to right plantar foot (heel) 2x2 cm and 1.5x.5 cm discoloration to inner foot close to the proximal phalanx (a bone) of the great toe. <BR/>Review of Nurse Progress Note for Resident #2 dated 02/12/24 14:10 revealed Note Text; Wound care treatment was performed to sacral wound. Cleansed area with normal saline, wound continues macerated (softened and breaking down due to moisture) , no exudate (drainage) noted no redness or swelling, applied MediHoney with border island gauze. Wound care right great toe redness, cleansed area with normal saline, pat dry, applied Betadine solution with border island gauze. The resident refused to be turned and repositioned. Educated resident on risk and benefits of his refusal of patient care. <BR/>In an interview on 02/12/2024 at 12:53 PM, the Wound Care Nurse revealed she assessed Resident #2 on 1/29/2024 and at that time, he had no open wounds. She stated she started treatments on 2/8/24 because a CNA (unidentified) told her to go see him. It was then that she called the doctor. The Wound Care Nurse described the wound as being 1CM X .5 CM X .2 CM, macerated (damaged by moisture) with no exudate (pus). The Wound Care Nurse confirmed that the wound had opened between 1/29/2024 and 2/8/2024. <BR/>Observation of Resident #2 on 02/12/24 at 1:31 PM, with Treatment Nurse, revealed Resident #2 was lying in bed on his back. Resident was alert and oriented, was able to follow commands. The nurse demonstrated to the surveyor that the resident's brief was clean and dry. It was observed that Resident #2 did not have a dressing on the sacral wound. The wound was macerated around the borders of the wound. The nurse stated, He should always have the dressing to prevent fecal matter from getting in the wound and prevent infection. She said the CNAs had been trained to immediately report to the assigned charge nurse if the resident did not have a dressing on the wounds. The nurse demonstrated the resident had a stage II pressure ulcer to right inner foot with no dressing. The wound had pink granulation. The nurse reported that sometimes the dressing was not re-applied by the nurses when the dressings fell off. <BR/>In an interview 02/12/24 at 1:48 PM, LVN J stated that she was not aware that Resident #2 did not have a wound dressing to the sacrum and right foot. LVN J stated, The CNAs should have noticed that when they got the resident ready for his appointment in the morning. The CNAs have been trained to immediately report to the charge nurses when the residents do not have the dressings to the wounds. <BR/>In an interview on 02/13/2024 at 9:02 AM, CNA I revealed she had gotten Resident #2 up and helped him dress for an appointment on 02/12/2024 and noticed he did not have a dressing on his lower back or right foot. The CNA stated she did not advise anyone that the resident did not have the dressings because she was in a hurry. She stated that based on her training, she should have advised the nurse. She said other times, she had noticed that the patch on his back was dirty and had advised the nurse. <BR/>In an interview on 02/13/2024 at 10:06 AM, LVN J revealed that CNAs were to report if there were changes in a resident. She said CNAs were to complete shower sheets showing brief skin assessments that were for LVN review. She said she did not receive a report that Resident #2 was missing wound treatment patches but heard about it later. She said if a resident was found to be missing a wound care patch and the Wound Care nurse was unavailable, it should be replaced by the nurse on floor. <BR/>In an interview and observation on 02/14/2024 at 11:41 AM, the Wound Care Nurse was observed removing a bandage dated 02/13/2024 from Resident #2's right big toe. Upon removal of the bandage, a round black scab (about &frac12; centimeter across) on the outside of Resident #2's right big toe was observed. The Wound Care Nurse said she did his dressings before he went to the hospital and had been doing the dressings every day since he returned to the facility including dressings to his toe. The Wound Care nurse was observed patting the wound on the resident's toe with a gauze pad she put a liquid on, and then patting the wound dry. She said she would dress the wound with calcium alginate, which was new to the resident's wound care. She was observed spraying a liquid on a dressing and putting a date (2/14/24) on the dressing. <BR/>In an interview on 02/15/2024 at 11:34 PM, the DON revealed she did not think there was an actual order for treatment of Resident #2's toe. She said there he had a history of treatment for his toe, but the resident had been in and out of the hospital and she was not sure of his orders. The DON stated that during the past week, the Wound Care Nurse had been treating Resident #2's toe. The DON said the Wound Care Nurse should not put dressings on Resident #2's toe if there were no orders. She said that one of the 5 Rights of wound care was to look at the physician's order for wound care before care was provided. <BR/>Resident #5 <BR/>Record review of Resident #5's face sheet dated 03/13/2023 revealed a [AGE] year-old male admitted to the facility on [DATE] from the hospital. <BR/>Record review of Resident #5's History and Physical dated 04/12/2023 revealed resident was awake and oriented to name, makes eye contact with verbal commands, patient nonverbal. He required total assistance with ADLs in toileting, dressing, and bathing. Patient with tracheostomy. Patient with Pegtube (tube into the stomach for feeding). Patient with skin wound sacral region on wound care daily. Past Medical History: Status Post craniotomy (surgical removal of part of the bone from the skull to expose the brain), gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach used to give drugs and nutrition), hypertension, and intraparenchymal hemorrhage (bleeding into the brain). Assessment: Hypertensive heart disease without heart failure, nontraumatic intracerebral hemorrhage, tracheotomy (tube for breathing into the neck) and gastrostomy (tube into the stomach for feeding) Treatment: Turn and reposition every 2 hours while in bed. Wound care evaluate and treat. <BR/>Record review of Resident #5's Quarterly MDS dated [DATE] revealed admission date 03/13/23. No speech; rarely/never understand; impaired vision; modified independence with cognitive skills for Daily Decision Making; impairment on upper and lower extremities; uses a wheelchair; dependent with eating, oral hygiene, toileting, shower, dressing, personal hygiene; mobility-dependent with roll left and right, sit to lying, chair/bed transfer, shower transfer; incontinent of bowel & bladder; active diagnoses: other neurological condition, hypertension, diabetes mellitus, aphasia, seizure disorder, traumatic brain injury, depression, respiratory failure, gastrostomy, tracheotomy; on scheduled pain management; no pressure ulcers documented on MDS. Skin and Ulcer/Injury Treatment: Pressure reducing device for chair and bed. <BR/>Record review of Resident #5's Care Plan revised 02/01/24 revealed ADL Self Care Deficit. Resident refuses to be repositioned in bed. Family member removes offloading boots. is resistant to care and refuses to allow the staff at times to reposition resident. Interventions: Dependent bed mobility, eating, toileting, dressing, personal hygiene, bathing, transfers 1-2 staff, and wheelchair dependent. Resident is Resistant to Care: Refusing to be repositioned in his bed and refusing wound care. Interventions: Allow resident to make decisions about treatment to provide sense of control. If the resident refuses, notify the nurse and re-approach later. Resident has the potential for the development of pressure ulcer r/t bedbound status, immobility, incontinence, total dependence for all care. Interventions: Reposition frequently or more often as needed or requested. Check frequently for wetness and soiling. Apply moisture barrier with each incontinent change. Weekly skin checks to monitor redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. <BR/>Review Physician Order Summary dated 11/01/23 - 02/29/24 for Resident #5 revealed Order Date: 02/09/24; Start Date: 02/10/24 Wound Care to sacral area pressure ulcer, cleanse area with NS/WC, pat dry, apply MediHoney, border island dressing everyday shift for wound. Order Date: 01/14/24 Cleanse excoriation to left side buttocks with wound cleanser, pat dry and apply Hydrogel q shift until resolved. <BR/>Review of Resident #5's Skin Observation Worksheet dated 02/09/24 provided by Treatment Nurse revealed Resident #5 had wound on sacral area measuring .5 cm x 1 cm x 2 cm. <BR/>Review of Nurses Progress Note for Resident #5 dated 02/09/24 revealed Note Text: Head to toe skin assessment performed, resident has sacral wound previously resolved, measured approximately .5 cm x 1.2 cm wound care orders. <BR/>Review of Nurses Progress Notes for Resident #5 dated 01/16/24 through 02/15/24 revealed no documentation of resident refused to turn and reposition every two hours as reported by DON and treatment nurse. <BR/>Review of the CNA Task report on Turning and Repositioning for Resident #5 revealed the resident refused on 01/20/24, 01/23/24, 01/24/24, 01/27/24, 01/29/24, 01/31/24, 02/02/24, 02/07/24, 02/12/24. <BR/>In an interview on 02/09/24 at 10:21 AM, Resident #5's family member reported the resident was admitted to the nursing home April of 2023. She reported the resident was not able to move his left side. She visited the resident every day from 9:30 AM to 6:00 PM and staff did not turn and reposition resident every two hours. He is turned at least 3 times while I am here. They also do not check to see if he is wet, because they depend on me to care for him. <BR/>In an interview on 02/09/24 at 3:33 PM, the Treatment Nurse reported Resident #5 was admitted a year ago, with a stage II pressure ulcer that had healed and recently had re-opened. It was reported resident refused to be turned & repositioned every two hours and preferred to stay on his back. It was reported Resident #5's had a trach, g-tube, required total assistance of two people with ADLS, needed a Hoyer Lift for transfers, and incontinent of bowel and bladder. <BR/>An observation and interview on 02/12/24 at 10:09 PM, with the DON and the Treatment Nurse revealed Resident #5, was lying in bed awake on his back and his Family member was at his bedside. The Treatment Nurse reported resident was admitted to the facility a year ago, status post stroke, non-verbal, communicated with sign language, answered yes and no questions by nodding his head or by moving his finger to answer yes and no. Resident had a tracheostomy, was NPO (not to receive anything by mouth) and had a G-tube. Resident required total assistance with ADLs, incontinent of bowel & bladder and used disposable briefs. Resident had a Bariatric Bed (extra heavy-duty bed designed to accommodate, comfortably and safely, larger and heavier patients). The surveyor asked the DON if the resident had a pressure relieving mattress. The DON stated, No ma'am, he does not. The DON stated, He should have a pressure relieving mattress due to limited mobility and history of pressure ulcers. I will order a pressure relieving mattress for him. The Treatment Nurse reported that they attempted to off-load the feet, but the resident removed the pillow. She reported that Resident #5 needed to be turned and re-positioned every 2 hours. The DON reported resident did not like to be turned and preferred to stay on his back. The DON stated resident asked his family member to scratch his bottom. The DON stated, The scratching can probably cause the scar tissue on the sacrum to re-open. It was observed resident had a lot of scar tissue on his buttocks and sacral area. The DON stated, Treatment Nurse noticed on 02/09/24 that resident had a new stage II pressure ulcer. An order was obtained on 02/10/24 to treat stage II pressure ulcer with MediHoney once a day. The Treatment nurse reported that the wound was approximately .5 cm x .5 cm x .2 cm. The DON pointed out to treatment nurse that Resident also had a new linear opened area on sacral area measuring approximately .5 cm. The DON stated, this is also a new development and will be staged as a stage II. Treatment Nurse will get physician's orders to treat the wound. <BR/>Review of Vendor Order Inquiry dated 02/12/24 at 12:52 PM, created by the Administrator for Resident #5, revealed a Bariatric Low Air Loss Mattress had been ordered. <BR/>Record review of the facility's policy Skin Prevention and Management Guidelines revised 07/06/2023 revealed that the facility is committed to prevention of avoidable pressure injuries and the promotion of existing pressure injuries. Guidelines: The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of interventions; and modifying the interventions as appropriate. Other factors will be taken into consideration when evaluating a resident's skin risk level: Impaired/decreased mobility and decreased functional ability. Co-morbid conditions, such as diabetes. Exposure of skin or urinary and fecal incontinence. The presence of a previously healed pressure injury. Licensed nurses will conduct a full body skin assessment on all residents with pressure injury/ ulcers. Documentation that the skin evaluation was completed is entered on the Treatment Administration Record. Nursing Assistants will inspect the resident's skin during bath and perineal area during incontinent care and will report any concerns to the resident's nurse. Interventions for Prevention and to Promote Healing. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.; Minimize exposure to moisture and keep skin clean; especially of fecal contamination; Provide appropriate, pressure-redistributing, support surfaces; Skin care interventions such as incontinent care, barrier creams, moisturizer, repositioning more often, adaptive devices, etc., are used to reduce the risk of pressure injury development and other alteration in skin integrity. Interventions will be documented in the care plan and communicated to all relevant staff. If a change in patient condition occurs, the licensed nurse notifies the physician. Nursing assistants will inspect residents' skin during bath, the perineal area during incontinent care and will report any concerns to the resident's nurse. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have pressure injury present. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 7 residents (Residents #4) reviewed for resident rights.<BR/>The facility failed to ensure the treatment nurse documented she notified the physician when Resident #4 had a change in skin integrity. <BR/>This deficient practice could place residents at risk of a delay of medical treatment. <BR/>Findings included: <BR/>Record review of Resident #4's admission record dated 02/12/2024 revealed Resident #4 was an [AGE] year-old woman admitted to the facility on [DATE]. <BR/>Record review of Resident #4's History & Physical dated 09/27/23 revealed Resident #4 was an [AGE] year-old female transferred from foster home. Past Medical History; dementia, depression, and insomnia. Skin: No rash. No skin breakdown. <BR/>Record review of Resident #4's MDS assessment dated [DATE] revealed she rarely made herself understood; had short-term memory problems. Her cognitive skills for Daily Decision Making were severely impaired. She required extensive assistance of one person with bed mobility, transfer, and eating. She received skin treatment including pressure reducing device for chair; pressure reduction device for bed, and to receive application of ointments other than to her feet. <BR/>Record review of Resident #4's undated care plan revealed she had an ADL Self-Care Deficit and was at risk for not having her needs met in a timely manner. Interventions were to include Substantial/Maximum assistance with bed mobility, transfers, toileting, and personal hygiene. Interventions for Incontinence were to include Check frequently for wetness and soiling and change as needed, apply barrier cream to skin after incontinent episodes. She was to receive weekly skin checks to monitor for redness, breakdown, or other skin concerns. Any new skin conditions were to be reported to the physician. <BR/>Review of Physician Order Recap dated 02/15/24 for Resident #4 revealed an order to perform a head to toe skin assessment every Saturday for wound prevention/early identification. Staff were to notify the physician of any changes in skin integrity. An order dated 02/12/24 said that Nystatin External Powder 100000 Unit/GM was to be applied to bilateral groin topically every shift for redness to bilateral groin area. The medication recap did not document an order for Hydrogel. <BR/>Record review of Resident #4's Physician Progress Note dated 01/23/24 revealed the resident's chief complaint was for a Comprehensive Monthly Visit. Patient required assistance with all ADLs including feeding. Patient ambulated with wheelchair. History of Present Illness indicated she was alert and oriented x 1. She had diagnoses including dementia, depression, cognitive communication deficits, abnormalities of gait and mobility, and dysphagia. She had no skin breakdown and no skin rash. The assessment/plan included that nursing would manage bowel and bladder. They were to turn the patient every 2 hours while in bed. They were to provide heel protectors while in bed, and wound care was to valuate and treat. <BR/>Review of Resident #4's Nurses Progress Notes revealed 02/09/24 07:39 Skin/Wound Note Text: Head to toe skin assessment performed, no discoloration, no open skin noted, call light within reach. <BR/>Review of Resident #4's Nurses Progress Notes on 02/09/24 revealed that Treatment Nurse had not documented that she reported to physician and/or NP that Resident #4 had a pink rash on groin area. <BR/>Review of Resident #4's Nurses Progress Notes dated 02/12/24 12:53 revealed a new order for Nystatin powder to apply topically Q shift to bilateral groin area for redness. RP notified. <BR/>Record Review Resident #4's Physician Order dated 02/12/24 at 12:38 PM, for Resident #4 written by ADON, documented Nystatin External Powder 100000 units/GM apply to bilateral groin every shift for redness to bilateral groin area. <BR/>Review of Resident #4's Skin Observation Worksheet provided by Treatment Nurse on 02/09/24 revealed [Resident #4] did not have any issues. <BR/>Interview on 02/09/24 at 3:33 PM, the Treatment Nurse stated charge nurses completed weekly skin assessments on all residents and were responsible for immediately reporting any changes in skin integrity to the attending physician and/or Nurse Practitioner. Treatment Nurses were responsible for completing the initial skin assessments on all admissions and for completing weekly skin assessments on all residents that had pressure ulcers, skin rashes, surgical wounds, or skin tears. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately reported any changes in skin integrity to the charge nurses and charge nurses would report to the treatment nurse. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately report any changes in skin integrity to the charge nurses. She reported that the new company would take over the last week of February 2024 and corporate staff had requested that she complete a skin sweep for all residents at the facility. She started the skin sweep in the South Side today [02/09/2024] at 4:00 AM. The Treatment Nurse did not know how often she would be expected to conduct skin sweeps on the residents. <BR/>Observation and interview on 02/09/24 at 4:32 PM with the DON and the Treatment Nurse revealed Resident #4 was lying in bed on her back, awake, and had a pressure relieving mattress. It was reported the resident was confused, incoherent speech, required total assistance of two persons with ADLs, and was incontinent of bowel & bladder. The DON pulled sheets down, noted that the resident was wearing double disposable briefs . The DON stated, CNAs have been trained not to put two briefs on the residents. The DON demonstrated to surveyor disposable briefs were clean and dry. Resident #4 had a light pink rash on the groin area. There was no urine smell, the bed sheets were clean and dry. The Treatment Nurse reported she called the physician today [02/09/2024] to report skin integrity change and was pending return call. <BR/>Interview on 02/12/24 at 11:30 AM, Treatment Nurse reported she got a telephone order on 02/09/24 for Resident #4 to apply Hydrogel to the perineal area every shift. When the surveyor asked the nurse if treatment had been started as ordered, The Treatment Nurse stated No, because I did not enter the new order in the resident's electronic record. The Treatment Nurse stated she had been trained to immediately enter new orders on the computer to ensure treatments were done as ordered. <BR/>Observation and interview 02/12/24 at 12:35 PM, with Treatment Nurse revealed Resident #4's brief was slightly wet with urine. It was noted resident had a pink rash on the groin area. The Treatment Nurse reported that she still had not added the new order for Hydrogel that was given by the physician on 02/09/24 to the resident's electronic record received on 02/09/24 to treat the rash on the pelvic area with Hydrogel because she was busy making rounds with the surveyors. <BR/>Interview 02/12/24 at 11:38 AM, with the DON, in the presence of the Administrator, reported licensed staff had been trained to immediately report changes in condition to the attending physician and/or nurse practitioner and to immediately enter the new physician's order in the resident's electronic record as soon as the order was given. <BR/>Review of the facility's policy on Notification of Changes in condition reviewed/revised 02/10/2021 revealed Policy: To provide guidance on when to communicate acute change in status to MD, NP and responsible party. The facility will immediately consult with the resident's physician of the following: A significant change in the physical status of residents. Policy Explanation and Compliance Guidelines: The facility must document resident assessment(s), interventions, physician and family notification(s) on SBAR, Nurse Progress Note or Telephone Order Form as appropriate. Immediate Physician Notification - the physician is notified immediately and should respond timely (within minutes). Non-Immediate Notification - the physician is notified and there should be a return call within the same day. <BR/>

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1(North Side) of 2 treatment carts checked for cross contamination, and in one (Room F-108) of seven resident rooms checked for cross contamination. <BR/>1. The facility stored a used wound vac (a machine that removes drainage from a wound) in the treatment cart. <BR/>2. The facility had multiple self-adhesive dressing rolls that were not stored in sealed container in the treatment cart. <BR/>3. The facility failed to ensure oral swabs were not stored with external ointments in the treatment cart. <BR/>4. The facility failed to ensure used resident gowns were not placed in garbage cans. <BR/>These failures could result in increased risk of infection to residents. <BR/>Findings include: <BR/>Observation on 02/12/12/2024 at 11:55 AM revealed a yellow cotton hospital gown on top of a trash can inside room F-108. <BR/>In an interview on 12/13/2023 at 9:02 AM, CNA I said she had worked on the F hall on 02/12/2024 and denied putting a hospital gown in a trash can during her shift. She said there was never a reason to but a hospital gown in the trash and that to do so could cause cross contamination since the gown might get mixed with the trash in the can. <BR/>In an interview on 02/13/2024 at 9:22 AM, CNA K revealed if there was no plastic bag available, CNAs might put a used hospital gown on a trash can to avoid contaminating the bed or the floor. She said that around lunch time on 02/13/2024, she was helping CNA A transfer a resident in room F-108 and put a used gown in the trash can because she did not have a plastic bag available. She said that based on her training if she did not have a bag ready, to avoid contamination of the bed or floor with a dirty gown, to put the used gown on the garbage can. She said it was the responsibility of the person she was helping to have the plastic bag ready for use. <BR/>In an interview on 02/13/2024 at 10:06 AM, LVN J revealed there was no reason a CNA should put soiled linen in a trash can. She said CNAs were instructed to carry bags with them in which to put dirty linen for transfer to bins. She said used gowns were not to be put in the trash due to infection control issues. The LVN the gown should not be put on the trash can because it was not known what was in the trash and the gown might get more soiled. The LVN said she knew that placing the gown on the trash created an infection control issue. She stated that most rooms had rolls of plastic bags in them, and that CNAs had never said they were low on bags. She said that if CNAs were low on bags, they knew who to ask for bags to make them available. <BR/>In an interview on 2/13/24 at 11:20 AM, the DON revealed that CNAs should place dirty gowns in a bag. She stated she had been made aware that a CNA had placed a gown in a trash can. The DON stated that if a CNA did not have bag available in which to place a used gown, putting the used gown in the trash can was a better alternative than placing it on the bed or floor for reasons of cross-contamination. The DON stated that there were bags around the facility, and CNAs may have bags in their pockets or may be placed in the halls. She stated if a trash can had trash in it, the CNA could remove the bag with trash in it and put the used gown in the empty trash bag. She said she would prefer that the CNAs put the used gown in an empty trash bag rather than placing a used gown on the floor or bed due to issues related to cross-contamination. <BR/>Observation and interview on 02/12/24 at 11:08 AM, with the Treatment Nurse revealed facility had two treatment carts. An observation of Treatment Cart #1 (North Side) revealed multiple tubes of MediHoney, Santyl, Mupirocin ointment was stored together in a square plastic box in the top drawer. The nurse stated, We have been trained to store the ointments in a sealed plastic bag with the resident's name. We buy MediHoney ointment over the counter, and each resident should have a tube for individual use and stored in a plastic bag with the resident's name. It was observed that the Santyl ointment tubes were not labeled. There was a wound vac stored in the treatment cart in the third drawer. The nurse stated, It belongs to one of the residents, it was discontinued two weeks ago. We stored the wound vac in the treatment cart because we did not know if we had to return it to the vendor. It should not be stored in the cart with the clean supplies. The wound vac was immediately removed by nurse from the treatment cart. The nurse reported there were a couple of ointments still stored in the treatment cart for residents that had been discharged home. The nurses had been trained to give all the medicines including ointments to the residents upon discharge and remove discontinued ointments from treatment carts. It was observed that oral care swabs were stored in the treatment cart with gauze bandages packets and rolls of self-adherent wrap. The self-adherent wrap was not stored in sealed bags. <BR/>Record review of the facility's policy Infection Prevention and Control Program dated 10/24/2022 revealed that the facility established and maintained an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. All staff were responsible for following all policies and procedures related to the program. Direct care staff shall handle, store, and transport linens to prevent the spread of infection. Soiled linen shall be collected at the bedside and placed in a linen bag. <BR/>

**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 any physical restraints imposed for the purposes of convenience and not required to treat the resident's medical symptoms for two (Resident #2 and Resident #4) of 7 residents reviewed for restraints. <BR/>The facility failed to ensure a scoop mattress (a mattress with built up sides that create a barrier to help stop residents from rolling or sliding out of bed) was not used with Resident #2 and Resident #4 without any medical indication. <BR/>This failure could result in residents having physical restraints used that limited their movement without being evaluated for the medical need for this. <BR/>Findings include:<BR/>Resident #2<BR/>Record review of Resident #2's face sheet dated 02/01/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #2's facility history and physical dated 09/27/23 revealed an [AGE] year-old female diagnosed with Dementia. <BR/>Record review of Resident #2's quarterly MDS dated [DATE] revealed a moderate impairment of cognition but no BIMS (a quick snapshot of how well you are functioning cognitively at the moment.) was taken for an unknown reason (to be able to recall and make daily decisions). Activities of daily living revealed substantial/maximal assistance from nursing staff for eating, oral hygiene, toileting, showering, and dressing. Resident #2 was dependent on nursing staff for personal hygiene and putting on footwear. <BR/>Record review of Resident #2's care plan dated 02/01/24 revealed there was no focus area or intervention for a scoop mattress or evaluation. <BR/>Record review of Resident #2's order recap dated 02/01/24 revealed there were no orders for a scoop mattress nor a therapy or nursing evaluation for the use of a scoop. <BR/>Observation and interview on 02/01/24 at 11:16 AM with the Director of Rehab, revealed Resident #2 had a scoop mattress. Director of Rehab stated Resident #2 did have a scoop mattress and looked like a regular mattress. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet dated 01/31/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #4's facility history and physical dated 03/01/23 revealed an [AGE] year-old female diagnosed with fall risk. <BR/>Record review of Resident #4's quarterly MDS dated [DATE] revealed a severe impairment of cognition BIMS (a quick snapshot of how well you are functioning cognitively at the moment.) score of 6 to be able to recall and make daily decisions. Activities of daily living revealed partial/moderate assistance from nursing staff to help toilet, oral hygiene, dressing, personal hygiene, and putting on footwear. Resident #4 was supervision or touching assistance from the nursing staff with sitting on bed to lying, lying on bed to sitting on the side of the bed, roll left or right, partial/moderate assistance from nursing staff with toilet transfers. Resident #4 was diagnosed with Hemiplegia (paralysis of one side of the body), Parkinson's Disease, and Dementia. Resident #4 was receiving occupational therapy and physical therapy. <BR/>Record review of Resident #4's care plan dated 01/31/24 revealed Resident #4 has the potential for falls. New care plan intervention for falls dated 07/25/22, revealed scoop mattress. The care planned had no focus area for therapy or nursing assessment for the scoop mattress. <BR/>Record review of Resident #4' order recap dated 01/31/24 revealed there was no physician order for a scoop mattress nor a therapy or nursing assessment for the use of a scoop mattress. <BR/>Observation and interview on 02/01/24 at 11:06 AM with Director of Rehab, revealed Resident #4 did not have a scoop mattress as a mattress. Director of Rehab stated she did not know why Resident #4 had a scoop mattress in her care plan if she did not have a scoop mattress. <BR/>During an interview on 01/31/24 at 4:54 PM with LVN C, she stated she had not seen a scoop mattress in her hallway with her residents. LVN C stated it would have to be care planned. LVN C stated the scoop mattress was not an enabler for a resident. LVN C stated there had to be an assessment or evaluation done to see if the resident qualifies for the use of a scoop mattress. LVN C stated there would need to be an order for a scoop mattress and an evaluation to use the scoop mattress. LVN C stated since there was not evaluation nor a physician order as per the facility restraint policy it could be considered a form of restraint. <BR/>Observation and interview on 02/01/24 at 10:51 AM, the Director of Rehab, she stated Resident #4 required minimal assistance form nursing staff to get out of bed. Director of Rehab stated Resident #4 at times will need a little bit more assistance from nursing staff to get out of bed. Director of Rehab stated she was not sure if a scoop mattress was a restraint. Director of Rehab stated Resident #4 did not have a scoop mattress but did not know why she had it in her care plan. Director of Rehab stated Resident #2 had a scoop mattress that she was unaware about. Director of Rehab stated Resident #2 was evaluated for bed mobility and needed maximal assistance from nursing staff in which they provided 75 percent of the work for Residnet#2 to get out of bed. Director of Rehab stated Resident #2 was not able to get out of bed on her own. Director of Rehab stated the scoop mattress would not let Resident #2 get out of bed. Director of Rehab stated she did not think the scoop mattress was a restraint and did not know if they needed a physician's order for the scoop mattress. Director of Rehab stated she could not answer if the scoop mattress was helping the resident with a medical symptom. <BR/>During an interview on 02/01/24 at 11:18 AM with the DON, she stated an intervention of a fall prevention would be the use of a scoop mattress. The DON stated the facility would not like to use the scoop mattress as it was a limiting device for the residents. The DON stated a scoop mattress keeps a resident in the middle and from rolling to either side of the bed. The DON stated there would have to be a physician's order for the scoop mattress. The DON stated Resident #2 and Resident #4 did not have a physician's order for the scoop mattress. The DON stated there would have to be an evaluation from either therapy or the nurses (nursing judgement) for the use of a scoop mattress. The DON stated Resident #4's care plan of a scoop mattress was used to prevent falls. The DON stated Resident #2 and Resident #4 did not have an evaluation completed for the use of a scoop mattress. The DON stated the use of a scoop mattress without a physician's order, evaluation, and as per facility restraint policy was a form of restraint. <BR/>During an interview on 02/01/24 at 4:18 PM with the Administrator, she stated she would not use a scoop mattress as an intervention to prevent falls. The Administrator stated it was considered a restraint. The Administrator stated if a scoop mattress was used there had to be an evaluation from either therapy or nursing and a physician order. The Administrator stated not having either a physician order and an evaluation would be considered a restraint. The Administrator stated there would be a risk to the resident could be major injury, injuries, and or death. <BR/>Record review of the facility Restraint Free Environment policy dated 10/24/22 revealed, It was the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints.<BR/>- <BR/>Physical Restraint - refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot move easily which restricts freedom of movement or normal access to one's body.<BR/>- <BR/>A physician's order alone was not sufficient to warrant the use of a physical restraint.<BR/>- <BR/>Before a resident was restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints and determine how the use of restraints would treat the medical symptom.<BR/>- <BR/>Medical symptoms warranting the use of restraints should be documented in the resident's medical record. The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint, and effectiveness of the restraint in treating the medical symptom. The care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint. <BR/>Record review of the facility Welcome to our community Standards of Service policy not dated revealed, The standard of service for this community was to focus on our customers and one another, the residents, their families, other visitors and all team members. Each team member was expected to exceed resident, family, and visitor expectations. Weather in person, on the telephone or in writing, we must be:<BR/>- <BR/>Reliable - Develop a positive relationship with all individuals we serve to give them peace of mind that all services will provided by competent staff on a consistent basis. <BR/>- <BR/>Accurate - Check and re-check to assure needs are met properly and completely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to provide or obtain laboratory services only when ordered by the physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State Law, including scope of practice laws and promptly notify the ordering physician of the results for 1 (Resident #3) of 7 residents reviewed for labs. <BR/>Resident #3's labs were not drawn monthly as ordered by the physician. <BR/>This failure could place residents at risk of a delay in receiving the necessary interventions to treat their medical condition. <BR/>Findings include: <BR/>Record review of Resident #3's face sheet dated 01/30/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #3's facility history and physical dated 01/04/24 revealed a [AGE] year-old female diagnosed with schizophrenia (a serious mental disorder in which people interpret reality abnormally). <BR/>Record review of Resident #3's quarterly MDS dated [DATE] revealed no impairment of cognition BIMS (a quick snapshot of how well you are functioning cognitively at the moment.) score of 13 to be able to recall and make daily decisions. Resident #3 was diagnosed with Non-Alzheimer's Dementia and Schizophrenia. Resident #3 was marked for anti-psychotic use. <BR/>Record review of Resident #3's care plan dated 08/23/22 and revised on 04/26/23 revealed psychotropic drug use related to schizophrenia. Administer medications (Clozapine) as ordered. Monitor/document for side effects and effectiveness. Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated . <BR/>Record review of Resident #3's order recap dated 12/29/23 revealed, Clozapine oral tablet 100 MG. Give 1 tablet by mouth at bedtime for schizophrenia. Physician order dated 08/15/23 revealed, please obtain complete, metabolic panel, complete blood count with different clozapine level every 4th day of the month for medication refill. Every night shift starting in the 4th and ending on the 4th of every month for medication levels. <BR/>During an interview on 01/30/24 at 8:54 AM with the DON, she stated the labs for Resident #3 had to be done monthly. The DON stated the labs needed to be done on the 4th day of every month. The DON stated the labs would indicate if Resident #3 would need an increase or decrease in dose . <BR/>During an interview on 01/30/24 at 12:00 PM with the DON, she stated she had order Resident #3 clozapine stat on Monday 01/29/24 and had arrived at 3AM on 01/30/24. The DON stated the labs needed to be done to know the resident ANC is an estimate of the body's ability to fight infections, especially bacterial infections to be able to accurately provide a correct dose of clozapine. The DON stated there could be a risk for not following physician orders because the Resident #3 needed to be within range of her lab levels. The DON stated they were following the outside agency's order and the facility needed to let the physician know that the orders needed to accommodate the outside agency orders which the nurses failed to do so. <BR/>During an interview on 01/31/24 at 4:54 PM with LVN C, she stated Resident #3's family was bringing the clozapine from an outside pharmacy and because of that the facility did not have all the lab work for every month. LVN C stated the lab drawn was not done monthly due to the family member not bringing the lab results to the facility so the physician could review it and then send it to the pharmacy. LVN C stated that 3 months' worth of labs were missing. LVN C stated the family member would tell the facility that the outside agency would not give them lab work. LVN C stated the family member was educated to bring the labs when drawn with the outside agency. LVN C stated Resident #6 had a 30-day supply of clozapine and a week before the resident runs out the facility would reach out to the pharmacy for a refill. LVN C stated that orders need to be followed. LVN C stated there could be a risk of physician orders not being followed in which the resident would not get the medication. LVN C stated Resident #6 did not receive her clozapine on 01/27/24, 01/28/24, 01/29/24. LVN C stated CMA E was to let her know when Resident #6 was down to her last 8 pills but I think she just dropped the ball. LVN C stated the nurses, DON, and ADONs oversee the CMAs to ensure they are ordering and letting the nurses know when medication needs to be ordered. LVN C stated there was no risk of Resident #6 missing her doses and for each resident on the clozapine the side effects would be different. LVN C stated Resident #6 did not report to her any side effects or differences with not taking her clozapine. <BR/>During an interview on 02/01/24 at 4:18 PM with the Administrator, she stated physician orders needed to be followed. The Administrator stated not following the orders could have a negative outcome for the resident. The Administrator did not state what the negative outcome would be. The Administrator stated all nursing staff have been trained to follow physician orders. The Administrator stated it was the responsibility of the nurses to ensure all physician orders are correct. <BR/>Record review of the facility following Physician Orders dated 09/28/21 revealed, The policy provide guidance on receiving and following physician orders.<BR/>- <BR/>Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record.<BR/>Record review of the facility Radiology and other Diagnostic Services and Reporting dated 07/26/22 revealed, The facility must provide or obtain radiology and other diagnostic services when ordered by a physician, physician assistant; nurse practitioner or clinical nurse specialist in accordance with state law. <BR/>- <BR/>Promptly notify the ordered by a physician, physician assistant; nurse practitioner or clinical nurse specialist of laboratory results that fall outside the clinical reference range.<BR/>- <BR/>The physician will provide an order, ether verbally or written for the specific test to be obtained. The test may be ordered STAT or at a specific time. <BR/>- <BR/>Routine orders and those orders for testing that are not ordered STAT will be communicated to the appropriate service to be performed/collected at the time specified by the physician.<BR/>Record review of the facility Labs for Resident #6 dated 05/22/23, 06/26/23, 07/25/23, 09/13/23, 12/05/23, 01/08/24 revealed labs were only done for 6 months and not monthly as ordered. <BR/>Record review of the facility Welcome to our community Standards of Service policy not dated revealed, The standard of service for this community was to focus on our customers and one another, the residents, their families, other visitors and all team members. Each team member was expected to exceed resident, family, and visitor expectations. Weather in person, on the telephone or in writing, we must be:<BR/>- <BR/>Reliable - Develop a positive relationship with all individuals we serve to give them peace of mind that all services will provided by competent staff on a consistent basis. <BR/>- <BR/>Accurate - Check and re-check to assure needs are met properly and completely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation.<BR/>1. <BR/>Facility Staff and Dietary Staff were not wearing hair nets or beard guards when entering or working in the kitchen. <BR/>This failure could affect residents by placing them at risk of food borne illness.<BR/>Findings include:<BR/>Observation and interview on 01/30/24 at 11:00 AM, the Maintenance Director was observed going into the kitchen without a hair net or beard guard. The Maintenance Director stated it was okay to go into the kitchen without a hair net or beard guard. In the back in the kitchen Dietary [NAME] did not have his hair net or beard guard on. The Maintenance Director stated the Dietary Manager had in-serviced all of the facility staff of what should be worn when in the kitchen. <BR/>During an interview on 01/30/24 at 11:20 AM with Dietary Cook, he stated a hair net and beard guard had to be worn. The Dietary [NAME] stated he had received training on what to wear while in the kitchen. The Dietary [NAME] stated not having a hair net or beard guard on could have hair falling into the food and contaminate it. The Dietary [NAME] stated the resident could get sick if eaten. <BR/>During an interview on 01/31/24 at 9:36 AM with the Dietary Manager, he stated everything passing the doors in the dining room was to be considered the kitchen. The Dietary Manager stated all dietary staff are to be wearing hairnets and the males would be beard guards if they have a beard. The Dietary Manager stated he had not in-serviced facility staff that were not dietary staff. The Dietary Manager stated there was a sign posted outside of the kitchen door revealing staff had to be wearing a hair net and beard guard. The Dietary Manager stated if they catch facility staff without a hairnet or beard guard, they do tell them to put one on. The Dietary Manager stated all staff have to follow the facility policy to wear hair nets and beard net and the sign posted says the something. The Dietary Manager stated the negative outcome of not wearing a hair net or beard guard would be not following facility policy of personal hygiene in which staff should be kept at all times for the safety of the residents. <BR/>During an interview on 02/01/24 at 11:18 AM with the DON, she stated she considered the kitchen area to be a clean location and sterile. The DON stated once the facility staff breach the kitchen doors in the dining area it was considered the kitchen. The DON stated facility and dietary staff have been trained and in-serviced on what the correct clothing was when entering the kitchen. The DON stated hair nets and beard guards for the males need to be warn. The DON stated the Maintenance Director stated that it was okay to enter the kitchen without hair net nor beard guard was inappropriate response and not okay. The DON stated the purpose of a hair net or beard guard was to prevent hair from falling into the food, floor, and dishes. The DON stated the risk to the residents would be infection. The DON stated it would not be appealing if she found hair in her food. <BR/>During an interview on 02/01/24 at 4:18 PM with the Administrator, she stated once facility staff cross the kitchen door in the dining room into the kitchen was consider being in the kitchen. The Administrator stated all facility staff to include dietary staff have to be wearing a hair net and for the males with facial hair a beard guard. The Administrative stated dietary staff are trained on the proper wear when being in the kitchen. The Administrator stated facility staff were trained on what to wear when entering the kitchen including the hair net and beard guard for males with facial hair. The Administrator stated the regulation says anybody working in the kitchen has to cover their hair. The Administrator stated not wearing a hair net or beard guard could be a risk of contamination. The Administrator stated she would not be okay finding hair in her food, it would be gross. <BR/>Record review of the facility Dietary Personal Hygiene policy dated 11/06 with no year revealed, Dietary employees will maintain proper food safety practices through proper personal hygiene.<BR/>- <BR/>Dietary employees shall wear, hair covering, beard restraint, and clothing that covers body hair.<BR/>- <BR/>All staff entering the kitchen must comply with hair restraints. <BR/>- <BR/>All personnel entering the kitchen to perform job functions shall follow all pertinent rules. <BR/>Record review of the facility Dietary Notice/Aviso Sign not dated revealed, Notice - Hairnets and beard covers required in this area. (Spanish) Aviso - Redecillas para el [NAME] y coberturas para la [NAME] son requeridas en areas de produccion. <BR/>Record review of facility Dietary [NAME] certification dated 08/06/21 revealed, Completion of food safety for handlers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement written policies that prohibit and <BR/>abuse, neglect, and exploitation of residents and to investigate any such allegations for one (Resident #1) of 7 residents reviewed for implementation of written abuse, neglect, and exploitation policies: <BR/>The facility failed to follow the facility policy on reporting allegations of all alleged violations to the Administrator, <BR/>State agency and other officials in accordance with state law on and to investigate any such allegations on 12/05/23 when Resident # 1 had bruises on left groin of unknown origin. <BR/>This failure could place all residents at the facility at risk for abuse. <BR/>Findings included:<BR/>Record review of admission record dated 12/09/2023 revealed Resident #1 was a [AGE] year-old woman admitted to the facility on [DATE]. <BR/>Record review of Resident #1's Annual History and Physical 10/03/2023 revealed she was non-verbal, not alert to surroundings and on hospice care. Patient requires total assistance with ADLs (activities of daily living). Patient bed-bound, gastrostomy tube (feeding tube inserted directly through the abdominal wall into the stomach). Past Medical History: Dementia of the Alzheimer's Type, and Depression. General Examination: Elderly female, ill-appearing, thin, frail. Full range of motion to bilateral lower extremities. Contractures to bilateral upper extremities. <BR/>Record review of Resident #1's annual MDS assessment dated [DATE] revealed minimal difficulty hearing; No speech; rarely/never makes self-understood; rarely/never understand others; impaired vision; Because she was nonverbal the BIMS (Brief Interview for Mental Status) was not completed. Staff assessment for mental status revealed she had problems with both short- and long-term memory. Cognitive Skills for daily decision making, severely impaired; no symptomatic behaviors; functional limitation in range of motion impairment on both sides of upper/lower extremities; Active diagnoses included Alzheimer disease and non-Alzheimer's dementia. She was totally dependent on staff for eating, oral hygiene, toileting, bathing, dressing and personal hygiene. Incontinent of bladder and bowel. Wheelchair. Active diagnoses included Progressive Neurological Conditions, non-Alzheimer's Dementia, malnutrition, anxiety, depression, psychotic disorder, muscle spasms. No history of falls. No pain. Feeding tube. No pressure ulcers. Medications-antidepressant/antianxiety. Hospice Care.<BR/>Record review of Resident #1's care plan revised on 01/28/2021 revealed she was never to rarely understood. Care plan revised 10/13/2022 revealed she had an ADL self-care performance deficit related to cognitive impairment, limitations in range of motion, impaired balance/impaired coordination, and visual impairment. Transfers required two staff members using a Hoyer (mechanical) lift. Toileting total assistance x 2 staff. Non-ambulatory. Wheelchair total x 1 staff. Dressing, Personal Hygiene, and Bathing x 1 staff. <BR/>Review of Hospice Visit Note Report dated 12/05/23 written by Hospice CNA revealed In-House Time: 8:29 AM; Completed: 9:46 AM. ADL Services completed: Turn and position in bed, bed bath, shampoo, skin care, oral care and changed linens.<BR/>Record review of Resident #1's Nursing Note by LVN C dated 12/05/2023 revealed that the Hospice CNA provided a shower to the resident and reported discoloration to left inguinal (groin area, where the leg meets the pelvis) area. Skin assessment was completed on resident, and she was noted to have a discoloration to left inguinal area. The note stated that education was provided to CNAs to not to tighten brief too much. A family member (unidentified) was at the facility and was aware. There were no new orders at this time.<BR/>Record review revealed In-Service Attendance Record dated 12/05/23 presented by DON, ADONs Topic: A& E; Brief not too tight. (Licensed Staff, Medication Aides, Certified Nurse Aides)<BR/>Record review revealed Lab requisition dated 12/07/23 18:59 Ordered by: Attending. Type of Lab: CBC (complete blood count. It can reflect acute or chronic infection, allergies, and problems with clotting.), CMP (Comprehensive Metabolic Panel is a test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working), PT/INR (Prothrombin time test measures the time it takes for a clot to form in a blood sample. An INR is a calculation based on PT test results) Stat. Created by RN I, at 19:01 (7:01 PM).<BR/>Review Hospice Visit note written by Hospice Nurse on 12/07/23 for Resident #1 revealed Nurse initial assessment was done to the resident's skin due to a call received from Family Member A 12/06/23 at 1530 (3:30 PM) reporting she had noticed a bruise in the resident's inguinal area and was upset as she did not know how she got that bruise, per Family Member A, facility told her it could be due to having her diaper tight yet she does not believe it was caused by a tight diaper. Upon assessment the hospice Nurse noted a green, yellow appearance bruise from left to right inguinal area, vagina and underneath her left posterior leg. Nurse also noted a bruise to her left breast approx. the size of a quarter. Pt was non-verbal and max assistance and could not express needs therefore Family Member A was asking for facility to update her on all the people that care for her on Sunday and Monday since she first noticed the bruise developing on Tuesday. Family Member A wanted answers on how pt. got those bruises. Incident Report initiated by Hospice nurse, reported case to supervisor and Hospice physician who gave orders for CBC with differential (blood tests), BMP (Basic metabolic panel - a number of blood tests) , X-ray of abdomen and pelvis to rule out any blood disorder or any suspected fracture. Pt. was not on any anticoagulants at the moment and Family Member believes this could be an incident related to abuse or negligence. Hospice Nurse went to DON to update her on Family Member A's concern and a POC (Plan of Care) meeting with the facility and hospice team was scheduled for Tuesday 12/12/23 at 1:30 PM to assist family with concerns and go over results of studies completed. LVN C updated on family concern. <BR/>Record Review of 24 Hour Report/Change of Condition Reports revealed:<BR/>12/05/23 6-2 Resident #1 discoloration to left inguinal area. Do not tighten brief.<BR/>12/05/23 2-10 Resident #1 discoloration to left inguinal area. Do not pull diaper tightly.<BR/>12/06/23 6-2 Resident #1 Continue with discoloration to left groin area-Diaper to be loose.<BR/>12/07/23 6-2 Resident #1 Continue with bruise to groin, RN from Hospice & attending physician assessed. Pending orders from Hospice. 12/08/23 X-rays completed. Negative for fractures. Noted Osteopenia. Labs drawn at 1300 (1:00 PM), pending results. <BR/>12/07/23 2-10 Resident #1 Stat X-Ray to right groin (Hip) femur, shoulder, heel, done. Awaiting results. No new bruises.<BR/>12/09/23 2-10 Resident #1 X-ray results no fractures. No new orders. Labs drawn pending results.<BR/>12/11/23 6-2 Resident #1 Discoloration growing. New Orders for Ultrasound of abdomen & inguinal area/BLE and x-rays. <BR/>12/11/23 2-10 Resident #1 X-ray results came in all Negative. <BR/>12/12/23 Resident #1 6-2 if resident (#1) returns from hospital no diaper. <BR/>12/13/23 Resident #1 6-2 stable, continue with no brief.<BR/>12/13/23 Resident #1 Returned to facility at 11:30 PM, No new orders.<BR/>12/14/23 Resident #1 6-2 continue no brief, 2 staff at all times, no male staff.<BR/>12/14/23 Resident #1 2-10 Stable. Continue with no briefs. <BR/>12/15/23 Resident #1 6-2 continue no brief, 2 caregiver/staff at all times, no male staff.<BR/>12/15/23 Resident #1 2-10 Continue with no brief. 2 Caregivers staff at all times. <BR/>Review Police Department Incident Information Card for Resident #1 revealed report dated 12/11/23. Time: 2300 (11:00 PM). The police Incident Information Card revealed no other information. <BR/>Review Physician Order 12/12/23 2:05 PM written by attending physician revealed Send out to Hospital emergency room for sexual assault exam.<BR/>Review Physician Order 12/12/23 19:26 written by attending physician revealed Resident transferred to Hospital emergency room in an Ambulance accompanied by Family Member A.<BR/>Review of Hospital emergency room Provider Report 12/12/23 Time: 2100 (9:00 PM) <BR/>revealed [AGE] year-old female with a past medical history of dementia, bed ridden on hospice care at nursing facility presenting to the emergency room for evaluation of bruising to her pelvic region for the last week-has been evaluated by nursing home physician with imaging and labs which were negative for fracture and only very mild thrombocytopenia. The patient's Family Member was wanting further evaluation by SANE (Sexual Assault Nursing Examination); they do have an Adult Protective Services case involved as they are not sure how the patient developed the bruising-she was bed ridden and contracted, nonverbal. Nursing home had contacted County Hospital who stated that the patient did not qualify for a SANE exam. Chief Complaint: Bruising to pelvic region. Patient with bruising to her lower pelvic region that extends to both her hips, Foley catheter in place, bruising in healing, no new bruises noted. EXT: Bruising noted to her pelvic region, extremities are contracted. Neuro: Frail, cachectic, nonverbal at baseline. Re-Evaluation MD Notes: Patient was a [AGE] year-old female with past medical history of dementia, arthritis, bed ridden on hospice presenting to the emergency room for bruising to her pelvic region that was noted about a week ago, patient was evaluated with labs as well as imaging. Patient's family member was under the impression that more evaluation was needed. [Reevaluating MD] spoke with the medical director of the nursing home who stated that he had already evaluated the patient's bruising, there was no evidence of a fractures to her hips or pelvis, her labs work only revealed very mild thrombocytopenia, otherwise within normal limits. Patient's family member was wanting a SANE evaluation however the Hospital declined this evaluation. Nursing staff spoke at length with the patient's Family Member, she stated that they have no APS case, and the nursing home was who told her that she needed to come to the emergency room to have the bruising looked at further, [Reevaluating MD] discussed the lab work that was obtained as well as the imaging that was obtained by the nursing home physician. Patient's Family Member would like Resident #1 to return to the nursing home. Discharge and Departure: discharged home at 2119 (9:19 PM) on 12/12/23.<BR/>In an interview on 12/09/2023 at 9:55 AM Resident #1's Family Member A revealed she visited Resident #1 every afternoon and helped with toileting, and Family Member B visited Resident #1 every morning and helped with toileting. Family Member A said she had changed Resident #1's briefs the afternoon of 12/04/2023 and saw no unusual discolorations in her pelvic area, but the afternoon of 12/05/2023 during brief changes she saw bruising on Resident #1's left inner thigh and left groin area. She described the bruising a purple and said that since the bruising was first noted it had spread across the pelvis and that there was also bruising near the resident's vagina. Family Member A said Family Member B had reported to her that the morning of 12/05/2023 Family Member B observed that Resident #1 had bruising in her pelvic area. Family Member A stated that Family Member B had reported the bruising to the Hospice CNA and the Hospice CNA had reported it to the facility LVN C. <BR/>In an interview on 12/09/2023 at 12:42 PM with the Administrator and DON, the DON stated that Resident #1's bruising was not considered to be of unknown origin because LVN C thought the bruising was due to the resident's brief being too tight, and so was not reported to the state. The DON said the facility had gone with LVN C's assessment that the bruising was from the brief being too tight but started post-risk management such as labs and x-rays. She said the facility was looking into the bruising to try to explain it. <BR/>In an interview on 12/09/2023 at 1:17 PM LVN C revealed that the morning of 12/05/2023 the Hospice CNA asked him to come and look at a bruise on Resident #1. LVN C stated the Hospice CNA had finished bathing Resident #1 and Resident #1 was lying in bed in a gown with no brief on. LVN C stated he examined Resident #1 and found a bruise on the left groin area that extended around six inches along the groin. LVN C stated he checked the resident for pain by touching the bruise but that she did not have any grimacing or moaning. LVN C said the next day the bruising had spread across the abdomen to the right groin and on the pelvic area. He stated that because of the shape of the bruise he continued to think the bruise might have been caused by a tight brief. <BR/>In an interview on 12/09/2023 at 1:50 PM CNA E revealed she had been assigned to Resident #1 the morning of 12/05/2023 and spoke to the Hospice CNA about Resident #1 around 6:15 AM that morning. CNA E said the Hospice CNA had provided a bed bath and mentioned that the resident had a bruise. CNA E observed that Resident #1 had a light-yellow bruise in the left inguinal area. The CNA said the resident would stiffen up when her brief was being changed but that did not make it difficult to change her brief. The CNA said all care was provided to the resident in bed, and that she had never transferred the resident out of bed. <BR/>In an interview on 12/11/2023 at 9:08 AM the Hospice CNA revealed she had provided a bed bath to Resident #1 on 12/05/2023. She stated that when she began care the resident was wearing a brief which was as tight as usual. The Hospice CNA stated when she removed the resident's brief, she noticed bruising and called the nurse. The bruises were purple and in the left inguinal (where the front of the upper thigh meets the body) area extending a little in the direction of the leg. There was no bruising noted in the other areas. The Hospice CNA said she told the nurse (LVN C) and he said the bruising was from the brief because it was more in the inguinal area. She said she worked with about five residents in the facility and had never found them with tight briefs.<BR/>In an interview on 12/11/2023 at 2:15 PM the DON revealed she assessed Resident #1 the afternoon of 12/05/2023 and observed bruising to the left inguinal area, with none to the pelvic area. She was unaware that the morning of 12/05/2023 the Hospice CNA had reported the bruising LVN C. <BR/>In an interview on 12/11/1023 at 4:32 PM the Hospice Nurse revealed she received a call on 12/05/2023 at 9:21 AM from the Hospice CNA advising her that Resident #1 had a bruise in the left inguinal area. The Hospice Nurse said she was scheduled to do a visit on 12/07/2023 and decided to wait until then to see the resident. <BR/>Second Interview 01/02/24 at 12:40 PM LVN C revealed Tuesday 12/05/23 at approximately 10:00 AM, Hospice CNA came to the nurse's station to report she had noted Resident #1 had a linear discoloration slightly below the fold to the left groin while giving resident a bed bath. Upon assessment Resident #1 was lying in bed on her back, without a disposable brief and noted linear reddish area below the left groin, no other discoloration was noted at time of assessment. The discoloration was on the area where the brief is placed between the folds of the legs and taped to the sides. Resident is non-verbal and requires total assistance with activities of daily living. LVN C reported he had assessed Resident #1 on Wednesday12/06/23 and noted no changes to linear reddish area below the fold to the left groin and had not noted any new bruises. LVN reported on Thursday 12/07/23 Hospice CNA reported purple discoloration below the fold to the left groin and purple bruises on pubic area. LVN C stated he assessed resident on that day and noted discoloration was turning purple on the area below the fold to the left groin and noted purple discoloration was spreading to pubic area, no other bruises were noted at time of assessment. LVN C reported MD came to examine resident in the evening and spoke to one of the Family Member s and gave new orders to the 2-10 nurse. LVN C reported on 12/08/23 Lab Tech came on the night shift and was not able to draw blood as ordered. Another Lab Tech came to facility 12/08/23 at approximately 1:00 PM, and resident's Family Member was present when blood was drawn from one of the hands since resident is not able to extend arm to draw blood. LVN C stated he had not received any complaints about brief being too tight, or seeing Family Member s perform ROM or sit the resident at the bedside. A long time ago, resident was able to sit at the side of the bed. She is no longer able to sit due to rigidity, tremors, and inability to bend legs at hip and knee joints. LVN C stated, on 12/09/23 resident had bruises to bilateral inguinal areas, outer labia with dark brown bruise, bruise behind left leg by panty line, MD notified, Family Member B at bedside. On 12/12/23 resident was sent to hospital emergency room for evaluation of bruises per MD order and returned at 11:30 PM with no new orders. Family Member A wanted resident to be sent to [Name] Hospital for SANE examination. LVN C reported he placed telephone call to [Name] Hospital and was informed resident did not meet the criteria for SANE examination because more than 5 days had passed since bruising was noted, Administrator and DON notified.<BR/>Second interview 01/02/24 at 1:10 PM CNA E revealed she was assigned to Resident #1 12/05/23 on the 6-2 shift. At approximately 6:15 AM, Hospice CNA was in the room giving Resident #1 a bed bath. I was in the room preparing the roommate to get her out of bed for breakfast. At that time the Hospice CNA asked if I had seen any bruises on resident on 12/04/23. I said no. She asked me to come and see the bruise resident had on left groin area. There was a linear bruise slightly below the fold of the left leg about 2 inches long and half the size of the width of a pen. There were no other bruises noted at that time. After lunch at approximately 12:30 PM, I was in the room attempting to explain Family Member B when she came to visit the resident what we thought had caused the bruise, when LVN C came to resident's room, and he informed Family Member B of the red area below the left groin. We do not force the legs open, and she cannot bend her legs at the knees. On 12/07/23 Hospice CNA noted Resident #1 had bilateral dark purple bruises on groins and pubic area, dark purple bruise behind the left leg on the panty line and bruise to left breast the size of a quarter when she was giving the bed bath. The Hospice CNA reported the bruises to LVN C. On 12/08/23 resident was still using disposable briefs, no new bruises noted. We started using under pads the week after. We were also instructed to have 2 people anytime we entered resident's room. CNA E reported staff had been trained to immediately report abuse/neglect/any injury to the nurses. <BR/>Second interview 01/02/24 2:47 PM RN I revealed she was assigned to Resident #1 on 2-10 shift on 12/05/23. She stated LVN C had reported at change of shift Resident #1 had a linear bruise slightly below the groin from the brief being too tight. RN stated, Upon assessment she noted Resident #1 had a linear bruise slightly below left groin that was approximately 1-1 &frac12; inches long. The bruising was at the front of the bulk of the brief in the groin area where the tapes are tied to the sides. I have never seen residents with tight briefs. I did not recall seeing any other bruises on that day. It looked like the bruise could have been caused by brief being pulled too tight. RN I, reported resident was non-verbal and required total assistance with ADLs, had contractures to all extremities, was very rigid, unable to bend the knees and hips and had tremors to all extremities. Resident needed to be log rolled in bed with the assistance of two people to provide care. Log rolling is a technique used to turn a patient whose body must always be kept in a straight alignment. RN I, stated, On 12/07/23 MD came to see resident and gave orders for stat labs and stat x-rays. Bruise on left groin had spread to right groin, pelvic area and behind the left leg by panty line. RN I, stated, they have been trained to immediately report injuries of unknow origin to the Administrator, ADON, Physician, and responsible party and document notification in electronic record.<BR/>Second interview 01/02/24 6:35 PM Family Member A reported she visits Resident #1 daily in the evening and Family Member A comes to visit Resident #1 during the day shift. She reported LVN C had informed Family Member B that Resident #1 had a bruise on the left groin and according to LVN C had been caused by a tight brief. Family Member A reported she took photos on her own on 12/05/23 to have records of the extent of bruising that the resident had on her private areas. Family Member stated, I was able to take the photos on my own, because the resident can relax her legs and slightly opened them for me to take the pictures of her private areas. I did not use any force to separate the legs. Family Member A stated, On 12/05/23 CNA F reported to Family Member B that the resident had a bruise on the groin to the left leg. I do not know who first noted the bruise to the left groin, on 12/05/23 and I do not know who reported the bruise to Family Member B. LVN C is the one who said that the bruise to the left groin was caused by the brief, and he is the one that convinced the doctors, administrator, and nursing director that the bruise was caused by tight brief. After that the physician told us the bruises had been caused by the brief. On 12/05/23 when I got here in the evening, I found her with a tight brief and told the CNAs. I did not report it to the nurses or Hospice staff. The Hospice CNA gives my [family member] a bed bath Monday-Friday, and not on the weekends. Family Member A reported she took photos on her own on 12/05/23 to have records of the extent of bruising that her [family member] had on her private areas. I was able to take the photos on my own, because my family member can relax her legs and slightly opened them for me to take the pictures of her private areas. I did not use any force to separate the legs. My family member [the resident] understands others and can answer questions at times with yes and no responses. At times she is more confused. On 12/08/23 I took a video of my family member, and I asked her if she had been abused and she responded yes and both of us cried. My family member [the resident] cannot talk she just mumbles, but at times can understand and answer yes and no. I did not report this to anyone at the facility, or to hospice. I do not know how they found out that I had taken a video of my family member [the resident]. The administrator kept insisting that I show her the video. I do not know who reported the bruise to APS. APS came 12/11/23 to investigate the dark purple bruises on the pubic area. I did not follow up with APS to see what they found when they came to investigate the bruises at the facility. Hospice staff cannot understand what happened to my family member [the resident] and neither can I. I talked to the nurse from Hospice Nurse, and I never made a comment to her about my family member [the resident] being abused or neglected. I never said that my family member [the resident] was sexually abused. I do not know who was requesting a SANE exam, but I do know that the nursing home staff did all they could to prevent my [family member] from going to UMC for the SANE exam. On 12/12/23 my family member [the resident] was sent to the emergency room by ambulance. The facility staff never told me why they were sending my family member [the resident] to Emergency Room. Nothing was done at the hospital, except to pull the sheets down, look at her private area and cover her up. The hospital staff did not know why my family member [the resident] was sent to the emergency room. They did not do anything to my family member [the resident], not even checked her private areas. I requested they called an ambulance to return to the nursing home. When the ambulance arrived at the nursing home the attendant pulled the sheets down, noted the bruises and he was the one that suggested to me that I talk to the facility staff and physician to try and find out what had happened to Resident #1. I do not know who called the police. The police asked me to leave the room to talk to Resident #1. The police were in the room for 1-2 minutes, and just left without telling me what they had found. Family A stated she was very disappointed with LVN C and the facility because they had not investigated how her family member [the resident] got the bruises and had not done a SANE examination to find out what had happened to her family member [the resident].<BR/>Interview 01/03/24 4:07 PM with DON revealed Administrator was the Abuse Prohibition Coordinator. DON reported ADON O had reported Resident #1 had discoloration to the left groin on 12/05/23 via text message at 1:30 PM to the Administrator. DON stated she had assessed resident on 12/05/23 and only noted linear discoloration to left hip. No other bruises were noted at time of assessment. DON stated she did not deem bruises suspicious because LVN C had reported that bruises were caused by disposable brief. DON stated, We follow the Provider Letter related to Reporting Guidelines for reporting incidents to state office and we determine that the bruising was not considered to be of unknown origin since LVN C had reported the bruise was caused by a tight brief. DON reported on 12/07/23 Nurse reported to DON Resident #1 had a bruise to left breast, to groin areas, pelvic area, and back of left knee approximately 1:30 PM. The resident's arms are contracture across her chest and the finger on the second finger on the right hand is pointing out and with the tremors was putting pressure directly where the resident had a quarter size discoloration on the left breast. DON reported she went to look at resident with LVN C and they had determined bruise to left breast was caused by contractures/tremors to hands. Resident is non-verbal. The physician and Hospice Nurse were at the facility on 12/07/23. MD gave orders for labs and x-rays on that day. X-rays were negative for fractures and labs revealed resident had anemia and thrombocytopenia. Thrombocytopenia is low platelet count. Platelets stop bleeding by clumping and forming plugs in blood vessel injuries. <BR/>Interview 01/03/24 beginning at 4:19 PM Administrator and DON revealed they did not know why LVN C was trying to explain what had caused the discoloration on Resident #1's left groin. DON stated On 12/05/23 I went to Resident #1's room to check the discoloration to the left groin. The liner discoloration measured 5 cm x 2.5 cm was pinkish/purple color and there were parallel marks on the skin over the discoloration. DON reported that she had not documented her assessment in the resident's electronic record but had written her assessment in her personal note book. We were trained in nursing school to document assessment in patient's clinical record. DON reported LVN C had not measured the discoloration on the left groin on 12/05/23. <BR/>Interview 01/04/24 at 12:24 PM Administrator revealed Hospice Nurse had called DON on 12/11/23 to report that the family of Resident #1 was upset and had called APS. The Hospice staff were trying to contact DON by telephone. DON did not answer because she was on the telephone with Hospice Nurse. Administrator reported the receptionist called her to report APS was at the facility. Administrator reported that she had asked DON to call APS right away to determine why they wanted to come to the facility since they do not have any jurisdiction at the nursing home. The investigator informed DON APS had received an intake that required immediate investigation related to sexual abuse. Administrator reported she had immediately called her supervisors, called DON to request that the nurses assist the investigator as needed. It was reported that resident's family member was at the facility when the administrator arrived. The family member denied filing a complaint with APS. The family member did not want Resident #1 to be sent out for SANE examination. It was reported that the resident's family member did not want to talk to the administrator about the bruises. Administrator reported she had reported the allegation of sexual abuse to the non-emergency police number and reported the incident to state office via Tulip on 12/11/23.<BR/>Telephone interview 01/04/24 at 11:56 AM with DON revealed she had received a return call regarding Resident #1 from Hospice Nurse after hours at approximately 5:30 PM - 6:00 PM, she was not at the facility at that time. Hospice Nurse told me that she wanted to be transparent because she did not have to call after hours and said the family was not happy with what I had explained to them about the bruise on the groin caused by a tight brief, and [family member] was calling APS. Plan of Care (POC) meeting was held on 12/12/23 with several staff members from Hospice, Administrator, DON, and resident's Family Member A. DON reported the nurses on the 2-10 shift had called her to informed her that APS investigator came to the facility on [DATE] at approximately 7:29 PM. He informed the nurses that he was investigating an allegation of sexual abuse involving Resident #1. He went in and out of the room and said resident was non-verbal and did not have any eye contact. He informed the nurses that resident was not in danger and this case would be passed on to the proper authority in the morning. DON reported she came to the facility as soon as possible after talking to the nurses. She reported that she had immediately reported the allegation to the Administrator via telephone and she was already on her way to the facility. APS was no longer at the facility when the Administrator arrived. DON reported the administrator had reported the allegation of sexual abuse to state office on 12/11/23. DON reported that during the POC meeting with Hospice Staff, Family Member A, Administrator & DON on 12/12/23, Hospice staff mentioned the allegation of sexual abuse.<BR/>Telephone interview 01/05/24 at 9:59 AM, Hospice CNA revealed 12/05/23 she had arrived at the facility at approximately 8:29 AM, to provide a bed bath to Resident #1. Resident #1 was lying in bed, when she removed the hospital gown, resident had on a disposable brief and noted linear bruise on left groin area. I immediately went to report the bruise to LVN C and both of us return to the room to show him the bruise on the left leg on the groin area. I had not provided a bed bath yet. I do not remember if the brief was tight or loose. If the brief is too tight, it will cause redness. After I completed the bed bath, I call the Hospice nurse to report the bruise to the left groin area. Resident did not have any other bruise at the time visit was completed. Hospice CNA reported that she provides a bed bath to Resident #1 Monday - Friday and the facility CNAs provide the bed bath on the weekends and that the resident was not showered. <BR/>Interview 01/05/24 11:18 AM with Administrator revealed ADON O, had sent her a text message on 12/05/23 at 1:32 PM notifying her Resident #1 was found with discoloration to the left groin. The Administrator stated, The DON and I were not at the facility, so I immediately called the facility and talked to LVN C, and he said that he had reported to ADON O approximately 15-20 minutes ago that Resident #1 had discoloration to the left groin. Administrator reported she had not asked LVN C what time the Hospice CNA had reported to him the discoloration to the left groin on 12/05/23. Administrator reported CNA E was assigned to Resident #1 on the morning shift on 12/05/23 and said Hospice CNA had reported the discoloration to LVN C after she had completed the bed bath. The Administrator stated that the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced dignity and respect for 2 (Resident #24 and #79) of 9 residents reviewed for care that maintained or enhanced their dignity. <BR/>-The facility failed to maintain Resident #24 ' s sense of dignity by not proving change in brief in a timely manner leaving resident soiled (wet) in the lobby area with other residents. <BR/>-The facility failed to maintain Resident #79's sense of dignity by leaving a portion of his left side of his body exposed during transportation to the shower. <BR/>These failures could place residents who require assistance with bathing and changing their clothing at risk of decreased self-esteem affecting their dignity. <BR/>Findings included: <BR/>Record Review of Resident #24 face sheet dated 09/19/23 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record Review of Resident #24 ' s History and Physical dated 08/30/23 revealed the resident had a diagnosis of depression. <BR/>Record review of Resident #24 ' s MDS dated [DATE] revealed her cognition was severely impaired and she was able to make herself understood and could understand others. <BR/>Record review of Resident #24 ' s care plan dated 9/15/20 revealed Resident #24 had an ADL self-care deficit and was at risk of not having her needs met in a timely manner due to related to a preference of female CNA A history of stroke, expressive aphasia (language disorder that affects the ability to communicate), hemiplegia (paralysis that affects one side of your body), and Parkinson's and required limited assistance x1 for bathing and changing. Interventions included the resident would l maintain a sense of dignity by being clean, dry and odor free and well- groomed. <BR/>Interview and observation on 09/19/23 at 11:28 AM with Resident #24 revealed Resident #24 was brought into her room, resident was soiled in urine pants observed wet, Resident #24 pants had wet stain that ended right above her knees. Resident #24 stated feeling bad being left soiled with urine in the lobby in wheelchair. Resident #24 appeared to have been crying eyes were red and still had tears, Resident #24 state she was crying because she didn ' t know what to do. The staff nurses brought the resident into the room and the resident was changed after 30 minutes by the CNAs. She stated her last brief change was at 6-7 AM, in the morning. <BR/>Record review of Resident #79's face sheet dated 09/20/23 revealed Resident #79 was admitted on [DATE] to the facility. <BR/>Record review of Resident #79's history and physical dated 08/30/23 revealed a [AGE] year-old male diagnosed with Alzheimer's and dementia. <BR/>Record review of Resident #79's quarterly MDS dated [DATE] revealed the resident could not make himself understood, speech was not clear, was able to understand others, and the resident BIMS indicated he was cognitively impaired. Section G reflected the resident was total care, maximum assistance with 2 people and utilized a wheelchair. Section I revealed diagnoses of Alzheimer's, Dementia, muscle weakness, shortness of breath, and dysphagia (swallowing difficulties). <BR/>Observation on 09/19/23 at 11:47 AM revealed Resident #79 was transported down the hall via a shower chair by CNA H to the community shower and was only covered with a sheet. It was observed that Resident #79 ' s left side of his body was exposed, leaving a visible portion of his left thigh, hip and abdomen. <BR/>Interview on 09/21/23 02:44 PM with LVN F revealed that residents needed to be changed every 2 hrs. if the resident is incontinent. LVN F stated she had taken Resident #24 in her room because she asked for assistance since she was wet. LVN F stated she doesn ' t check if the staff change the residents every 2 hrs. but knows they usually go to lay them down after breakfast and that ' s when they change the brief. LVN F confirmed Resident #24 was soiled with urine all the way to her knee. LVN F stated, if I was soiled, I would feel bad and embarrassed. The residents are covered in a sheet or a towel when sitting on the shower chair and the CNAs transport them down the hallway to the community showers. The CNAs need to ensure the residents are completely covered and are not exposed when taking them to the shower room. If the residents are exposed while taking them to the shower room or are left wet for extended periods of time it can affect their dignity. <BR/>Interview on 09/21/23 at 03:25 PM with the DON and the Administrator revealed that nursing staff needed to be checking residents every 2 hrs for incontinent episodes and as needed. There is no excuse for not making rounds every two hours and providing incontinent care as needed stated the Administrator. The DON stated there was no excuse for Resident #24 to be left soiled for that long period of time because it can affect resident ' s dignity. The DON stated the residents exposed while being transported to the community showers could affect the dignity and privacy of the residents. <BR/>Record review of the facility policy Resident Rights dated 02/23/2016 revealed in part; the resident has a right to be treated with respect and dignity, including the right to reside and receive services in the facility with reasonable accommodation of residents needs and preferences, except when they would endanger the health and safety of other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident ' s right to formulate advance directives for two (Resident #62 and Resident #29) of 27 residents reviewed for enactment of advance directives. <BR/>Resident #62 had both an out-of-hospital DNR order (tells health care providers not to do cardiopulmonary resuscitation) and a physician ' s order for full code (meaning if her heart stopped beating and/or she stopped breathing, all resuscitation procedures will be provided to keep her alive) in her medical record. <BR/>Resident #29 had both an out-of-hospital DNR form and a physician ' s order for full code in his medical record. <BR/>The failures could put residents at risk of not having their end of life wishes honored. <BR/>Findings include: <BR/>Resident #62 <BR/>Record review of Resident #62 ' s face sheet dated 09/19/2023 revealed she was [AGE] years old and admitted to the facility on [DATE]. <BR/>Record review of Resident #62 ' s history and physical dated 08/24/2023 revealed that she had diagnoses including dementia. The physician noted that he had a long discussion about DNR, and code status and that Resident #62 was to be full code. The history and physical did not indicate with whom the physician had discussed the resident ' s code status. <BR/>Record review of Resident #62 ' s admission MDS dated [DATE] revealed that her BIMS was an 8 (moderate cognitive impairment). She had symptoms of delirium including intermittent difficulty focusing attention, and intermittent disorganized thinking. <BR/>Record review of Resident #62 ' s care plan dated 08/29/2023 revealed she had a physician's orders that included a status of full code. <BR/>Record review of Resident #62 ' s physician ' s order dated 08/25/2023 revealed she was a full code. <BR/>Record review of Resident #62 ' s Out of Hospital DNR with an attached fax cover sheet revealed it was faxed to the facility on [DATE] by a hospice physician and had been signed on 08/25/2023 by an adult child, two witnesses and the hospice physician. <BR/>In an interview on 09/21/23 at 03:57 PM the Social Worker said Resident #62 was full code when admitted to the facility, and that the family completed the DNR after admission. She said the family brought the document shortly after the resident was admitted but could not give an exact date. The Social Worker said when she received the DNR she scanned it, uploaded it to the resident ' s chart, then asked the floor nurse to contact the physician to write a DNR order to place in the resident ' s electronic record. She could not remember who the floor nurse was. The Social Worker said the DNR was the valid document that should be honored. She said having a full code order in Resident #62 ' s chart put the resident at immense risk of not having her wishes honored and did not protect the resident ' s desires regarding advance directives. <BR/>In an interview on 09/21/23 at 05:36 PM the Administrator said having both a full code order and a completed DNR in Resident #62 ' s electronic record put the resident at risk of not receiving the care she wanted. The Administrator said when a resident ' s status changed staff were supposed to update the resident ' s record. The Administrator said when the Social Worker received the DNR she scanned it, uploaded it to the resident ' s chart, and asked the floor nurse to contact the physician to write a DNR order to place in the resident ' s electronic record, but that the nurse (unidentified) did not contact the physician to request a DNR be written to place in the resident ' s electronic record. <BR/>Resident #29 <BR/>Record Review of Resident #29 face sheet dated 9/19/23 revealed an 85year old male with an admission dated of 9/8/23. Resident #29 ' s initial admission date to the facility on [DATE]. <BR/>Record review of Resident #29 DNR form dated 7/9/20 revealed was signed by the resident ' s state appointed legal guardian. <BR/>Record review of Resident #29 ' s baseline care plan dated 08/15/23 revealed it did not address the resident's code status; the section advance directives was left blank. <BR/>Record review of Resident #29 ' s order summary report dated 9/19/23 revealed a full code order status was active, order dated was 09/08/23. <BR/>Interview on 09/26/2023 at 09:00 AM with Resident #24 revealed he was unable to express his desires. <BR/>Interview on 09/21/23 at 02:35pm with LVN E, revealed she was unsure what order she would follow in that situation where a resident had a DNR in chart and was a full code. LVN E stated the Social Worker was the person in charge of obtaining the DNR for the residents. LVN E stated if a resident has a full code order and a DNR documented in the chart it could place the resident at risk of not getting the appropriate care desired. <BR/>Record review of the facility policy Advance Directives/Advance Care Planning dated 4/2015 revealed that the facility recognized the right of a person to refuse unwanted treatment, and that the facility would honor resident ' s advance directives. Advance Directive included the Out of Hospital DNR. On admission the facility would determine if the resident had executed advance directives and would obtain copies to place on the resident ' s medical record. Social Services coordinates notification of the physician of the existence of any directives and the need for any orders related to advance directives or code status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 (Resident #5) of 7 residents whose records were reviewed for assessments. <BR/>Resident #5 was not listed as having behaviors on her annual MDS assessment. <BR/>This failure to ensure comprehensive and accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. <BR/>Findings included: <BR/>Record review of Resident #5's face sheet dated 9/17/24 revealed a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses of generalized anxiety, major depressive disorder, and mild cognitive impairment. <BR/>Record review of Resident #5's annual MDS assessment dated [DATE] revealed BIMS score of 15, indicating her cognitive was intact and the behaviors section revealed no history of any behavior. <BR/>Record review of Resident #5's comprehensive care plan dated 8/27/24 revealed a focus area for frequently requesting HIPPA information on other residents; wants to put staff in trouble with state and get them fired; tends to be going into other residents' rooms asking for information and making notes on her notepad with interventions that included Give a clear explanation of daily care activities prior to and as they occur during each contact. Encourage as much participation and interaction by the resident as possible and redirect and remind resident of certain information is HIPPA protected. <BR/>Record review of Resident #5's progress notes dated 7/30/24 read in part This Nurse was notified by ADON that there was someone at the front looking for this resident to deliver some medication that she instructed no Nurse or staff from this facility can received except her. Resident tends to get prescriptions without letting this Nurse Know, due to resident voiced to other staff members that is not an 'RN which does not make her feel safe. DON and administrator notify. No prescription was delivered or notified from any DR's office.<BR/>During an interview on 9/17/24 at 2:39 pm, the MDS Nurse stated she was familiar with Resident #5 and knew about her behavior. The MDS Nurse stated her behavior consisted of asking questions about other residents, their medications, their doctor appointments, and at time their family members information. The MDS Nurse stated Resident #5 required a lot of redirection and education on HIPPA. The MDS Nurse stated she had not thought of including her behavior on her MDS assessment due to the examples provided were more on the verbal aggressive side. The MDS Nurse stated the behaviors that were addressed in MDS as behaviors that would warrant a medical diagnosis with medication. <BR/>During an interview on 9/17/24 at 3:04 pm, the DON stated Resident #5 had history of fabricating stories, false allegations, she does not like the ADON and LVN A and would try to find anything she thought they might do wrong to try and get them terminated. The DON stated Resident #5 also had history of asking for HIPPA information for other residents. The DON stated Resident #5 required a lot of education on HIPAA rules. The DON stated Resident #5's type of behavior were hard to capture in MDS due to the wording of the assessment, they were more on the aggressive, combative, and insulting side. <BR/>During an interview on 9/17/24 at 3:36 pm, the Administrator stated she was familiar with Resident #5 history of behavior which included meddling in residents care, false accusations against staff to attempt to get them fired and asking for residents HIPPA information. The Administrator stated since Resident #5 became [NAME] President of resident council she has gone around and been asking residents for HIPPA information i.e., their doctor appointments, health issues, and family member information. The Administrator stated Resident #5 was questioned on those behaviors and her response was she wanted to ensure they were receiving the proper care. The administrator stated Resident #5 required a lot of redirection and education. The Administrator stated she was not well versed on MDS assessment, but her basic understating of behaviors accounted for on the MDS assessment were to bill for. <BR/>Record review of CMS's RAI version 3.0 manual dated October 2016 page E-10 read in part E0600: Impact on others: health related quality of life- behaviors identified in item E0200 put others at risk for significant injury, intrude on their privacy or activities and/or disrupt their care or living environments. The impact on others code here in item E0600. Steps for assessment: 2- to code E0600, determine if the behaviors identified put others at significant risk of physical illness or injury, intruded on their privacy or activities, and/or interfered with their care of living arrangements. Coding instructions for E0600B. Did any of the identified symptoms significantly intrude on the privacy or activities of others? Code 1, yes if any of the identified behavioral symptoms kept other residents from enjoying privacy or engaging in informal activities. Includes coming in uninvited, invading, or forcing oneself on other's private activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for four (Residents #29, #79, #89, and #212) for 27 residents reviewed for an ongoing program to support residents in their choice of activities. <BR/>- The facility failed to provide individualized activities for Residents #29 and #79 who were bedbound. <BR/>-The facility failed to provide Resident #89 with individualized activities reflecting his impaired visual status or preferences. <BR/>-Resident #212 was not provided in room-activities, since it was his preference to stay in his room. <BR/>This failure places residents at risk of feelings of isolation and depression.<BR/>Findings included: <BR/>Resident #29 <BR/>Record review of Resident #29 ' s face sheet dated 9/19/23 revealed he was an [AGE] year-old male who was initially admitted to the facility on [DATE] with a re-admission dated of 09/08/23. <BR/>Record review of Residents #29 ' s History and Physical dated 09/14/23 revealed the resident had CVA (interruption in the flow of blood to cells in the brain) with right sided weakness. <BR/>Record review of Activity Evaluation dated 9/18/23 by Activities Director revealed Resident #29 would prefer to participate in activities in his room. The evaluation indicated Resident #29 liked to participate in games, listening to music, and coloring. <BR/>No Baseline Care plan addressing his need for in-room activities in place. <BR/>Observation and interview on 09/18/2023 at 09:00 AM revealed Resident #29 was lying in bed with the windows blinds closed and the television off. Resident #29 stated he would like to have the television on, he liked to see both Spanish and English shows and likes a variety of shows like sports. <BR/>Interview on 09/20/23 02:30 PM revealed Resident #29 denied participating in any activities or having any activities staff member visit for the week and stated his nurse turned on his television. <BR/>Interview on 09/21/23 at 10:58 AM with Activities Director revealed she looks into the room will ask resident if he needed anything but not participated in actual activity with the resident. The Activities Director stated she had taken him once to the activity room to play loteria (mexican card game), and resident likes to color. <BR/>Resident #79 <BR/>Record review of Resident #79's face sheet dated 09/20/23 revealed Resident #79 was admitted on [DATE]. <BR/>Record review of Resident #79's history and physical dated 08/30/23 revealed a [AGE] year-old male diagnosed with urinary retention, Alzheimer's, and dementia. <BR/>Record review of Resident #79's quarterly MDS dated [DATE] revealed the resident cannot make himself understood, speech is not clear is able to understand others, and resident BIMS indicates he was cognitively impaired. Section G reflected the resident was total care dependent, maximum assistance with 2 people and utilized a wheelchair. Section I reflect diagnoses of Alzheimer's, Dementia, muscle weakness, shortness of breath, and dysphagia (swallowing difficulties). <BR/>Resident is not interviewable he is nonverbal and does not respond to questions asked on 09/18/23 at 01:00 PM. <BR/>Interview 09/18/23 at 01:05 pm with family member of Resident #79 stated he does not participate in any activities, and during the time they are visiting he has never seen the Activities Director or staff go in and do activities with him. The family member stated him, and his sisters alternated to ensure someone always stayed with him, and the family member stated they don ' t leave resident bedside until from 9 am until 7-8 pm. <BR/>Interview on 09/21/23 at 09:40 PM with LVN E, stated she knows they do activities according to what is care plan, but has never seen the activities staff member go into the Resident #79 room. LVN E, stated activities are very important because it affects their social and emotional state. <BR/>Resident #89 <BR/>Record review of Resident #89 ' s face sheet dated 09/20/2023 revealed he was [AGE] years old and was initially admitted to the facility on [DATE] and re-admitted on [DATE]. <BR/>Record review of Resident #89 ' s electronic Medical Diagnosis listing accessed 9/21/2023 revealed he had diagnoses including anoxic brain damage (brain damage due to lack of oxygen), gastrostomy tube (tube into the stomach for feeding) and a tracheostomy (tube into the neck for breathing). <BR/>Record review of Resident #89 ' s admission MDS dated [DATE] revealed he had adequate vision and was able to see fine detail such as regular print in newspapers/books. He was rarely or never understood so his cognitive status was assessed by staff. The MDS reflected he short- and long-term memory problems. He knew that he was in a nursing home and recognized staff by face or name. He was totally dependent on staff members to move around in bed, dress, use the toilet and for personal hygiene. He did not transfer between surfaces, walk or move around his room or the facility during the look-back period. His activity preferences were determined by talking with a patient representative. It was very important to him to listen to music. The MDS Activity Preference items for keeping up with the news and doing things with groups of people were coded 5 indicating the activities were important but Resident #89 was not able to do them. <BR/>Record review of Resident #89 ' s Care Plan dated 01/16/2023 revealed he had little or no activity involvement due to immobility. The goal for the resident was that the activity director would attempt to include the resident in daily activities. This goal was reviewed on 04/18/2023 and on 05/16/2023 and did not reflect any revisions. An intervention initiated on 01/16/2023 reflected, The resident ' s preferred activities are and there were not any preferred activities listed. Interventions initiated on 02/15/2023 included: Assist/escort resident to activity functions; Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary; and Introduce the resident to residents with similar background, interests and encourage/facilitate interaction. <BR/>Record review of Resident #89 ' s Care Plan dated 05/26/2023 revealed he was dependent on staff for cognitive stimulation, activity attendance, and social interaction related to cognitive impairment and was at risk for isolation. He was [AGE] years old or younger and had little or no activity involvement due to immobility. Interventions included adapting activities as needed so they are compatible with the resident's needs, such as large print, holders if resident lacks hand strength, or task segmentation. The care plan reflected the resident would be assisted or escorted to activity functions. <BR/>Record review of Resident #89 ' s Activities - Initial Review for admission [DATE] revealed the resident enjoyed watching TV and listening to gospel music in his room. The assessment reflected the resident wasn ' t very alert but would look at the TV and seemed to enjoy music. The assessment further reflected that activities did not need to be modified to address a visual deficit. <BR/>Record review of Resident #89 ' s Activity Participation Review dated 09/07/2023 reflected the resident did all activities in his room. He loved music and family visits. He tried to speak and liked lotion massages. <BR/>Observation and interview on 09/20/23 08:58 AM revealed Resident #89 was awake, lying in bed, and responded verbally to questions. It was observed that the resident had difficulty speaking, but could partially form words, and move his head in response to questions. The television in the room was off and when asked if he liked to watch television, the resident said he could not see. When asked if he could see the color of the surveyor's shirt, he said he could see colors close up. He said that if the TV was closer, he still would not be able to see it. The television was located at ceiling level in a corner of the room, about 7 feet from the resident ' s bed and had a 24-inch screen. A radio was observed out of the resident's reach on a bedside table, but it was not turned on. The resident said he liked to listen to music but no one turned the radio on for him. He said no one came in to ask what he would like to do. <BR/>In an observation and interview and on 09/20/23 at 02:53 PM it was observed that Resident #89 was lying in bed with his eyes open. The television in Resident #89 ' s room was on. When asked if he could see the television, he said he could not. The resident said he could not hear the television. He was asked if the radio worked, and he said it did. <BR/>In a telephone interview on 09/20/23 at 03:03 PM Resident #89 ' s family member said he and other family members visited the resident on a regular basis, had attended monthly care plan meetings and had met with facility staff about two weeks prior to 09/20/2023. The family member said that during the meetings the family had requested that the resident be gotten out of bed and pushed around the facility more often. The family had requested that the TV and radio be turned on. The family member said the facility had improved a little in responding to the family ' s requests to turn on the radio or television or to get the resident out of bed and take him around the facility. <BR/>In a telephone interview on 09/20/23 at 05:40 PM Resident #89 ' s family member said the resident had impaired vision. He said the resident could see colors and shadows but could not make out images or people. <BR/>Record review of Resident #89 ' s Optometry Evaluation dated 6/28/2023 revealed the resident was non-verbal or comatose, and so his ability to see in adequate light was not assessed. The evaluation did not identify a diagnosis. <BR/>In an interview and record review on 09/21/23 at 10:29 AM the Activities Director said she and the Activities Assistant visited residents who required in-room activities about once a week for 15 to 20 minutes. She said she saw Resident #89 about once a week and that he was becoming more verbal than he had been before. She said the resident liked music. She would talk with him and turn on his radio when she visited and leave it on when she left. She stated she knew he could not see, and that his family had said the resident could not see anything except what was right in front of his face. Record review of the facility ' s in-room activity logs for September 2023 with the Activities Director revealed the Activities Director provided muscle memory activities for Resident #89 on 9/8/2023. No other activity with Resident #89 was documented for September. The in-room activity log for the month of August 2023 by the Activities Assistant was reviewed and did not reflect any activity for Resident #89. Review of the folder of in-room activity logs revealed that it contained no Activity Director in-room activity logs for the months of June, July or August 2023. No activities were logged for Resident # 89 for June, July or August of 2023. The Activities Director said in-room activity logs for the months of June, July and August 2023 were partially completed by a prior Activities Assistant. Record review revealed the folder contained no logs by the Activities Director for the months of June, July and August 2023. When asked about her activity logs for the months of June, July and August, the Activities Director said she had a lot going on during that time period and would look to see if she could find other records of in-room activities. The Activities Director did not submit any other documentation of in-room activity for Resident #89 prior to exit. <BR/>Resident #212 <BR/>Review of Resident #212 ' s face sheet dated 09/20/2023 revealed a [AGE] year-old male with an admission date to the facility of 09/12/23. <BR/>Record review of Resident #212 ' s electronic Medical Diagnosis list revealed localized swelling of the lower limbs and acute kidney failure. <BR/>Review of Resident #212 ' s History and Physical dated 09/14/2023 revealed Resident #212 had been at hospital due to a fall which led him to require surgery to the right knee and stitches to some of his fingers. <BR/>Review of Resident #212 ' s physician ' s orders dated 09/13/2023 revealed May participate in activities per care plan. <BR/>Review of Resident #212 ' s admission MDS assessment dated [DATE] revealed it was still in process and was not complete. <BR/>Review of Resident #212 ' s baseline care plan dated 09/13/2023 revealed Resident #212 had the potential for falls and the goal was to not sustain a fall related injury by utilizing fall precautions. Interventions included encourage socialization and activity attendance as tolerated and encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. <BR/>Review of Resident #212 ' s medical record revealed no evidence an Activity Assessment had not been completed. <BR/>In an interview on 09/18/23 at 11:13 AM with Resident #212 revealed no activities had been offered in his room since admission. He stated he would not get out of bed due to being weak from his legs but had received physical therapy in his room. He stated no activity personnel had come by his room to talk to him or get to know what his preferences were. <BR/>Observation on 09/19/23 at 2:23 PM revealed Resident #212 was lying in his bed watching television. <BR/>Observation on 09/20/23 at 11:00 AM revealed Resident #212 was sitting on his bed and was on his phone. <BR/>Observation on 09/20/23 at 2:30 PM revealed Resident #212 was lying in bed watching television. <BR/>In an interview on 09/20/23 2:34 PM with Resident #212 he stated today 9/20/2023 was the first day the staff had offered activities. He stated when he had returned from his doctor ' s appointment, he found a word search sheet on his bedside table. He stated since his admission, nobody had gone into his room to talk to him or ask him anything about his preferences or activities he would like. He stated he would like to do the word searches and crossword puzzles, but nobody had asked him. <BR/>In an interview on 09/20/23 at 3:19 PM with the Activities Assistant revealed she had done in-room activities with some of the residents on 9/20/2023. She stated she visited residents at least once a week. She revealed she had not gone to visit Resident #212 or had asked him what he would like to do. She could not state why it had not been done. <BR/>In an interview on 09/21/23 at 9:01 AM with LVN C revealed she knew the activities personnel would go into rooms with residents who did not come out of their rooms, and would provide in-room activities, but she had not seen anybody go into Resident #212's room. She said with other residents, she had seen coloring books and reading books such as magazines being given to residents =. She stated it was important to provide activities for residents who were not able to get out of bed because it was important to make them feel valued. She stated activities served as a distraction for pain management, socialization and to help decrease depression in residents. <BR/>In an interview on 09/21/2023 at 10:21 AM with the Activities Director, revealed she had been the activities director since May 2022. She stated her responsibilities included providing group activities and in-room activities. She stated she also completed the activity assessments for new admissions within 3 days of their admission. The purpose of the assessment was to gather the residents' preferences, likes and dislikes, and information about their demographic background. She stated for in-room activities, she would provide massages, television time, music, and aroma therapy. She stated it was important to provide in-room activities in order to prevent residents from becoming depressed. Since some residents did not have family that visit, she made sure to see all residents at least once a week to let them know they were not alone. She stated she was not familiar with Resident #212 and that her Activities Assistant was responsible for his room. She ensured the assistant was completing the activities by walking through the hallways and seeing if the assistant was in the room with the residents. She stated she was not sure if she had done an activities assessment on Resident #212 but thought she might have. <BR/>In a follow-up interview on 09/21/23 at 10:48 AM with the Activities Assistant revealed she started in August 2023 as the activities assistant. She stated her job was to help the activity director, provide group activities, and would help with interviews for the activities assessments. She stated in-room activities were done to ensure residents were not bored, and to motivate their mind. She stated she had gone to see Resident #212 around 8-10 times since he was admitted . She stated she saw him at least once a week to talk to him, had offered to play cards, color and do word search puzzles. She stated she would document resident in-room visits on a sheet of paper and would transfer them into the activity binder. She stated she tried talking to residents to see what they preferred to do. <BR/>In a follow-up interview on 09/21/23 at 1:20 PM with the Activities Director revealed activity assessments were done within 3 days of admission. She stated Resident #212 was a Spanish speaker and she had tried to complete the assessment 3 times, but he was asleep. She confirmed the activity assessment had not been completed for Resident #212. She revealed she had placed a word search and a crossword puzzle on his table but had not spoken to him because he was not in his room. She stated the risk of not completing an assessment and activities according to the assessment was that Resident #212 could get depressed and may not want to remain in the facility. She stated she did not think enough effort had been made to talk to him to complete the assessment. <BR/>In an interview on 09/21/23 at 1:58 PM with the DON, revealed she oversaw the activities department. She stated the activities assessment was to gather information on a residents ' likes and dislikes, religion, spiritual needs, and work history. She stated the risk of not completing activities according to the assessment could lead to isolation and depression. It could also impede appropriate health quality. She stated for every activity there should be engagement between the staff and the residents. She stated dropping off an activity sheet was not an activity. <BR/>In an interview on 09/21/23 at 2:49 PM with the Administrator, revealed her job was to oversee all the operations at the facility, all departments, all staff, including the activities department. She stated she expected the activities department to ensure that they were following activities with group, in-room activities, and outings. She stated the activities department were responsible for completing activities assessments withing 24 hours. The purpose of those was for staff to get to know the residents better. To get to know their preferences, likes, dislikes, and religious beliefs. She said if the assessments were not completed, it could absolutely be a risk to the resident. The residents' preferences would not be known, and activities would not be for them, since activities were based on preferences. She stated that a word search puzzle that was done as an activity without an activity assessment was not done correctly, since the needs and preferences were unknown. She stated there was a risk to the resident if activities were not done correctly but could not state what it was. <BR/>In a follow-up interview on 09/21/23 at 3:32 PM with the Activities Assistant, revealed today (9/21/2023) was the first time she had gone to talk to Resident#212 about his activity preferences. She said the times before she had only gone into his room to chat. She was unable to provide notes of the dates that she had gone into his room and denied ever putting them on the activity binder. <BR/>Review of facility policy titled Recreational Services Policies and Procedures Manual: Individual Programming dated 12/97 reflected in part .Individual programming ensures that all residents who are unable and/or unwilling to participate in group programs have consistent, goal-oriented, and individualized recreation opportunities .residents who are unable to participate in group activities will be identified through the assessment process .structured individual programs will be developed based on each resident ' s assessed needs .each resident ' s individual program will include interventions which meet the resident ' s assessed social, emotional, physical and cognitive functioning needs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #207) of 3 residents observed for oxygen management. <BR/>-Resident #207 utilized oxygen in his room and did not have an oxygen sign posted outside of the room. <BR/>This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. <BR/>Findings include: <BR/>Review of Resident #207 ' s face sheet dated 09/20/2023 revealed a [AGE] year-old male with an admission date to the facility of 09/01/2023. <BR/>Review of Resident #207 ' s electronic Medical Diagnosis list revealed acute respiratory failure with hypoxia (low oxygen) and tracheostomy (incision on the neck to allow for breathing). <BR/>Review of Resident #207 ' s History and Physical dated 09/08/2023 revealed Resident #207 had a tracheostomy and was to receive oxygen to maintain an oxygen reading greater than 90%. <BR/>Review of Resident #207 ' s MDS assessment dated revealed BIMS assessment was not completed. A BIMS assessment is used to assess the cognition of an individual through a variety of questions. The MDS assessment also revealed Resident #207 was receiving oxygen therapy and confirmed a diagnosis of respiratory failure with a tracheostomy. <BR/>Review of Resident #207 ' s comprehensive care plan dated 09/02/2023 revealed Resident #207 used oxygen therapy routinely or as needed and was at risk for ineffective gas exchange. The goal was for Resident #207 to have no signs or symptoms of hypoxia (low oxygen) through interventions such as administering oxygen therapy per physician's orders and monitor for signs and symptoms of respiratory distress. The care plan also revealed Resident #207 had a tracheostomy and was at risk for potential complications. The goal was for Resident #207 to have clear airways with adequate ventilation through interventions such as providing oxygen, humidity, tracheostomy care, and tubing changes as indicated by physician's orders. <BR/>Review of Resident #207 ' s physician ' s order dated 09/10/2023 revealed Cool mist aerosol management via trach mask with O2 at 3L. <BR/>Observations on 09/18/23 at 8:40 AM of Resident #207 revealed he was receiving oxygen therapy through a trach mask. There was no oxygen sign noted on the outside of Resident #207 ' s room. <BR/>In an interview on 09/18/23 at 11:29 AM with the DON revealed any resident that was receiving oxygen in their room had to have an oxygen posting outside of their room to indicate oxygen was being provided. She stated it was important to have a posting to ensure that everyone knew that oxygen was being used. It was for the visitors, staff and employees to be aware and not have any open flames and to be cautious. <BR/>In an interview on 09/21/2023 at 8:55 AM with LVN C revealed when a new resident arrived to the facility on oxygen or when oxygen was added in their orders, the nursing staff had to post an oxygen sign on the door. The sign served to tell visitors and other staff to be careful and gave them a warning that oxygen therapy was being used in the room. It warned others to not keep or use hot items near the oxygen. <BR/>In an interview on 09/21/23 at 1:54 PM with the DON revealed for residents with oxygen, the staff had to post a magnetic sticker that indicated others of the use of oxygen. It was done to ensure there was no smoking, lip balms or minerals that could be a safety hazard to the resident on oxygen therapy. <BR/>Review of the facility policy titled Oxygen Administration dated 09/14/2014 revealed in part .Oxygen sign remain on room doorway the entire time the O2 source is in the patient room .No smoking oxygen in use sign .Place No Smoking Oxygen in use sign on the doorway .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation.<BR/>1. <BR/>Facility Staff and Dietary Staff were not wearing hair nets or beard guards when entering or working in the kitchen. <BR/>This failure could affect residents by placing them at risk of food borne illness.<BR/>Findings include:<BR/>Observation and interview on 01/30/24 at 11:00 AM, the Maintenance Director was observed going into the kitchen without a hair net or beard guard. The Maintenance Director stated it was okay to go into the kitchen without a hair net or beard guard. In the back in the kitchen Dietary [NAME] did not have his hair net or beard guard on. The Maintenance Director stated the Dietary Manager had in-serviced all of the facility staff of what should be worn when in the kitchen. <BR/>During an interview on 01/30/24 at 11:20 AM with Dietary Cook, he stated a hair net and beard guard had to be worn. The Dietary [NAME] stated he had received training on what to wear while in the kitchen. The Dietary [NAME] stated not having a hair net or beard guard on could have hair falling into the food and contaminate it. The Dietary [NAME] stated the resident could get sick if eaten. <BR/>During an interview on 01/31/24 at 9:36 AM with the Dietary Manager, he stated everything passing the doors in the dining room was to be considered the kitchen. The Dietary Manager stated all dietary staff are to be wearing hairnets and the males would be beard guards if they have a beard. The Dietary Manager stated he had not in-serviced facility staff that were not dietary staff. The Dietary Manager stated there was a sign posted outside of the kitchen door revealing staff had to be wearing a hair net and beard guard. The Dietary Manager stated if they catch facility staff without a hairnet or beard guard, they do tell them to put one on. The Dietary Manager stated all staff have to follow the facility policy to wear hair nets and beard net and the sign posted says the something. The Dietary Manager stated the negative outcome of not wearing a hair net or beard guard would be not following facility policy of personal hygiene in which staff should be kept at all times for the safety of the residents. <BR/>During an interview on 02/01/24 at 11:18 AM with the DON, she stated she considered the kitchen area to be a clean location and sterile. The DON stated once the facility staff breach the kitchen doors in the dining area it was considered the kitchen. The DON stated facility and dietary staff have been trained and in-serviced on what the correct clothing was when entering the kitchen. The DON stated hair nets and beard guards for the males need to be warn. The DON stated the Maintenance Director stated that it was okay to enter the kitchen without hair net nor beard guard was inappropriate response and not okay. The DON stated the purpose of a hair net or beard guard was to prevent hair from falling into the food, floor, and dishes. The DON stated the risk to the residents would be infection. The DON stated it would not be appealing if she found hair in her food. <BR/>During an interview on 02/01/24 at 4:18 PM with the Administrator, she stated once facility staff cross the kitchen door in the dining room into the kitchen was consider being in the kitchen. The Administrator stated all facility staff to include dietary staff have to be wearing a hair net and for the males with facial hair a beard guard. The Administrative stated dietary staff are trained on the proper wear when being in the kitchen. The Administrator stated facility staff were trained on what to wear when entering the kitchen including the hair net and beard guard for males with facial hair. The Administrator stated the regulation says anybody working in the kitchen has to cover their hair. The Administrator stated not wearing a hair net or beard guard could be a risk of contamination. The Administrator stated she would not be okay finding hair in her food, it would be gross. <BR/>Record review of the facility Dietary Personal Hygiene policy dated 11/06 with no year revealed, Dietary employees will maintain proper food safety practices through proper personal hygiene.<BR/>- <BR/>Dietary employees shall wear, hair covering, beard restraint, and clothing that covers body hair.<BR/>- <BR/>All staff entering the kitchen must comply with hair restraints. <BR/>- <BR/>All personnel entering the kitchen to perform job functions shall follow all pertinent rules. <BR/>Record review of the facility Dietary Notice/Aviso Sign not dated revealed, Notice - Hairnets and beard covers required in this area. (Spanish) Aviso - Redecillas para el [NAME] y coberturas para la [NAME] son requeridas en areas de produccion. <BR/>Record review of facility Dietary [NAME] certification dated 08/06/21 revealed, Completion of food safety for handlers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 7 residents (Residents #4) reviewed for resident rights.<BR/>The facility failed to ensure the treatment nurse documented she notified the physician when Resident #4 had a change in skin integrity. <BR/>This deficient practice could place residents at risk of a delay of medical treatment. <BR/>Findings included: <BR/>Record review of Resident #4's admission record dated 02/12/2024 revealed Resident #4 was an [AGE] year-old woman admitted to the facility on [DATE]. <BR/>Record review of Resident #4's History & Physical dated 09/27/23 revealed Resident #4 was an [AGE] year-old female transferred from foster home. Past Medical History; dementia, depression, and insomnia. Skin: No rash. No skin breakdown. <BR/>Record review of Resident #4's MDS assessment dated [DATE] revealed she rarely made herself understood; had short-term memory problems. Her cognitive skills for Daily Decision Making were severely impaired. She required extensive assistance of one person with bed mobility, transfer, and eating. She received skin treatment including pressure reducing device for chair; pressure reduction device for bed, and to receive application of ointments other than to her feet. <BR/>Record review of Resident #4's undated care plan revealed she had an ADL Self-Care Deficit and was at risk for not having her needs met in a timely manner. Interventions were to include Substantial/Maximum assistance with bed mobility, transfers, toileting, and personal hygiene. Interventions for Incontinence were to include Check frequently for wetness and soiling and change as needed, apply barrier cream to skin after incontinent episodes. She was to receive weekly skin checks to monitor for redness, breakdown, or other skin concerns. Any new skin conditions were to be reported to the physician. <BR/>Review of Physician Order Recap dated 02/15/24 for Resident #4 revealed an order to perform a head to toe skin assessment every Saturday for wound prevention/early identification. Staff were to notify the physician of any changes in skin integrity. An order dated 02/12/24 said that Nystatin External Powder 100000 Unit/GM was to be applied to bilateral groin topically every shift for redness to bilateral groin area. The medication recap did not document an order for Hydrogel. <BR/>Record review of Resident #4's Physician Progress Note dated 01/23/24 revealed the resident's chief complaint was for a Comprehensive Monthly Visit. Patient required assistance with all ADLs including feeding. Patient ambulated with wheelchair. History of Present Illness indicated she was alert and oriented x 1. She had diagnoses including dementia, depression, cognitive communication deficits, abnormalities of gait and mobility, and dysphagia. She had no skin breakdown and no skin rash. The assessment/plan included that nursing would manage bowel and bladder. They were to turn the patient every 2 hours while in bed. They were to provide heel protectors while in bed, and wound care was to valuate and treat. <BR/>Review of Resident #4's Nurses Progress Notes revealed 02/09/24 07:39 Skin/Wound Note Text: Head to toe skin assessment performed, no discoloration, no open skin noted, call light within reach. <BR/>Review of Resident #4's Nurses Progress Notes on 02/09/24 revealed that Treatment Nurse had not documented that she reported to physician and/or NP that Resident #4 had a pink rash on groin area. <BR/>Review of Resident #4's Nurses Progress Notes dated 02/12/24 12:53 revealed a new order for Nystatin powder to apply topically Q shift to bilateral groin area for redness. RP notified. <BR/>Record Review Resident #4's Physician Order dated 02/12/24 at 12:38 PM, for Resident #4 written by ADON, documented Nystatin External Powder 100000 units/GM apply to bilateral groin every shift for redness to bilateral groin area. <BR/>Review of Resident #4's Skin Observation Worksheet provided by Treatment Nurse on 02/09/24 revealed [Resident #4] did not have any issues. <BR/>Interview on 02/09/24 at 3:33 PM, the Treatment Nurse stated charge nurses completed weekly skin assessments on all residents and were responsible for immediately reporting any changes in skin integrity to the attending physician and/or Nurse Practitioner. Treatment Nurses were responsible for completing the initial skin assessments on all admissions and for completing weekly skin assessments on all residents that had pressure ulcers, skin rashes, surgical wounds, or skin tears. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately reported any changes in skin integrity to the charge nurses and charge nurses would report to the treatment nurse. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately report any changes in skin integrity to the charge nurses. She reported that the new company would take over the last week of February 2024 and corporate staff had requested that she complete a skin sweep for all residents at the facility. She started the skin sweep in the South Side today [02/09/2024] at 4:00 AM. The Treatment Nurse did not know how often she would be expected to conduct skin sweeps on the residents. <BR/>Observation and interview on 02/09/24 at 4:32 PM with the DON and the Treatment Nurse revealed Resident #4 was lying in bed on her back, awake, and had a pressure relieving mattress. It was reported the resident was confused, incoherent speech, required total assistance of two persons with ADLs, and was incontinent of bowel & bladder. The DON pulled sheets down, noted that the resident was wearing double disposable briefs . The DON stated, CNAs have been trained not to put two briefs on the residents. The DON demonstrated to surveyor disposable briefs were clean and dry. Resident #4 had a light pink rash on the groin area. There was no urine smell, the bed sheets were clean and dry. The Treatment Nurse reported she called the physician today [02/09/2024] to report skin integrity change and was pending return call. <BR/>Interview on 02/12/24 at 11:30 AM, Treatment Nurse reported she got a telephone order on 02/09/24 for Resident #4 to apply Hydrogel to the perineal area every shift. When the surveyor asked the nurse if treatment had been started as ordered, The Treatment Nurse stated No, because I did not enter the new order in the resident's electronic record. The Treatment Nurse stated she had been trained to immediately enter new orders on the computer to ensure treatments were done as ordered. <BR/>Observation and interview 02/12/24 at 12:35 PM, with Treatment Nurse revealed Resident #4's brief was slightly wet with urine. It was noted resident had a pink rash on the groin area. The Treatment Nurse reported that she still had not added the new order for Hydrogel that was given by the physician on 02/09/24 to the resident's electronic record received on 02/09/24 to treat the rash on the pelvic area with Hydrogel because she was busy making rounds with the surveyors. <BR/>Interview 02/12/24 at 11:38 AM, with the DON, in the presence of the Administrator, reported licensed staff had been trained to immediately report changes in condition to the attending physician and/or nurse practitioner and to immediately enter the new physician's order in the resident's electronic record as soon as the order was given. <BR/>Review of the facility's policy on Notification of Changes in condition reviewed/revised 02/10/2021 revealed Policy: To provide guidance on when to communicate acute change in status to MD, NP and responsible party. The facility will immediately consult with the resident's physician of the following: A significant change in the physical status of residents. Policy Explanation and Compliance Guidelines: The facility must document resident assessment(s), interventions, physician and family notification(s) on SBAR, Nurse Progress Note or Telephone Order Form as appropriate. Immediate Physician Notification - the physician is notified immediately and should respond timely (within minutes). Non-Immediate Notification - the physician is notified and there should be a return call within the same day. <BR/>

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1(North Side) of 2 treatment carts checked for cross contamination, and in one (Room F-108) of seven resident rooms checked for cross contamination. <BR/>1. The facility stored a used wound vac (a machine that removes drainage from a wound) in the treatment cart. <BR/>2. The facility had multiple self-adhesive dressing rolls that were not stored in sealed container in the treatment cart. <BR/>3. The facility failed to ensure oral swabs were not stored with external ointments in the treatment cart. <BR/>4. The facility failed to ensure used resident gowns were not placed in garbage cans. <BR/>These failures could result in increased risk of infection to residents. <BR/>Findings include: <BR/>Observation on 02/12/12/2024 at 11:55 AM revealed a yellow cotton hospital gown on top of a trash can inside room F-108. <BR/>In an interview on 12/13/2023 at 9:02 AM, CNA I said she had worked on the F hall on 02/12/2024 and denied putting a hospital gown in a trash can during her shift. She said there was never a reason to but a hospital gown in the trash and that to do so could cause cross contamination since the gown might get mixed with the trash in the can. <BR/>In an interview on 02/13/2024 at 9:22 AM, CNA K revealed if there was no plastic bag available, CNAs might put a used hospital gown on a trash can to avoid contaminating the bed or the floor. She said that around lunch time on 02/13/2024, she was helping CNA A transfer a resident in room F-108 and put a used gown in the trash can because she did not have a plastic bag available. She said that based on her training if she did not have a bag ready, to avoid contamination of the bed or floor with a dirty gown, to put the used gown on the garbage can. She said it was the responsibility of the person she was helping to have the plastic bag ready for use. <BR/>In an interview on 02/13/2024 at 10:06 AM, LVN J revealed there was no reason a CNA should put soiled linen in a trash can. She said CNAs were instructed to carry bags with them in which to put dirty linen for transfer to bins. She said used gowns were not to be put in the trash due to infection control issues. The LVN the gown should not be put on the trash can because it was not known what was in the trash and the gown might get more soiled. The LVN said she knew that placing the gown on the trash created an infection control issue. She stated that most rooms had rolls of plastic bags in them, and that CNAs had never said they were low on bags. She said that if CNAs were low on bags, they knew who to ask for bags to make them available. <BR/>In an interview on 2/13/24 at 11:20 AM, the DON revealed that CNAs should place dirty gowns in a bag. She stated she had been made aware that a CNA had placed a gown in a trash can. The DON stated that if a CNA did not have bag available in which to place a used gown, putting the used gown in the trash can was a better alternative than placing it on the bed or floor for reasons of cross-contamination. The DON stated that there were bags around the facility, and CNAs may have bags in their pockets or may be placed in the halls. She stated if a trash can had trash in it, the CNA could remove the bag with trash in it and put the used gown in the empty trash bag. She said she would prefer that the CNAs put the used gown in an empty trash bag rather than placing a used gown on the floor or bed due to issues related to cross-contamination. <BR/>Observation and interview on 02/12/24 at 11:08 AM, with the Treatment Nurse revealed facility had two treatment carts. An observation of Treatment Cart #1 (North Side) revealed multiple tubes of MediHoney, Santyl, Mupirocin ointment was stored together in a square plastic box in the top drawer. The nurse stated, We have been trained to store the ointments in a sealed plastic bag with the resident's name. We buy MediHoney ointment over the counter, and each resident should have a tube for individual use and stored in a plastic bag with the resident's name. It was observed that the Santyl ointment tubes were not labeled. There was a wound vac stored in the treatment cart in the third drawer. The nurse stated, It belongs to one of the residents, it was discontinued two weeks ago. We stored the wound vac in the treatment cart because we did not know if we had to return it to the vendor. It should not be stored in the cart with the clean supplies. The wound vac was immediately removed by nurse from the treatment cart. The nurse reported there were a couple of ointments still stored in the treatment cart for residents that had been discharged home. The nurses had been trained to give all the medicines including ointments to the residents upon discharge and remove discontinued ointments from treatment carts. It was observed that oral care swabs were stored in the treatment cart with gauze bandages packets and rolls of self-adherent wrap. The self-adherent wrap was not stored in sealed bags. <BR/>Record review of the facility's policy Infection Prevention and Control Program dated 10/24/2022 revealed that the facility established and maintained an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. All staff were responsible for following all policies and procedures related to the program. Direct care staff shall handle, store, and transport linens to prevent the spread of infection. Soiled linen shall be collected at the bedside and placed in a linen bag. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 1 of 7 residents (Residents #4) reviewed for resident rights, in that: <BR/>The facility failed to ensure the treatment nurse notified the physician when Resident #4 had a change in skin integrity. <BR/>This deficient practice could place residents at risk of a delay of medical treatment. <BR/>Findings included: <BR/>Record review of Resident #4's admission record dated 02/12/2024 revealed Resident #4 was an [AGE] year-old woman admitted to the facility on [DATE]. <BR/>Record review of Resident #4's History & Physical dated 09/27/23 revealed Resident #4 was an [AGE] year-old female transferred from foster home. Past Medical History; dementia, depression, and insomnia. Skin: No rash. No skin breakdown. <BR/>Record review of Resident #4's MDS assessment dated [DATE] revealed she rarely made herself understood; had short-term memory problems. Her cognitive skills for Daily Decision Making were severely impaired. She required extensive assistance of one person with bed mobility, transfer, and eating. She received skin treatment including pressure reducing device for chair; pressure reduction device for bed, and to receive application of ointments other than to her feet. <BR/>Record review of Resident #4's undated care plan revealed she had an ADL Self-Care Deficit and was at risk for not having her needs met in a timely manner. Interventions were to include Substantial/Maximum assistance with bed mobility, transfers, toileting, and personal hygiene. Interventions for Incontinence were to include Check frequently for wetness and soiling and change as needed, apply barrier cream to skin after incontinent episodes. She was to receive weekly skin checks to monitor for redness, breakdown, or other skin concerns. Any new skin conditions were to be reported to the physician. <BR/>Review of Physician Order Recap dated 02/15/24 for Resident #4 revealed an order to perform a head to toe skin assessment every Saturday for wound prevention/early identification. Staff were to notify the physician of any changes in skin integrity. An order dated 02/12/24 said that Nystatin External Powder 100000 Unit/GM was to be applied to bilateral groin topically every shift for redness to bilateral groin area. The medication recap did not document an order for Hydrogel. <BR/>Record review of Resident #4's Physician Progress Note dated 01/23/24 revealed the resident's chief complaint was for a Comprehensive Monthly Visit. Patient required assistance with all ADLs including feeding. Patient ambulated with wheelchair. History of Present Illness indicated she was alert and oriented x 1. She had diagnoses including dementia, depression, cognitive communication deficits, abnormalities of gait and mobility, and dysphagia. She had no skin breakdown and no skin rash. The assessment/plan included that nursing would manage bowel and bladder. They were to turn the patient every 2 hours while in bed. They were to provide heel protectors while in bed, and wound care was to valuate and treat. <BR/>Review of Resident #4's Nurses Progress Notes revealed 02/09/24 07:39 Skin/Wound Note Text: Head to toe skin assessment performed, no discoloration, no open skin noted, call light within reach. <BR/>Review of Resident #4's Nurses Progress Notes on 02/09/24 revealed that Treatment Nurse had not documented that she reported to physician and/or NP that Resident #4 had a pink rash on groin area. <BR/>Review of Resident #4's Nurses Progress Notes dated 02/12/24 12:53 revealed a new order for Nystatin powder to apply topically Q shift to bilateral groin area for redness. RP notified. <BR/>Record Review Resident #4's Physician Order dated 02/12/24 at 12:38 PM, for Resident #4 written by ADON, documented Nystatin External Powder 100000 units/GM apply to bilateral groin every shift for redness to bilateral groin area. <BR/>Review of Resident #4's Skin Observation Worksheet provided by Treatment Nurse on 02/09/24 revealed [Resident #4] did not have any issues. <BR/>Interview on 02/09/24 at 3:33 PM, the Treatment Nurse stated charge nurses completed weekly skin assessments on all residents and were responsible for immediately reporting any changes in skin integrity to the attending physician and/or Nurse Practitioner. Treatment Nurses were responsible for completing the initial skin assessments on all admissions and for completing weekly skin assessments on all residents that had pressure ulcers, skin rashes, surgical wounds, or skin tears. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately reported any changes in skin integrity to the charge nurses and charge nurses would report to the treatment nurse. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately report any changes in skin integrity to the charge nurses. She reported that the new company would take over the last week of February 2024 and corporate staff had requested that she complete a skin sweep for all residents at the facility. She started the skin sweep in the South Side today [02/09/2024] at 4:00 AM. The Treatment Nurse did not know how often she would be expected to conduct skin sweeps on the residents. <BR/>Observation and interview on 02/09/24 at 4:32 PM with the DON and the Treatment Nurse revealed Resident #4 was lying in bed on her back, awake, and had a pressure relieving mattress. It was reported the resident was confused, incoherent speech, required total assistance of two persons with ADLs, and was incontinent of bowel & bladder. The DON pulled sheets down, noted that the resident was wearing double disposable briefs . The DON stated, CNAs have been trained not to put two briefs on the residents. The DON demonstrated to surveyor disposable briefs were clean and dry. Resident #4 had a light pink rash on the groin area. There was no urine smell, the bed sheets were clean and dry. The Treatment Nurse reported she called the physician today [02/09/2024] to report skin integrity change and was pending return call. <BR/>Interview on 02/12/24 at 11:30 AM, Treatment Nurse reported she got a telephone order on 02/09/24 for Resident #4 to apply Hydrogel to the perineal area every shift. When the surveyor asked the nurse if treatment had been started as ordered, The Treatment Nurse stated No, because I did not enter the new order in the resident's electronic record. The Treatment Nurse stated she had been trained to immediately enter new orders on the computer to ensure treatments were done as ordered. <BR/>Observation and interview 02/12/24 at 12:35 PM, with Treatment Nurse revealed Resident #4's brief was slightly wet with urine. It was noted resident had a pink rash on the groin area. The Treatment Nurse reported that she still had not added the new order for Hydrogel that was given by the physician on 02/09/24 to the resident's electronic record received on 02/09/24 to treat the rash on the pelvic area with Hydrogel because she was busy making rounds with the surveyors. <BR/>Interview 02/12/24 at 11:38 AM, with the DON, in the presence of the Administrator, reported licensed staff had been trained to immediately report changes in condition to the attending physician and/or nurse practitioner and to immediately enter the new physician's order in the resident's electronic record as soon as the order was given. <BR/>Review of the facility's policy on Notification of Changes in condition reviewed/revised 02/10/2021 revealed Policy: To provide guidance on when to communicate acute change in status to MD, NP and responsible party. The facility will immediately consult with the resident's physician of the following: A significant change in the physical status of residents. Policy Explanation and Compliance Guidelines: The facility must document resident assessment(s), interventions, physician and family notification(s) on SBAR, Nurse Progress Note or Telephone Order Form as appropriate. Immediate Physician Notification - the physician is notified immediately and should respond timely (within minutes). Non-Immediate Notification - the physician is notified and there should be a return call within the same day. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 7 residents (Residents #4) reviewed for resident rights.<BR/>The facility failed to ensure the treatment nurse documented she notified the physician when Resident #4 had a change in skin integrity. <BR/>This deficient practice could place residents at risk of a delay of medical treatment. <BR/>Findings included: <BR/>Record review of Resident #4's admission record dated 02/12/2024 revealed Resident #4 was an [AGE] year-old woman admitted to the facility on [DATE]. <BR/>Record review of Resident #4's History & Physical dated 09/27/23 revealed Resident #4 was an [AGE] year-old female transferred from foster home. Past Medical History; dementia, depression, and insomnia. Skin: No rash. No skin breakdown. <BR/>Record review of Resident #4's MDS assessment dated [DATE] revealed she rarely made herself understood; had short-term memory problems. Her cognitive skills for Daily Decision Making were severely impaired. She required extensive assistance of one person with bed mobility, transfer, and eating. She received skin treatment including pressure reducing device for chair; pressure reduction device for bed, and to receive application of ointments other than to her feet. <BR/>Record review of Resident #4's undated care plan revealed she had an ADL Self-Care Deficit and was at risk for not having her needs met in a timely manner. Interventions were to include Substantial/Maximum assistance with bed mobility, transfers, toileting, and personal hygiene. Interventions for Incontinence were to include Check frequently for wetness and soiling and change as needed, apply barrier cream to skin after incontinent episodes. She was to receive weekly skin checks to monitor for redness, breakdown, or other skin concerns. Any new skin conditions were to be reported to the physician. <BR/>Review of Physician Order Recap dated 02/15/24 for Resident #4 revealed an order to perform a head to toe skin assessment every Saturday for wound prevention/early identification. Staff were to notify the physician of any changes in skin integrity. An order dated 02/12/24 said that Nystatin External Powder 100000 Unit/GM was to be applied to bilateral groin topically every shift for redness to bilateral groin area. The medication recap did not document an order for Hydrogel. <BR/>Record review of Resident #4's Physician Progress Note dated 01/23/24 revealed the resident's chief complaint was for a Comprehensive Monthly Visit. Patient required assistance with all ADLs including feeding. Patient ambulated with wheelchair. History of Present Illness indicated she was alert and oriented x 1. She had diagnoses including dementia, depression, cognitive communication deficits, abnormalities of gait and mobility, and dysphagia. She had no skin breakdown and no skin rash. The assessment/plan included that nursing would manage bowel and bladder. They were to turn the patient every 2 hours while in bed. They were to provide heel protectors while in bed, and wound care was to valuate and treat. <BR/>Review of Resident #4's Nurses Progress Notes revealed 02/09/24 07:39 Skin/Wound Note Text: Head to toe skin assessment performed, no discoloration, no open skin noted, call light within reach. <BR/>Review of Resident #4's Nurses Progress Notes on 02/09/24 revealed that Treatment Nurse had not documented that she reported to physician and/or NP that Resident #4 had a pink rash on groin area. <BR/>Review of Resident #4's Nurses Progress Notes dated 02/12/24 12:53 revealed a new order for Nystatin powder to apply topically Q shift to bilateral groin area for redness. RP notified. <BR/>Record Review Resident #4's Physician Order dated 02/12/24 at 12:38 PM, for Resident #4 written by ADON, documented Nystatin External Powder 100000 units/GM apply to bilateral groin every shift for redness to bilateral groin area. <BR/>Review of Resident #4's Skin Observation Worksheet provided by Treatment Nurse on 02/09/24 revealed [Resident #4] did not have any issues. <BR/>Interview on 02/09/24 at 3:33 PM, the Treatment Nurse stated charge nurses completed weekly skin assessments on all residents and were responsible for immediately reporting any changes in skin integrity to the attending physician and/or Nurse Practitioner. Treatment Nurses were responsible for completing the initial skin assessments on all admissions and for completing weekly skin assessments on all residents that had pressure ulcers, skin rashes, surgical wounds, or skin tears. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately reported any changes in skin integrity to the charge nurses and charge nurses would report to the treatment nurse. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately report any changes in skin integrity to the charge nurses. She reported that the new company would take over the last week of February 2024 and corporate staff had requested that she complete a skin sweep for all residents at the facility. She started the skin sweep in the South Side today [02/09/2024] at 4:00 AM. The Treatment Nurse did not know how often she would be expected to conduct skin sweeps on the residents. <BR/>Observation and interview on 02/09/24 at 4:32 PM with the DON and the Treatment Nurse revealed Resident #4 was lying in bed on her back, awake, and had a pressure relieving mattress. It was reported the resident was confused, incoherent speech, required total assistance of two persons with ADLs, and was incontinent of bowel & bladder. The DON pulled sheets down, noted that the resident was wearing double disposable briefs . The DON stated, CNAs have been trained not to put two briefs on the residents. The DON demonstrated to surveyor disposable briefs were clean and dry. Resident #4 had a light pink rash on the groin area. There was no urine smell, the bed sheets were clean and dry. The Treatment Nurse reported she called the physician today [02/09/2024] to report skin integrity change and was pending return call. <BR/>Interview on 02/12/24 at 11:30 AM, Treatment Nurse reported she got a telephone order on 02/09/24 for Resident #4 to apply Hydrogel to the perineal area every shift. When the surveyor asked the nurse if treatment had been started as ordered, The Treatment Nurse stated No, because I did not enter the new order in the resident's electronic record. The Treatment Nurse stated she had been trained to immediately enter new orders on the computer to ensure treatments were done as ordered. <BR/>Observation and interview 02/12/24 at 12:35 PM, with Treatment Nurse revealed Resident #4's brief was slightly wet with urine. It was noted resident had a pink rash on the groin area. The Treatment Nurse reported that she still had not added the new order for Hydrogel that was given by the physician on 02/09/24 to the resident's electronic record received on 02/09/24 to treat the rash on the pelvic area with Hydrogel because she was busy making rounds with the surveyors. <BR/>Interview 02/12/24 at 11:38 AM, with the DON, in the presence of the Administrator, reported licensed staff had been trained to immediately report changes in condition to the attending physician and/or nurse practitioner and to immediately enter the new physician's order in the resident's electronic record as soon as the order was given. <BR/>Review of the facility's policy on Notification of Changes in condition reviewed/revised 02/10/2021 revealed Policy: To provide guidance on when to communicate acute change in status to MD, NP and responsible party. The facility will immediately consult with the resident's physician of the following: A significant change in the physical status of residents. Policy Explanation and Compliance Guidelines: The facility must document resident assessment(s), interventions, physician and family notification(s) on SBAR, Nurse Progress Note or Telephone Order Form as appropriate. Immediate Physician Notification - the physician is notified immediately and should respond timely (within minutes). Non-Immediate Notification - the physician is notified and there should be a return call within the same day. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 1 of 8 residents (Resident #1) reviewed for accommodation of needs:<BR/>-Residents #1's push button call system was not adequate to meet the needs of the residents who required padded call light button.<BR/>-Resident #1's call system was not placed within reach of the resident. <BR/>This failure could place residents at risk of not being able to have their needs met.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 09/08/2023, revealed a [AGE] year-old male, with a readmission date of 05/03/2023 and initially admitted to the facility on [DATE]. Resident #1's diagnoses included: anoxic brain damage (a process that begins with the cessation of cerebral blood flow to brain tissue), tracheostomy status (surgically created hole in windpipe that provides an alternative airway for breathing), hypertension (high blood pressure), dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), seizures (a sudden uncontrolled burst of electrical activity in the brain), and pain (physical suffering or discomfort caused by illness or injury).<BR/>Record review of Resident #1's MDS quarterly assessment dated [DATE] revealed BIMS score of 0, indicating he was severely cognitive impaired. Section G. revealed Resident #1 required total dependence with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. <BR/>Record review of Resident #1's care plan dated 09/08/2023, revealed Resident #1 had focus area that included: Focused area Communication (Impaired): Resident #1 has a communication problem related to rarely/never understood/understands related to anoxic brain injury. Part of the interventions included: Ensure/provide a safe environment: Call light in reach. Another focus area included: ADLs: Resident #1 utilizes padded call light, placed on his right side of head. Part of the interventions included: Encourage resident to use call light to call for assistance before attempting any activities of daily living (ADLs) that resident cannot do independently. Another focus area included: Falls: Resident #1 has the potential for falls related to cognitive impairment, antihypertensive drug use, psychoactive drug use. Part of the interventions included: Place the resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 09/08/2023 at 3:00 p.m., in Resident #1's room revealed the call light button was not visible. Further observation revealed Resident #1's unpadded call light button was on the floor under the resident's bed. Resident #1 did not respond to questions about his call button and whether he was able to reach the button. <BR/>During an interview on 09/08/2023 at 3:02 p.m., the ADON said Resident #1's call button was out of his reach being under the bed. The ADON said that CNAs were making rounds but does not know how long the call button had been out of reach of Resident #1. The ADON said Resident #1 could not use the push button call button and should have had a padded call button. The ADON said she did not know why Resident #1 had a push button call light and would have it changed out immediately. The ADON said the risk to Resident #1 of not having the proper call button and button being out of reach was his needs may not be met. <BR/>Record review of Call Light Response policy dated 2/10/21 revealed 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. 3. Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system. 4. Special accommodations will be identified on the resident's person-centered plan of care and provided accordingly. (Examples include touch pads, larger buttons, bright colors, etc.) 5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Residents #1) reviewed for assistance with ADLs in that: <BR/>-Resident #1 had long fingernails that were dirty and had a black substance underneath them.<BR/>This failure could place residents who required assistance with showering and maintaining good personal hygiene at risk for not receiving care and services to meet their needs and avoid ADL decline.<BR/>Findings include: <BR/>Record review of Resident #1's face sheet dated 09/08/2023, revealed a [AGE] year-old male, with a readmission date of 05/03/2023 and initially admitted to the facility on [DATE]. Resident #1's diagnoses included: anoxic brain damage (a process that begins with the cessation of cerebral blood flow to brain tissue), tracheostomy status (surgically created hole in windpipe that provides an alternative airway for breathing), hypertension (high blood pressure), dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), seizures (a sudden uncontrolled burst of electrical activity in the brain), and pain (physical suffering or discomfort caused by illness or injury).<BR/>Record review of Resident #1's MDS quarterly assessment dated [DATE] revealed BIMS score of 0, indicating he was severely cognitively impaired. Section G. revealed Resident #1 required total dependence with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing.<BR/>Record review of Resident #1's care plan dated 09/08/2023, revealed Resident #1 had focus area that included: ADLs: Resident #1 has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Part of the interventions included: Provide .nail care per schedule and when needed.<BR/>Record review of Resident #1's Order Summary dated 09/08/2023, revealed Resident #1 had an order with start date of 05/10/2023 that read Licensed nurse to perform nail care, every day shift, every Wednesday for diabetic care.<BR/>Record review of Resident 1's MAR for the month of September 2023, revealed on 09/06/2023, staff initialed that licensed nurse performed nail care.<BR/>Observation and interview on 09/08/2023 at 3:00 p.m., Resident #1 was lying on a bed. Resident #1's fingernails on both hands were long (approximately 1 &frac12; cm long) with sharp edges and his index finger of left hand with black substance under the nail. Resident #1 did not respond to questions about who cuts/files his nails or when the last time his nails were trimmed/filed. <BR/>During an interview on 09/08/2023 at 3:02 p.m., the ADON looked at Resident #1's fingernails and said his nails were long and will have nurse check nails. The ADON said she did not know the order for when nurse was supposed to groom nails. The ADON said the nurses were responsible for cutting/trimming/filing Resident #1's fingernails. The ADON said the risk of not providing nail care was the resident could scratch himself. <BR/>Record review of the facility's Nail Care policy dated 02/10/2020, reads in part Purpose: to provide for personal hygiene needs and prevent infection. Note: Precautions should be used when trimming nails of a resident with diabetes and should be done by a Licensed Nurse or Physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #8) of 3 residents reviewed for catheter care. <BR/>The facility failed to ensure Residents #8s catheter leg strap was in place to secure the catheter. <BR/>This failure could place residents with foley catheters at risk of catheter pulling causing pain. <BR/>Findings included:<BR/>Record review of Resident #8's face sheet dated 1/14/25 revealed a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of retention of urine and neuromuscular dysfunction of bladder. <BR/>Record review of Resident #8's significant change MDS assessment dated [DATE] revealed a BIMS score of 15, her cognition was intact and had and had indwelling catheter. <BR/>Record review of Resident #8's physician order dated 10/16/24 revealed ensure catheter strap in place and holding, every shift change as needed. <BR/>Record review of Resident #8's care plan dated 11/19/24 revealed a focus area for [Resident #8] has a Indwelling Catheter with goal of will remain free from catheter-related trauma through review date and interventions that included ensure tubing is anchored to the residents leg or linens so that tubing is not pulling on the urethra. <BR/>In an observation and interview on 1/14/25 at 11:26 am, Resident # 8 was alert and oriented to place, time, and event. While in bed, it was observed that Resident # 8's urinary catheter was positioned below the bladder and hanging over the bed, with no leg strap secured. Resident # 8 stated that the catheter strap had not been in place for two days and that she had reported the issue, though she could not recall to whom or when. Resident # 8 stated that the lack of a secured strap caused discomfort when moving, as it allowed the catheter to shift.<BR/>In an interview on 1/14/25 at 11:35 am, RN B stated that it was the responsibility of nursing aides and nurses to ensure urinary catheters were secured with leg straps and checked at least every two hours or as needed. RN B stated she had not received any communication indicating that Resident #8's catheter strap was not secured. RN B stated that she had spoken to Resident #8 that morning and asked how she was doing, but the resident had not mentioned the issue. RN B stated that during her check that morning, she only ensured the urinary catheter bag was off the floor and in a privacy bag, and she did not verify if the leg strap was in place. RN B stated that checking for the leg strap was part of her assessment, but she had forgotten to do so. RN B stated that the risk of not securing the leg strap included the catheter being tugged or pulled, potentially causing injury or trauma to the urethra. RN B stated she had received training on urinary catheter to include ensuring catheter strap was secured upon hire. <BR/>In an interview on 1/14/25 at 11:49 am, CNA A stated that she had received training on urinary catheter care upon hire and at least twice a year. CNA A explained that it was the CNA's responsibility to ensure the leg strap was secured at all times, with checks performed at least every two hours or as needed. CNA A noted that Resident #8 was verbal and able to communicate her needs. CNA A clarified that she was not the CNA assigned to the resident but had assisted with perineal care. CNA A stated that the risk of an unsecured catheter included possible discomfort, as she had been told that catheter movement when not secured could cause residents some pain.<BR/>In an interview on 1/14/25 at 3:00 pm, the DON stated that all staff, including CNAs, nurses, and nurse managers, were required to conduct rounds regularly. The DON stated nurse managers were expected to perform daily rounds, while CNAs and nurses were required to check on residents constantly and as needed throughout the day. The DON stated that nurses were expected to check catheter placement during their rounds, not just the privacy bags. The DON stated that nurses oversee the CNAs, while nurse managers oversee the nurses. The DON stated that failing to secure the catheter properly increases the risk of it being pulled out accidentally.<BR/>In an interview on 1/14/25 at 4:01 pm, the Administrator referred the question to the DON.<BR/>Record review of the facility's Cather Care policy dated 02/13/2007 read in part hold catheter tubing to one side and support against leg to avoid traction or unnecessary movement of the catheter while washing perineum.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must (i) Be developed within 48 hours of a resident's admission for 1 of 5 (Resident #2) residents reviewed for baseline care plans.<BR/>The facility failed to ensure a baseline care plan was developed with 48 hours for Resident #2 readmission on [DATE] and 8/2/23. <BR/>This failure could have placed newly admitted residents at risk of not receiving the care and services and continuity of care.<BR/>Findings include: <BR/>Record review of Resident #2's face sheet dated 8/22/23 revealed an [AGE] year-old female who was readmitted on [DATE] with diagnoses of dementia and anorexia. <BR/>Record review of Resident #2's MDS quarterly assessment dated [DATE] revealed a BIMS score of 3, she was severely cognitive impaired. Skin condition section revealed she had an unstageable pressure ulcer. <BR/>Record review of Resident #2's clinical record from July 2023 to August 2023 revealed a baseline care plan had not been created for stage 2 pressure ulcer and/or stage 4 pressure ulcer to coccyx. <BR/>Record review of Resident #2's progress note dated 07/07/2023 written by Wound Care Nurse revealed a head-to-toe assessment was completed post hospitalization (returned on 07/06/2023) and stage 2 pressure ulcer was noted to sacral area. <BR/>Record review of Resident #2's physician order dated 07/10/23 revealed wound care to stage 2 pressure wound to sacrum, cleanse area with wound cleanser, pat dry, add collagen powder, place calcium alginate with silver, cover with sacrum foam bordered dressing to area every day.<BR/>Record review of Resident #2's TAR dated July 2023 revealed wound care to stage 2 pressure wound to sacrum, cleanse area with wound cleanser, pat dry, add collagen powder, place calcium alginate with silver, cover with sacrum foam bordered dressing to area every day. Wound care was administered 07/10/2023 thru 07/25/2023 when she was transferred to hospital.<BR/>Record review of Resident #2's progress note dated 08/03/2023 written by Wound Care Nurse revealed a head-to-toe assessment was completed post hospitalization stage 4 pressure ulcer measuring approx. 3.5 x 3cm was noted to sacral area.<BR/>Record review of Resident #2's physician order dated 08/04/2023 revealed wound care to sacral area, cleanse with normal saline, pat dry, apply Santyl ointment, Silicone gauze every shift.<BR/>Record review of Resident #2's TAR dated August 2023 revealed wound care to sacral area, cleanse with normal saline, pat dry, apply Santyl ointment. Silicone gauze every shift. Wound care was administered from 08/04/2023 thru 08/20/23 when she was transferred to hospital. <BR/>Record review of Resident #2's local hospital emergency provider report dated 8/20/23 revealed Resident #2 was previously admitted (07/25/2023) for pneumonia and was discharged back to the nursing home on August 3, 2023. Resident #2's RP is concerned about the large sacral wound that she has. Upon review of her last admission [DATE]) it was documented that the patient arrived at the hospital with stage 2 sacral ulcer. This hospital record reflect Resident #2 was on 07/25/2023 to the hospital with stage 2 sacral ulcer and was discharged [DATE] from hospital back to nursing home with a stage 4 sacral ulcer. <BR/>During interview on 08/24/2023 at 10:32 am, ADON stated admitting nurses were responsible of developing a baseline care plan within 48 hours of admission. ADON referred to Resident #2 electronic records and stated she could not find a baseline care plan for Resident #2 stage 2 sacral wound post return from hospitalization on 07/06/2023 and did not see a baseline care plan Resident #2 stage 4 sacral wound post return from hospitalization on 08/02/2023. ADON stated risks included lack of sacral wound monitoring that could result in not repositioning as needed and wound worsening or infection. <BR/>During interview on 08/24/2023 at 2:57 pm, LVN A state she was the admitting nurse for Resident #2 readmission from hospital on [DATE]. LVN A stated admitting nurses were responsible of developing a baseline care plan. She stated on readmissions she did not get an alert from the electronic system to create a baseline care plan. LVN A stated she should have created a baseline care plan for Resident #2 stage 4 sacral ulcer. LVN A stated there was no risk to Resident #2 by not developing baseline care plan addressing sacral wound because she reported to CNAs and nurses. <BR/>During interview on 08/24/2023 at 3:19 pm, CNA B stated she had worked with Resident #2 when she returned from last hospitalization and was aware she had a wound on her back. CNA B stated she received report from a charge nurse who instructed to reposition every 2 hours and as needed during perineal care. <BR/>During interview on 08/24/2023 at 3:31 pm, CNA C stated she had worked with Resident #2 when she returned from last hospitalization and was aware she had a wound on her back. CNA C stated she received report from a charge nurse who instructed to reposition every 2 hours and as needed during perineal care. <BR/>During interview on 08/24/2023 at 3:37 pm, CNA D stated she had worked with Resident #2 when she returned from last hospitalization and was aware she had a wound on her back. CNA D stated she received report from a charge nurse who instructed to reposition every 2 hours and as needed during perineal care. <BR/>During interview on 08/24/2023 at 3:43 pm, the DON stated admitting nurses were responsible of creating a baseline care plan for new admissions and readmissions. DON stated it was expected for baseline care plans to be created within 48 hours of admission. DON stated risks included failure of sacral wound monitoring that could result in wound worsening or infection. DON stated nursing administration was responsible for checking care plans daily and had overlooked Resident #2 care plan that did not address her stage 4 sacral ulcer. <BR/>Record review of Baseline Care Plans dated 05/13/2021 revealed Resident person-centered baseline care plans and implemented for new admission and readmission residents. Baseline care plans are developed and implemented within 48 hours of a resident new admission and/or readmission. The baseline care plan includes measurable objectives to address the residents immediate medical, clinical, functional, mental, and psychosocial person-centered needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #4 & #3) of three residents reviewed for quality of care. <BR/>The facility failed to ensure treatment nurse transcribed the physician treatment order to treat Resident #4's rash on groin area. <BR/>The facility failed to identify and treat Resident #3's rash and behavior of scratching. <BR/>This failure placed residents at risk for delays in treatment, developing infections and deterioration of skin condition. <BR/>Findings included: <BR/>Resident #4<BR/>Record review of Resident #4's admission record dated 02/12/2024 revealed Resident #4 was an [AGE] year-old woman admitted to the facility on [DATE]. <BR/>Record review of Resident #4's History & Physical dated 09/27/23 revealed Resident #4 was an [AGE] year-old female transferred from foster home. Past Medical History; dementia, depression, and insomnia. Skin: No rash. No skin breakdown. <BR/>Record review of Resident #4's MDS assessment dated [DATE] revealed she rarely made herself understood; had short-term memory problems. Her cognitive skills for Daily Decision Making were severely impaired. She required extensive assistance of one person with bed mobility, transfer, and eating. She received skin treatment including pressure reducing device for chair; pressure reduction device for bed, and to receive application of ointments other than to her feet. <BR/>Record review of Resident #4's undated care plan revealed she had an ADL Self-Care Deficit and was at risk for not having her needs met in a timely manner. Interventions were to include Substantial/Maximum assistance with bed mobility, transfers, toileting, and personal hygiene. Interventions for Incontinence were to include Check frequently for wetness and soiling and change as needed, apply barrier cream to skin after incontinent episodes. She was to receive weekly skin checks to monitor for redness, breakdown, or other skin concerns. Any new skin conditions were to be reported to the physician. <BR/>Review of Physician Order Recap dated 02/15/24 for Resident #4 revealed an order to perform a head to toe skin assessment every Saturday for wound prevention/early identification. Staff were to notify the physician of any changes in skin integrity. An order dated 02/12/24 said that Nystatin External Powder 100000 Unit/GM was to be applied to bilateral groin topically every shift for redness to bilateral groin area. The medication recap did not document an order for Hydrogel. <BR/>Record review of Resident #4's Physician Progress Note dated 01/23/24 revealed the resident's chief complaint was for a Comprehensive Monthly Visit. Patient required assistance with all ADLs including feeding. Patient ambulated with wheelchair. History of Present Illness indicated she was alert and oriented x 1. She had diagnoses including dementia, depression, cognitive communication deficits, abnormalities of gait and mobility, and dysphagia. She had no skin breakdown and no skin rash. The assessment/plan included that nursing would manage bowel and bladder. They were to turn the patient every 2 hours while in bed. They were to provide heel protectors while in bed, and wound care was to valuate and treat. <BR/>Review of Resident #4's Nurses Progress Notes revealed 02/09/24 07:39 Skin/Wound Note Text: Head to toe skin assessment performed, no discoloration, no open skin noted, call light within reach. <BR/>Review of Resident #4's Nurses Progress Notes on 02/09/24 revealed that Treatment Nurse had not documented that she reported to physician and/or NP that Resident #4 had a pink rash on groin area. <BR/>Review of Resident #4's Nurses Progress Notes dated 02/12/24 12:53 revealed a new order for Nystatin powder to apply topically Q shift to bilateral groin area for redness. RP notified. <BR/>Record Review Resident #4's Physician Order dated 02/12/24 at 12:38 PM, for Resident #4 written by ADON, documented Nystatin External Powder 100000 units/GM apply to bilateral groin every shift for redness to bilateral groin area. <BR/>Review of Resident #4's Skin Observation Worksheet provided by Treatment Nurse on 02/09/24 revealed [Resident #4] did not have any issues. <BR/>Interview on 02/09/24 at 3:33 PM, the Treatment Nurse stated charge nurses completed weekly skin assessments on all residents and were responsible for immediately reporting any changes in skin integrity to the attending physician and/or Nurse Practitioner. Treatment Nurses were responsible for completing the initial skin assessments on all admissions and for completing weekly skin assessments on all residents that had pressure ulcers, skin rashes, surgical wounds, or skin tears. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately reported any changes in skin integrity to the charge nurses and charge nurses would report to the treatment nurse. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately report any changes in skin integrity to the charge nurses. She reported that the new company would take over the last week of February 2024 and corporate staff had requested that she complete a skin sweep for all residents at the facility. She started the skin sweep in the South Side today [02/09/2024] at 4:00 AM. The Treatment Nurse did not know how often she would be expected to conduct skin sweeps on the residents. <BR/>Observation and interview on 02/09/24 at 4:32 PM with the DON and the Treatment Nurse revealed Resident #4 was lying in bed on her back, awake, and had a pressure relieving mattress. It was reported the resident was confused, incoherent speech, required total assistance of two persons with ADLs, and was incontinent of bowel & bladder. The DON pulled sheets down, noted that the resident was wearing double disposable briefs . The DON stated, CNAs have been trained not to put two briefs on the residents. The DON demonstrated to surveyor disposable briefs were clean and dry. Resident #4 had a light pink rash on the groin area. There was no urine smell, the bed sheets were clean and dry. The Treatment Nurse reported she called the physician today [02/09/2024] to report skin integrity change and was pending return call. <BR/>Interview on 02/12/24 at 11:30 AM, Treatment Nurse reported she got a telephone order on 02/09/24 for Resident #4 to apply Hydrogel to the perineal area every shift. When the surveyor asked the nurse if treatment had been started as ordered, The Treatment Nurse stated No, because I did not enter the new order in the resident's electronic record. The Treatment Nurse stated she had been trained to immediately enter new orders on the computer to ensure treatments were done as ordered. <BR/>Observation and interview 02/12/24 at 12:35 PM, with Treatment Nurse revealed Resident #4's brief was slightly wet with urine. It was noted resident had a pink rash on the groin area. The Treatment Nurse reported that she still had not added the new order for Hydrogel that was given by the physician on 02/09/24 to the resident's electronic record received on 02/09/24 to treat the rash on the pelvic area with Hydrogel because she was busy making rounds with the surveyors. <BR/>Interview 02/12/24 at 11:38 AM, with the DON, in the presence of the Administrator, reported licensed staff had been trained to immediately report changes in condition to the attending physician and/or nurse practitioner and to immediately enter the new physician's order in the resident's electronic record as soon as the order was given. <BR/>Review of the facility's policy on Notification of Changes in condition reviewed/revised 02/10/2021 revealed Policy: To provide guidance on when to communicate acute change in status to MD, NP and responsible party. The facility will immediately consult with the resident's physician of the following: A significant change in the physical status of residents. Policy Explanation and Compliance Guidelines: The facility must document resident assessment(s), interventions, physician and family notification(s) on SBAR, Nurse Progress Note or Telephone Order Form as appropriate. Immediate Physician Notification - the physician is notified immediately and should respond timely (within minutes). Non-Immediate Notification - the physician is notified and there should be a return call within the same day. <BR/>Resident #3<BR/>Record review of Resident #3's face sheet dated 02/15/2024 revealed she was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. <BR/>Record review of Resident #3's History and Physical (H&P) dated 1/10/2024 revealed she was nonverbal and had diagnoses including Type 2 Diabetes mellitus, high blood pressure, and cerebral infarction (stroke). She was bed-bound and was non-verbal. She had no issues with her skin. The History and Physical stated right ulcer but did not specify the type or where the ulcer was located. The plan included to turn patient every 2 hours while in bed and that wound care was to evaluate and treat. <BR/>Record review of Resident #3's discharge MDS assessment dated [DATE] revealed she was nonverbal and was assessed by staff regarding her mental status. She had moderately impaired skills for daily decision making and had poor short- term memory. She was dependent on staff for toileting hygiene. She had behavioral symptoms not directed toward others. The MDS did not specify what these behaviors were. She was always incontinent of bladder and bowel. <BR/>Record review of Resident #3's Care Plan dated 06/19/2023 revealed she was incontinent of bowel and bladder. The goal was that she was to remain free from skin breakdown due to incontinence and brief use through the next review date (revised 01/26/2024). Interventions included weekly skin checks to monitor for redness, circulatory problems, breakdown, or other skin concerns and to report any new skin conditions to the physician. There was no care plan that addressed her behavior of scratching her inguinal area (where the thigh meets the front of the lower body) and abdominal fold. <BR/>Record review of Resident #3's Progress note dated 02/14/2024 revealed that a skin assessment revealed an inguinal rash (a rash where the thigh meets the front of the lower body). <BR/>Record review of progress notes for Resident #3 dated 01/15/2024 through 2/14/2024 revealed a Skin/Wound note dated 02/09/2024 that the resident had an inguinal rash. There were no notes regarding scratches. <BR/>Record review of Resident #3's physician's orders dated 2/12/2024 revealed an order to apply Nystatin power (a treatment for a yeast or fungal infection of the skin) 100000 unit/gm to her inguinal folds for a rash. <BR/>In an interview on 02/14/2024 at 12:27 PM, CNA B revealed that she provided help with ADLs to Resident #3 on 02/14/2024 and that Resident #3 had a rash in her inguinal area. The CNA said the rash was because the resident would scratch her inguinal area and her abdominal fold (the area under the stomach above the pelvis). <BR/>In an interview on 02/14/2024 at 3:10 PM, CNA C revealed that she was assigned to provide help with ADLs to Resident #3 about one week a month and had provided help to the resident on 02/14/2024. The CNA said the resident had flaky skin and scratched her inner thighs to the point she would bleed a little. The CNA stated she applied a cream that the resident's family provided and would put zinc oxide on the areas where she scratched. <BR/>In an interview on 02/14/2024 at 3:27 PM, CNA D revealed that she had provided help with ADLs to Resident #3 since the resident returned from the hospital. The CNA stated the resident had a rash between her legs and under her stomach. The CNA had no idea why the resident had a rash but said that resident did tend to scratch herself under her stomach and would also scratch her bottom. , <BR/>In an interview on 02/14/2024 at 4:13 PM, RN E revealed she was not aware that Resident #3 had a behavior of scratching her legs and under the abdomen. She stated that the CNAs should have told her if the resident had this behavior. She said that if she was aware that resident had behavior of scratching herself, she would get an order from the nurse practitioner to treat it. She said the CNAs had not indicated the resident had scratches or rashes on the shower sheets. <BR/>In an Interview on 2/14/24 at 4:25 PM, ADON G revealed she had become aware last week that Resident #3 was scratching. She said residents' skin condition was assessed weekly and the charge nurse should have been aware that the resident scratches. She stated that Resident #3's behavior of scratching should be on the care plan. The purpose of the care plan was for all nursing and management to be aware of the care the resident needed and pass along to take better care of her. The ADON said that if there was no care plan for scratching, the result was that the resident could be at risk to not accomplish goal of protecting skin. <BR/>In an interview on 02/15/2024 at 8:29 AM, CNA F revealed that had provided help with ADLs to Resident #3 two week before and the resident had a rash in her abdominal fold. The CNA said that the resident had a behavior of scratching herself was not new and had been occurring over the past six months. The CNA stated she had reported it to the charge nurse (unnamed) a while back (date unknown). The CNA said she told the resident not to scratch herself and would apply a diaper rash ointment to the scratched areas. <BR/>In an interview on 02/15/2024 at 11:14 PM, MDS Nurse H LVN revealed that Resident #3's behavior of scratching would be on care plan which had been brought to his attention a couple of days ago (date not remembered). He said the care plan's purpose was to paint a picture of the resident for staff members not familiar with the patient so they would know what to expect and how to care for them. The care plan might let someone familiar with the resident know what interventions are being used for a particular issue which was important because although a staff member might be familiar with a resident, they may not know everything about them. <BR/>In an interview on 02/15/2024 at 11:34 AM, the DON revealed she was aware of Resident #3's excoriation (raw or scraped skin) to the skin fold under abdomen and stated this should be on the resident's care plan. She stated the CNAs should have reported the excoriation and the resident's scratching behavior to the nurses. The resident's scratching behaviors and the possible causes for it should have been put on care plan. The DON said if the behavior was not on care plan, staff would not be aware of it which could lead to further skin breakdown and possible infection. <BR/>Record review of the facility policy Comprehensive Care Plans dated 02/10/2021 revealed the facility would develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical needs that are identified in the resident comprehensive assessment. The care plan process includes an assessment of the resident's needs and concerns identified by the interdisciplinary team. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 7 residents (Residents #4) reviewed for resident rights.<BR/>The facility failed to ensure the treatment nurse documented she notified the physician when Resident #4 had a change in skin integrity. <BR/>This deficient practice could place residents at risk of a delay of medical treatment. <BR/>Findings included: <BR/>Record review of Resident #4's admission record dated 02/12/2024 revealed Resident #4 was an [AGE] year-old woman admitted to the facility on [DATE]. <BR/>Record review of Resident #4's History & Physical dated 09/27/23 revealed Resident #4 was an [AGE] year-old female transferred from foster home. Past Medical History; dementia, depression, and insomnia. Skin: No rash. No skin breakdown. <BR/>Record review of Resident #4's MDS assessment dated [DATE] revealed she rarely made herself understood; had short-term memory problems. Her cognitive skills for Daily Decision Making were severely impaired. She required extensive assistance of one person with bed mobility, transfer, and eating. She received skin treatment including pressure reducing device for chair; pressure reduction device for bed, and to receive application of ointments other than to her feet. <BR/>Record review of Resident #4's undated care plan revealed she had an ADL Self-Care Deficit and was at risk for not having her needs met in a timely manner. Interventions were to include Substantial/Maximum assistance with bed mobility, transfers, toileting, and personal hygiene. Interventions for Incontinence were to include Check frequently for wetness and soiling and change as needed, apply barrier cream to skin after incontinent episodes. She was to receive weekly skin checks to monitor for redness, breakdown, or other skin concerns. Any new skin conditions were to be reported to the physician. <BR/>Review of Physician Order Recap dated 02/15/24 for Resident #4 revealed an order to perform a head to toe skin assessment every Saturday for wound prevention/early identification. Staff were to notify the physician of any changes in skin integrity. An order dated 02/12/24 said that Nystatin External Powder 100000 Unit/GM was to be applied to bilateral groin topically every shift for redness to bilateral groin area. The medication recap did not document an order for Hydrogel. <BR/>Record review of Resident #4's Physician Progress Note dated 01/23/24 revealed the resident's chief complaint was for a Comprehensive Monthly Visit. Patient required assistance with all ADLs including feeding. Patient ambulated with wheelchair. History of Present Illness indicated she was alert and oriented x 1. She had diagnoses including dementia, depression, cognitive communication deficits, abnormalities of gait and mobility, and dysphagia. She had no skin breakdown and no skin rash. The assessment/plan included that nursing would manage bowel and bladder. They were to turn the patient every 2 hours while in bed. They were to provide heel protectors while in bed, and wound care was to valuate and treat. <BR/>Review of Resident #4's Nurses Progress Notes revealed 02/09/24 07:39 Skin/Wound Note Text: Head to toe skin assessment performed, no discoloration, no open skin noted, call light within reach. <BR/>Review of Resident #4's Nurses Progress Notes on 02/09/24 revealed that Treatment Nurse had not documented that she reported to physician and/or NP that Resident #4 had a pink rash on groin area. <BR/>Review of Resident #4's Nurses Progress Notes dated 02/12/24 12:53 revealed a new order for Nystatin powder to apply topically Q shift to bilateral groin area for redness. RP notified. <BR/>Record Review Resident #4's Physician Order dated 02/12/24 at 12:38 PM, for Resident #4 written by ADON, documented Nystatin External Powder 100000 units/GM apply to bilateral groin every shift for redness to bilateral groin area. <BR/>Review of Resident #4's Skin Observation Worksheet provided by Treatment Nurse on 02/09/24 revealed [Resident #4] did not have any issues. <BR/>Interview on 02/09/24 at 3:33 PM, the Treatment Nurse stated charge nurses completed weekly skin assessments on all residents and were responsible for immediately reporting any changes in skin integrity to the attending physician and/or Nurse Practitioner. Treatment Nurses were responsible for completing the initial skin assessments on all admissions and for completing weekly skin assessments on all residents that had pressure ulcers, skin rashes, surgical wounds, or skin tears. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately reported any changes in skin integrity to the charge nurses and charge nurses would report to the treatment nurse. The Treatment Nurse reported CNAs made rounds every two hours, completed skin checks when residents were given a bath and immediately report any changes in skin integrity to the charge nurses. She reported that the new company would take over the last week of February 2024 and corporate staff had requested that she complete a skin sweep for all residents at the facility. She started the skin sweep in the South Side today [02/09/2024] at 4:00 AM. The Treatment Nurse did not know how often she would be expected to conduct skin sweeps on the residents. <BR/>Observation and interview on 02/09/24 at 4:32 PM with the DON and the Treatment Nurse revealed Resident #4 was lying in bed on her back, awake, and had a pressure relieving mattress. It was reported the resident was confused, incoherent speech, required total assistance of two persons with ADLs, and was incontinent of bowel & bladder. The DON pulled sheets down, noted that the resident was wearing double disposable briefs . The DON stated, CNAs have been trained not to put two briefs on the residents. The DON demonstrated to surveyor disposable briefs were clean and dry. Resident #4 had a light pink rash on the groin area. There was no urine smell, the bed sheets were clean and dry. The Treatment Nurse reported she called the physician today [02/09/2024] to report skin integrity change and was pending return call. <BR/>Interview on 02/12/24 at 11:30 AM, Treatment Nurse reported she got a telephone order on 02/09/24 for Resident #4 to apply Hydrogel to the perineal area every shift. When the surveyor asked the nurse if treatment had been started as ordered, The Treatment Nurse stated No, because I did not enter the new order in the resident's electronic record. The Treatment Nurse stated she had been trained to immediately enter new orders on the computer to ensure treatments were done as ordered. <BR/>Observation and interview 02/12/24 at 12:35 PM, with Treatment Nurse revealed Resident #4's brief was slightly wet with urine. It was noted resident had a pink rash on the groin area. The Treatment Nurse reported that she still had not added the new order for Hydrogel that was given by the physician on 02/09/24 to the resident's electronic record received on 02/09/24 to treat the rash on the pelvic area with Hydrogel because she was busy making rounds with the surveyors. <BR/>Interview 02/12/24 at 11:38 AM, with the DON, in the presence of the Administrator, reported licensed staff had been trained to immediately report changes in condition to the attending physician and/or nurse practitioner and to immediately enter the new physician's order in the resident's electronic record as soon as the order was given. <BR/>Review of the facility's policy on Notification of Changes in condition reviewed/revised 02/10/2021 revealed Policy: To provide guidance on when to communicate acute change in status to MD, NP and responsible party. The facility will immediately consult with the resident's physician of the following: A significant change in the physical status of residents. Policy Explanation and Compliance Guidelines: The facility must document resident assessment(s), interventions, physician and family notification(s) on SBAR, Nurse Progress Note or Telephone Order Form as appropriate. Immediate Physician Notification - the physician is notified immediately and should respond timely (within minutes). Non-Immediate Notification - the physician is notified and there should be a return call within the same day. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure allegations of abuse and neglect were thoroughly investigated and reported results of the investigation to the state agency within 5 working days of the incident for 1 of 4 residents (Resident #3) reviewed for allegation investigation. <BR/>The facility did not complete a thorough investigation regarding an allegation of abuse involving Resident #3. <BR/>The failure of not investigating abuse allegations thoroughly could place residents at risk for continued abuse and or unrecognized abuse and emotional distress<BR/>Findings included: <BR/>Record review of Resident #3's face sheet revealed she was an [AGE] year-old female who was admitted on [DATE]. Her diagnosis included anemia (condition in which the body does not have enough healthy red blood cells), type 2 diabetes (body does not use insulin properly), high blood pressure, and urinary tract infection.<BR/>Record review of Resident 3's MDS dated [DATE], revealed Resident #3 had a BIMS score of 11 out of 15, which indicated moderate cognitive impairment. She required extensive assistance of one-person physical assist in bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. <BR/>During an interview on 06/07/2023 at 11:25 a.m., the Administrator B said she started at the facility on 5/8/2023. The Administrator B said the investigation involving Resident #3 was reported on 4/18/2023, prior to her working there. The Administrator B said the investigation folder containing information related to the self-report intake involving Resident #3 included limited information of a preliminary 3613 Provider Investigation Report, resident face sheet, and record of police notification. The Administrator B said the Provider Investigation Report was not thoroughly completed. The Administrator B said that the Administrator A was hospitalized a few days after reporting the incident involving Resident #3 and the Administrator A did not return to work at the facility. The Administrator B said she would reach out to corporate office to find out more information. <BR/>Record review of Risk Event Sheet dated 4/18/2023, provided by the Administrator B, revealed Administrator A was notified of the incident involving Resident #3 on 4/18/2023 at approximately 11:20 p.m. A complete head to toe assessment was conducted. The document revealed Safe Surveys were conducted, and in-services on Abuse and Neglect. There was no documentation inside the investigation folder showing Safe Surveys or in-services on Abuse and Neglect were conducted. <BR/>During an interview on 06/07/2023 at 11:49 a.m., the ADON said on 4/18/2023, PTA G went into Resident #3's bedroom and woke her up. The ADON said at that time Resident #3 made a comment to PTA G about being abused by having her hair pulled, drugged, and raped. The ADON said that PTA G reported to her the comments Resident #3 made. The ADON said that she immediately reported the allegation to the former Administrator A. The ADON said on 4/18/2023 she went asked Resident #3 if anything had happened to her, and Resident #3 said she was happy at the facility. The ADON said that Resident #3 said that sometimes when she wakes up immediately, she is confused. The ADON said that Resident #3 said she had nightmares and that it was hard for her to come to reality. The ADON said Resident #3 said she was asleep and heard someone in the room and when the therapist woke up Resident #3, she was scared. The ADON said the Administrator A called the police to report allegation and had Resident #3 assessed with no findings of injuries. The ADON said Resident #3's family was contacted, and the family visited the facility and spoke with the resident. The ADON said family talked to resident and after speaking with Resident #3, they did not want to do anything further such as reporting to the police or sending the resident to the hospital for further evaluation. The ADON said family thought it might be one of Resident #3's medications that caused her confusion. The ADON said the physician was contacted regarding family concern. <BR/>During an interview on 06/07/2023 at 10:07 a.m., Resident #3 said no one had abused or drugged her at any time at the facility. She said she had never been touched inappropriately by anyone at the facility. She said she once was confused after suddenly waking up from a dream and said something to the staff who woke her up about having hair pulled and being drugged. Resident #3 said none of those things had ever happened at the facility and she told staff she was confused. She said all the staff at the facility have been very professional and respectful towards her. She said she feels safe and protected at the facility. <BR/>During an interview on 6/7/2023 at 3:50 p.m., the Administrator B said she looked through all the administration offices, filling cabinets, and recording files for reportable information related to the investigation. The Administrator B said she was not able to find any Safe Surveys for the case. The Administrator B said she was unable to find Abuse and Neglect in-services that were noted to have been started on the Risk Event Sheet. The Administrator B said that backup to Administrator A would have been the DON. The Administrator B said that unfortunately in this case there was a transition from the corporate DON to the newly hired DON. The Administrator B said the Administrator A submitted the 3613 Provider Investigation Report on the 4/18/2023, with preliminary information but report sections Investigation Summary, Investigation Findings, and Provider Post Investigation Actions were not completed. <BR/>Record review of the 3613-A Provider Investigation Report related to self-report of abuse dated 4/18/2023, revealed the report did not have the Investigation Summary, Investigation Findings, and Provider Action Taken Post-Investigation completed.<BR/>Record review of facility Abuse policy, dated 09/17/2017, reads in part in Section V Investigation: The facility must have evidence that all violations, including allegations, are thoroughly investigated. The results of the investigation must be reported to the Administrator and to other officials in accordance with state law (including the State survey and certification agency) within 5 working days of the incident.

**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 any physical restraints imposed for the purposes of convenience and not required to treat the resident's medical symptoms for two (Resident #2 and Resident #4) of 7 residents reviewed for restraints. <BR/>The facility failed to ensure a scoop mattress (a mattress with built up sides that create a barrier to help stop residents from rolling or sliding out of bed) was not used with Resident #2 and Resident #4 without any medical indication. <BR/>This failure could result in residents having physical restraints used that limited their movement without being evaluated for the medical need for this. <BR/>Findings include:<BR/>Resident #2<BR/>Record review of Resident #2's face sheet dated 02/01/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #2's facility history and physical dated 09/27/23 revealed an [AGE] year-old female diagnosed with Dementia. <BR/>Record review of Resident #2's quarterly MDS dated [DATE] revealed a moderate impairment of cognition but no BIMS (a quick snapshot of how well you are functioning cognitively at the moment.) was taken for an unknown reason (to be able to recall and make daily decisions). Activities of daily living revealed substantial/maximal assistance from nursing staff for eating, oral hygiene, toileting, showering, and dressing. Resident #2 was dependent on nursing staff for personal hygiene and putting on footwear. <BR/>Record review of Resident #2's care plan dated 02/01/24 revealed there was no focus area or intervention for a scoop mattress or evaluation. <BR/>Record review of Resident #2's order recap dated 02/01/24 revealed there were no orders for a scoop mattress nor a therapy or nursing evaluation for the use of a scoop. <BR/>Observation and interview on 02/01/24 at 11:16 AM with the Director of Rehab, revealed Resident #2 had a scoop mattress. Director of Rehab stated Resident #2 did have a scoop mattress and looked like a regular mattress. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet dated 01/31/24 revealed admission on [DATE] to the facility. <BR/>Record review of Resident #4's facility history and physical dated 03/01/23 revealed an [AGE] year-old female diagnosed with fall risk. <BR/>Record review of Resident #4's quarterly MDS dated [DATE] revealed a severe impairment of cognition BIMS (a quick snapshot of how well you are functioning cognitively at the moment.) score of 6 to be able to recall and make daily decisions. Activities of daily living revealed partial/moderate assistance from nursing staff to help toilet, oral hygiene, dressing, personal hygiene, and putting on footwear. Resident #4 was supervision or touching assistance from the nursing staff with sitting on bed to lying, lying on bed to sitting on the side of the bed, roll left or right, partial/moderate assistance from nursing staff with toilet transfers. Resident #4 was diagnosed with Hemiplegia (paralysis of one side of the body), Parkinson's Disease, and Dementia. Resident #4 was receiving occupational therapy and physical therapy. <BR/>Record review of Resident #4's care plan dated 01/31/24 revealed Resident #4 has the potential for falls. New care plan intervention for falls dated 07/25/22, revealed scoop mattress. The care planned had no focus area for therapy or nursing assessment for the scoop mattress. <BR/>Record review of Resident #4' order recap dated 01/31/24 revealed there was no physician order for a scoop mattress nor a therapy or nursing assessment for the use of a scoop mattress. <BR/>Observation and interview on 02/01/24 at 11:06 AM with Director of Rehab, revealed Resident #4 did not have a scoop mattress as a mattress. Director of Rehab stated she did not know why Resident #4 had a scoop mattress in her care plan if she did not have a scoop mattress. <BR/>During an interview on 01/31/24 at 4:54 PM with LVN C, she stated she had not seen a scoop mattress in her hallway with her residents. LVN C stated it would have to be care planned. LVN C stated the scoop mattress was not an enabler for a resident. LVN C stated there had to be an assessment or evaluation done to see if the resident qualifies for the use of a scoop mattress. LVN C stated there would need to be an order for a scoop mattress and an evaluation to use the scoop mattress. LVN C stated since there was not evaluation nor a physician order as per the facility restraint policy it could be considered a form of restraint. <BR/>Observation and interview on 02/01/24 at 10:51 AM, the Director of Rehab, she stated Resident #4 required minimal assistance form nursing staff to get out of bed. Director of Rehab stated Resident #4 at times will need a little bit more assistance from nursing staff to get out of bed. Director of Rehab stated she was not sure if a scoop mattress was a restraint. Director of Rehab stated Resident #4 did not have a scoop mattress but did not know why she had it in her care plan. Director of Rehab stated Resident #2 had a scoop mattress that she was unaware about. Director of Rehab stated Resident #2 was evaluated for bed mobility and needed maximal assistance from nursing staff in which they provided 75 percent of the work for Residnet#2 to get out of bed. Director of Rehab stated Resident #2 was not able to get out of bed on her own. Director of Rehab stated the scoop mattress would not let Resident #2 get out of bed. Director of Rehab stated she did not think the scoop mattress was a restraint and did not know if they needed a physician's order for the scoop mattress. Director of Rehab stated she could not answer if the scoop mattress was helping the resident with a medical symptom. <BR/>During an interview on 02/01/24 at 11:18 AM with the DON, she stated an intervention of a fall prevention would be the use of a scoop mattress. The DON stated the facility would not like to use the scoop mattress as it was a limiting device for the residents. The DON stated a scoop mattress keeps a resident in the middle and from rolling to either side of the bed. The DON stated there would have to be a physician's order for the scoop mattress. The DON stated Resident #2 and Resident #4 did not have a physician's order for the scoop mattress. The DON stated there would have to be an evaluation from either therapy or the nurses (nursing judgement) for the use of a scoop mattress. The DON stated Resident #4's care plan of a scoop mattress was used to prevent falls. The DON stated Resident #2 and Resident #4 did not have an evaluation completed for the use of a scoop mattress. The DON stated the use of a scoop mattress without a physician's order, evaluation, and as per facility restraint policy was a form of restraint. <BR/>During an interview on 02/01/24 at 4:18 PM with the Administrator, she stated she would not use a scoop mattress as an intervention to prevent falls. The Administrator stated it was considered a restraint. The Administrator stated if a scoop mattress was used there had to be an evaluation from either therapy or nursing and a physician order. The Administrator stated not having either a physician order and an evaluation would be considered a restraint. The Administrator stated there would be a risk to the resident could be major injury, injuries, and or death. <BR/>Record review of the facility Restraint Free Environment policy dated 10/24/22 revealed, It was the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints.<BR/>- <BR/>Physical Restraint - refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot move easily which restricts freedom of movement or normal access to one's body.<BR/>- <BR/>A physician's order alone was not sufficient to warrant the use of a physical restraint.<BR/>- <BR/>Before a resident was restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints and determine how the use of restraints would treat the medical symptom.<BR/>- <BR/>Medical symptoms warranting the use of restraints should be documented in the resident's medical record. The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint, and effectiveness of the restraint in treating the medical symptom. The care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint. <BR/>Record review of the facility Welcome to our community Standards of Service policy not dated revealed, The standard of service for this community was to focus on our customers and one another, the residents, their families, other visitors and all team members. Each team member was expected to exceed resident, family, and visitor expectations. Weather in person, on the telephone or in writing, we must be:<BR/>- <BR/>Reliable - Develop a positive relationship with all individuals we serve to give them peace of mind that all services will provided by competent staff on a consistent basis. <BR/>- <BR/>Accurate - Check and re-check to assure needs are met properly and completely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 6 (Resident #s: 6, 29, 44, 107, 24, and 213) of 10 reviewed for care plans.<BR/>Comprehensive care plans revealed no evidence that care plan was reviewed quarterly.<BR/>This failure places residents at risk of not having their care needs met.<BR/>The findings include:<BR/>Record review of Resident # 6's electronic face sheet dated 07/20/22 revealed a [AGE] year-old-make admitted on [DATE]with diagnosis including: Dementia, Anxiety, Epilepsy, Raspatory failure, Major Depressive Disorder and traumatic brain injury. <BR/>Record review of Resident #6's MDS dated [DATE] revealed Section C: Cognitive Patterns a Brief Interview for Mental Status (BIMS) of a 0(severe cognitive impairment). Section G: Function Status revealed total dependence for bed mobility and eating; extensive assistance for transfers, dressing, toilet use, and personal hygiene. Section H: Bladder and Bowel revealed Resident had an indwelling catheter and Ostomy. Section K: Swallowing/Nutritional Status revealed Resident received 51% or more total calories and fluid intake come through parenteral or tube feeding. Section M: Skin Condition revealed Resident is at risk of pressure ulcers. <BR/>Record review on 07/20/2022 of Resident #6's most recent comprehensive care plan revealed no evidence that care plan was reviewed quarterly. <BR/>Review of Resident #29's electronic face sheet dated 7/20/2022, revealed a [AGE] year-old-female admitted on [DATE] with diagnoses including: Kidney Failure, Diabetes, Congestive Heart Failure, and Dialysis.<BR/>Record review of Resident # 29's Minimum Data Set (MDS) dated [DATE] revealed Section C: Cognitive Patterns a Brief Interview for Mental Status (BIMS) of a 14(cognitively intact). Section O: Special Treatments and Programs revealed Resident received Dialysis while a resident. <BR/>Record review on 07/20/2022 of Resident #29's most recent comprehensive care plan revealed no evidence that care plan was reviewed quarterly. <BR/>Review of Resident # 44's electronic face sheet dated 07/20/22 revealed a [AGE] year-old-female admitted on [DATE] with diagnosis including Dementia, Chronic kidney disease, Diabetic, Heart failure, Major Depressive Disorder, Anxiety, and Colostomy. <BR/>Record review of Resident #44's MDS dated [DATE] revealed Section C: Cognitive Patterns a Brief Interview for Mental Status (BIMS) of a 0(severe cognitive impairment). Section G: Function Status revealed total dependence for bed mobility and eating; extensive assistance for transfers, dressing, toilet use, and personal hygiene. Section H: Bladder and Bowel revealed Resident had an Ostomy. Section M: Skin Condition revealed Resident is at risk of pressure ulcers and had an unstageable deep tissue injury. Section O: Special Treatments and Programs revealed Resident on Hospice. <BR/>Record review on 07/20/2022 of Resident #44's most recent comprehensive care plan revealed no evidence that care plan was reviewed quarterly.<BR/>Review of Resident # 107's electronic face sheet dated 07/20/22 revealed a [AGE] year-old-male admitted on [DATE] with the following diagnosis: End Stage Renal Disease, Cirrhosis of Liver, Dementia, Dialysis Dependent and Diabetes. <BR/>Record review of Resident #107's MDS dated [DATE] revealed Section C: Cognitive Patterns a Brief Interview for Mental Status (BIMS) of a 9(moderate cognitive impairment). Section N: Medications revealed resident received Insulin injections, and antidepressants. Section O: Special Treatments and Programs revealed Resident received Dialysis while a resident. <BR/>Record review on 07/20/2022 of Resident #107's most recent comprehensive care plan revealed no evidence that care plan was reviewed quarterly.<BR/>Record review of Resident #24 electronic face sheet dated 7/20/22 revealed a [AGE] year-old male admitted on [DATE] and re-admission on [DATE] with diagnosis of Diabetes type two, Hypertension, Pain, Benign prostatic hyperplasia without lower track symptoms, muscle wasting atrophy.<BR/>Record review of Resident #24's MDS dated [DATE] revealed Section C: Cognitive Patterns a Brief Interview for Mental Status (BIMS) of 12 (cognitively intact). Section H: Bladder and Bowel revealed indwelling catheter and ostomy. <BR/>Record review of Resident #24's care plan dated 11/3/21 most recent comprehensive care plan revealed no evidence that care plan was reviewed quarterly.<BR/>Record review of Resident #213 electronic face sheet dated 7/20/22 revealed a [AGE] year-old female admitted on [DATE] with diagnosis of major depressive disorder, prediabetes, anemia, obstructive and reflux uropathy, hypertensive heart disease without heart failure. <BR/>Record review of Resident #213 MDS dated [DATE] revealed a BIMS score of 11. Section K: Swallowing/ Nutritional Status revealed a therapeutic diet, and no parental/ IV feeding or feeding required. <BR/>Record review of Resident #213 care plan dated 8/26/21 most recent comprehensive care plan revealed no evidence that care plan was reviewed quarterly.<BR/>During an interview on 07/20/22 at 2:13 PM with MDS Coordinator, she stated she was in charge of completing comprehensive care plans. MDS Coordinator she was aware she was behind on updating quarterly comprehensive care plans. MDS Coordinator stated care plans were required to be reviewed and updated quarterly and on any change of condition. MDS Coordinator stated Administrator was aware of her being behind and hired a new MDS nurse to assist as well as corporate will assist remotely but has not been able to catch up. MDS Coordinator stated since the pandemic hit, it had been impossible to catch up with the workload. <BR/>During interview on 07/20/22 at 3:30 PM with the DON, she stated IDT meetings occurred at a minimum quarterly and care plans were revised during IDT's. The DON stated the IDT team was responsible to make sure the care plan was correct and up to date. The DON stated if a resident's goal was met then it should be removed. The DON stated the Target Date should have been the next review date. The DON stated she was aware that the MDS Coordinator was behind on care plans, the facility had hired another person to assist her and Corporate had been helping remotely with completing assessments and care plans. The DON stated care plans were on-going but have set time frames that have to be met. The DON stated what led to failure was the pandemic caused the facility to get behind and then one of the MDS coordinators resigned a year ago. The DON stated the facility was a busy facility and made it hard to get caught up. The DON stated ultimately the MDS department is responsible to ensure Care Plans were completed. The DON stated the ADMN was over the MDS department. The DON stated the result of resident care plans not being completed affects the resident's plan of care is not followed through.<BR/>Interview on 07/20/22 at 04:04 PM Administrator stated comprehensive care plans were required to be completed 7 days after admission and reviewed and updated quarterly and annually. Administrator stated IDT team meet on a daily basis and would discuss an y change of condition had been noted the department would be the one to update their portion on the resident's care plan. Administrator stated ultimately the MDS coordinators were the ones in charge of ensuring care plans were kept up to date and reviewed quarterly and annually. Administrator stated she was aware the MDS coordinator was behind on workload and had hired a new MDS nurse to assist and reached out to corporate for further assistance. Administrator stated due to a lot of staff overturn since the pandemic it had become very difficult for MDS coordinator to catch up. Administrator stated a lot of nurses had been applying for the MDS position open but none of them had any experience with MDS assessment and felt it would be a disservice to current MDS coordinator to have to train on top of trying to catch up with care plan revisions. Administrator stated by not updating comprehensive care plans quarterly or annually would affect the residents in monitoring that their goals had been met and proper care was given by all staff.<BR/>Record review of Comprehensive Care Plans policy dated 2/10/21 revealed It is the policy of this facility to develop and implement a comprehensive person - centered care plan for each resident, consistent with residents' rights, that includes measurable objectives and timeframes to meet a residents medical, nursing, and mental and physiological needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

**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 for 2 (Resident #81 and Resident #48) of 4 residents reviewed for nutrition status.<BR/>1) <BR/>The facility failed to follow dietary recommendations for Resident #81. Resident # 81 lost 16 pounds from 05/20/2022 to 07/14/2022 which was a 12.46% weight loss - severe weight loss.<BR/>2) <BR/>The facility failed to follow dietary recommendations for Resident #48. Resident #48 lost 12.4 pounds from 02/27/200 to 07/14/2022 which was a 11.88% weight loss - severe weight loss.<BR/>This failure could place residents at-risk for loss of weight and inadequate nutrition.<BR/>Findings included:<BR/>Record review of electronic face sheet accessed on 07/20/2022 for Resident #81 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of liver cirrhosis, pancreatitis, Gastro-reflux disease, and diabetes. <BR/>Record review of MDS dated [DATE] for Resident #81 revealed BIMS score of 14 indicating no cognitive impairment. Further review of MDS revealed Section K: Nutritional Approaches: Parental/IV feeding.<BR/>Record review of electronic resident's record vital signs accessed on 07/20/2022 for Resident #81's revealed Resident #81 was 62 inches tall. On 05/20/2022 Resident #81 weighed 128.4 pounds. On 07/14/2022 Resident #81 weighed 112.4 pounds. <BR/>Record review of Resident #81's Nutrition/Dietary note written on 07/02/2022 at 03:29 PM by Dietician revealed: Dietician recommends provide Med Pass 2.0 Cal- 120 ml three times daily and Provide Juven 1 packet twice daily. <BR/>Record review of Resident #81's Nutrition/Dietary note written 07/19/2022 at 11:02 AM by Dietician revealed: Dietician recommends provide Med Pass 2.0 Cal- 120 ml three times daily and Provide Juven 1 packet twice daily.<BR/>Record review of electronic physician orders accessed on 07/20/2022 revealed: Diet- Low fat, Low Cholesterol, 2-gram sodium (cardiac) diet, Regular texture, Thin liquids consistency ordered on 06/20/2022. Fat Emulsion 20% Lipid (2Kcal/ml) infuse at 21 ml/hr via picc line total 250cc every Tuesday and Thursday evening ordered on 05/26/2022 with no changes or reviews since. Further review of physician's orders revealed orders written 05/26/2022 TPN Electrolytes Concentrate/Parenteral Electrolytes at 63 mg/ml intravenously with no changes or reviews since. Further review of electronic physician orders revealed no order for frequent weights and no orders for Med Pass 2.0 Cal or Juven packet. <BR/>Record review of Resident #81's Physician Progress note date 06/22/2022 written by the Medical Director revealed no evidence of addressing Resident #81's weight loss. <BR/>Record review of Resident #81's care plan last revised on 07/13/2022 revealed: Focus: The resident has unplanned/unexpected weight loss related to current diagnosis. Goal: The resident will have no further weight loss through the next review date of 10/13/2022. Interventions: Monitor and evaluate any weight loss. Determine percentage lost and follow protocol for weight loss. Monitor and record food intake each meal. Offer substitutes as requested or indicated. Provide and serve diet as ordered. Provide the resident with favorite/comfort foods. RD to evaluate and make diet/supplement change recommendations PRN.<BR/>Record review of Resident #81's electronic progress note written on 07/20/2022 at 11:31 AM by LVN A revealed: As per nurse practitioner resident to be sent to the hospital via ambulance Diagnosis: failure to thrive, untreatable vomiting and nausea, weight loss, acute pancreatitis, and chronic cirrhosis of the liver.<BR/>During an interview on 07/19/2022 at 9:30 AM Resident #81 stated she asked to be sent to the hospital and to a specialist multiple times and when the facility sent her to the hospital, the hospital just sent her back. She stated she was very scared and felt as if the facility and the doctors were not doing enough. She stated she had never been offered Med Pass 2.0 Cal or Juven. <BR/>Record review of electronic face sheet accessed on 07/20/2022 for Resident #48 on revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of seizures, anxiety, and Downs Syndrome. <BR/>Record review of MDS dated [DATE] for Resident #48 revealed BIMS score unable to complete interview. Further review Section K: Nutritional Approaches: Mechanically altered diet and Therapeutic diet.<BR/>Record review of electronic resident record vital signs accessed on 07/20/2022 for Resident #48's revealed Resident #41 was 58 inches tall. On 02/27/2022 Resident #48 weighed 104.4 pounds. On 07/14/2022 Resident #48 weighed 92 pounds. <BR/>Record review of electronic physician orders accessed on 07/20/2022 for Resident #48 revealed: No restrictions diet, Pureed texture, Thin liquids. No salt added med plus 1.7 three times a day as a supplement. <BR/>Record review of Resident 48's Nutrition/Dietary note written on 05/09/2022 at 07:20 PM by Dietician revealed: Dietician recommends add fortified foods to all meals. <BR/>Record review of Resident #48's Physician Progress note dated 05/06/2022 written by the Medical Director revealed no evidence of addressing Resident #48's weight loss. <BR/>Record review of Resident #48's care plan last revised on 03/29/2022 revealed: Focus: Resident has unplanned/unexpected weight loss due to Intellectual Disability/Down Syndrome. Goal: The resident will have no further weight loss through the next review date of 07/31/2022. Interventions: Invite the resident to activities that promote additional intake. Labs as orders. Report results to physician and ensure dietician is aware. Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. Monitor and record food intake at each meal. RD to evaluate and make diet/supplement change recommendations PRN.<BR/>During interview on 07/20/22 at 11:10 AM DON stated she receives dietary recommendations via email from the dietician . She stated she printed the recommendations, and they were given to the charge nurses to enter the orders or sometimes the dietician entered the orders into the resident's record himself. She stated she did not follow up and make sure the recommendations were entered. She stated this could affect the residents negatively by continuing to have weight loss. DON failed to provide a policy on weight loss of following dietary recommendations when requested by the time of exit. <BR/>During on observation on 07/20/2022 at 12:00 PM Resident #48's diet ticket showed no evidence of resident receiving fortified foods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record and failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days for 4 (Residents #62, #84, #44, and #82) of 6 residents reviewed for unnecessary medication in that:<BR/>Resident #62 was prescribed an antipsychotic medication for anxiety and depression.<BR/>Resident #84 was prescribed an antipsychotic medication for anxiety. <BR/>The facility failed to ensure Resident #44's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication.<BR/>The facility failed to ensure Resident #82's PRN Zyprexa (medicine used to treat symptoms of schizophrenia and bipolar disorders) medication was discontinued after 14 days or a documented rational for the continued provision of the medication.<BR/>These failures could place residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.<BR/>Findings include:<BR/>Record review of Resident #62's admission Record dated 07/18/2022 documented in part that he was [AGE] years old and was initially admitted to the facility on [DATE] and again on 05/27/2022. His diagnoses included unspecified dementia without behavioral disturbance, and unspecified psychosis not due to a substance or known physiological condition, diagnosed on [DATE]. <BR/>Record review of Resident #62's history and physical dated 12/10/2021 documented in part that he had a history of altered mental status after a fall with traumatic brain injury (a head injury causing damage to the brain). He was alert, able to state his name, and unable to recall date, time, place, and situation. He was receiving 2 MG of Aripiprazole (an antipsychotic - brand name Abilify) once a day and 12.5 MG of Seroquel (an antipsychotic - generic name aripiprazole) once a day. Diagnoses for these medications were not indicated on the history and physical. No psychotic conditions or history of psychotic conditions were indicated in his past medical history. The assessment in the history and physical indicated he had diagnoses of Unspecified dementia without behavioral disturbance; Anxiety Disorder, Unspecified; and Other recurrent depressive disorders. <BR/>Record review of Resident #62's MDS dated [DATE] (discharge - return anticipated) documented that staff assessed his mental status and that he had severely impaired cognitive skills for daily decision making. He had no symptoms of delirium or psychosis and no behavioral symptoms. He was totally dependent or required extensive assistance from facility staff for most activities of daily living. Diagnoses included anxiety disorder, depression, and psychotic disorder. He received antipsychotics for 7 of the 7 days prior to the assessment. <BR/>Record review of Resident #62's MDS (significant change) dated 06/02/2022 documented that his BIMS was 0 (severe cognitive impairment). He had no symptoms of delirium or psychosis and no behavioral symptoms. He was totally dependent or required extensive assistance from facility staff for most activities of daily living. Diagnoses included Non-Alzheimer's Dementia, anxiety disorder, depression, and psychotic disorder. He received no antipsychotics and received antianxiety medications for 6 of the 7 days prior to the assessment.<BR/>Record review of Resident #62's Care Plan dated 05/31/2022 documented in part that the resident received antidepressants and antipsychotics for depression and psychosis. When he was readmitted on [DATE] he was receiving Abilify, Seroquel, and Venlafaxine. <BR/>Record review of Resident #62's physician orders for 07/01/2021 - 07/19/2022 documented an order for 12.5 mg of quetiapine fumarate daily for anxiety from 12/10/2021 to 01/06/2022; for 12.5 mg of quetiapine fumarate daily for depression from 05/03/2022 to 05/27/2022; for 12.5 of quetiapine fumarate daily for depression from 05/28/2022 to 07/17/2022; and for 12.5 quetiapine fumarate daily for unspecified psychosis not due to a substance or know physiological condition. <BR/>In an interview on 07/20/22 at 06:10 PM the DON said regarding Resident #62 that depression was not an appropriate diagnosis for quetiapine, which was an antipsychotic. She said that antipsychotics posed a risk to older adults with dementia because the medications could cause adverse effects. She was not able to identify the adverse effects that antipsychotic medications could cause for older patient with dementia. She said that the ADON had been working for about two weeks to correct the diagnoses for residents who were prescribed antipsychotics with inappropriate diagnoses. <BR/>Resident #84<BR/>Record review of Resident #84's admission Record dated 07/19/2022 documented in part that he was i[AGE] years old, was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Alzheimer's disease; unspecified; Unspecified Dementia with behavioral disturbance; Generalized Anxiety Disorder; Major Depressive Disorder, Recurrent, unspecified. <BR/>Record review of Resident #84's History and Physical dated 07/13/2021 documented in part that he had diagnoses of Alzheimer's dementia. He was taking quetiapine fumarate 100 MG Tablet 1 tablet at bedtime Orally Once a day. No diagnosis was provided for the quetiapine fumarate. The assessment included a diagnosis of Major Depressive disorder, recurrent, unspecified and of Anxiety disorder, unspecified. <BR/>Record review of Resident #84's quarterly MDS dated [DATE] documented a BIMS 13 (cognitively intact). He had no signs or symptoms of delirium or psychosis and no symptomatic behaviors. His diagnoses included Alzheimer's dementia; Non-Alzheimer's dementia; Anxiety and Depression. He had received antipsychotic and antidepressant medication for seven of the seven days previous to the assessment.<BR/>Record review of Resident #84's annual MDS dated [DATE] documented a BIMS of 13 (cognitively intact). He had no signs or symptoms of delirium or psychosis and no symptomatic behaviors. His diagnoses included Alzheimer's dementia; Non-Alzheimer's dementia; Anxiety and Depression. He had received antipsychotic and antidepressant medication for seven of the seven days previous to the assessment. <BR/>Record review of Resident #84's hospital record dated 03/22/2022 documented that he had diagnoses including major neurocognitive disorder due to probably Alzheimer's disease with behavioral disturbance; major depression, recurrent; and generalized anxiety disorder. <BR/>Record Review of Resident #84's Care plan updated on 03/22/2022 documented in part that Resident used psychotropic medications (antidepressants, antipsychotics, anxiolytics, or hypnotics) related to depression and generalized anxiety disorder. <BR/>Record review of Resident's #84's physician orders for 07/01/2021 - 07/19/2022 documented that he had orders to receive 75 MG of quetiapine fumarate daily for anxiety between 07/10/2021 - 09/30/2021; 75 MG of quetiapine fumarate daily for anxiety between 09/30/2021 - 12/03/2021; 100 MG of quetiapine fumarate for anxiety between 12/03/2022 and 02/18/2022; and 100 MG of quetiapine fumarate for anxiety from 02/18/2022 with no end date. Resident #84 had orders to receive 0.5 MG of risperidone for major neurocognitive disorder beginning on 03/22/2022 with no end date. <BR/>In an interview on 07/20/22 at 06:03 PM the DON said that quetiapine did not treat anxiety. She said that Resident #84 returned from the hospital 03/22/2022 with orders for quetiapine for anxiety. She said that the facility does review orders within a few days after a resident's return from the hospital to ensure that they are appropriate. The surveyor requested documentation showing that the facility reviewed Resident #84's hospital orders but documentation was not received prior to exit from the facility . <BR/>Review of Resident #44's electronic face sheet accessed on 07/20/2022 revealed: resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of Stroke, Anxiety, Depression, and Heart Failure. <BR/>Review of Resident #44's MDS dated [DATE] revealed a BIMS score of 00 which indicated severe cognitive impairment. Further review of MDS Section N. Medications received during the last 7 days. 1 day of antianxiety medications.<BR/>Review of Resident #44's electronic physicians orders dated 07/20/2022 revealed: Lorazepam Intensol Concentrate 2MG/ML by mouth every 2 hours as needed for anxiety with a start date of 03/28/2022 and no stop date.<BR/>Record review of pharmacy recommendations dated 03/2022 up until 06/2022 revealed no evidence of gradual dose reduction attempted for Resident # 44. <BR/>Review of Resident #82's electronic face sheet accessed 07/20/2022 revealed: resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of Bipolar disorder, Stroke, and Depression. <BR/>Review of Resident #82's MDS dated [DATE] revealed a BIMS score of 13 which indicated no cognitive impairment. <BR/>Review of Resident #82's electronic physicians orders dated 07/20/2022 revealed: Zyprexa Tablet 5mg Give 1 tablet by mouth as need every 6 hours for bipolar disorder with a start date of 07/14/2022 and no stop date. Orders also revealed a previous order for Zyprexa Tablet 5mg Give 1 tablet by mouth as needed every 6 hours for depression with a start date of 05/24/2022 and stopped on 07/13/2022.<BR/>Review of Resident #82's electronic MAR for 05/2022 and 07/2022 revealed no evidence that Resident #82's PRN Zyprexa had been administered. <BR/>Record review of pharmacy recommendations dated 05/2022 up until 06/2022 revealed no evidence of gradual dose reduction attempted for Resident #82. <BR/>During an interview on 07/20/2022 at 11:10 AM the DON stated all PRN psychotropic medications should have a 14 day stop date. She stated Lorazepam and Zyprexa used as a PRN medication are all medications that require a stop date even if the resident was on hospice services. She stated every 14 days the facility should reevaluate the need for these medications and request a new order if needed. She stated these orders were just somehow overlooked and she does not know why the failure occurred. The DON stated this failure could lead to residents receiving unnecessary medications. The DON stated the Zyprexa PRN order for Resident #82 should have been discontinued for non-use. The DON stated that both residents had not been in the facility long enough for a gradual dose reduction from the pharmacist. <BR/>Review of facility policy titled Antipsychotic Medications last reviewed 02/10/2020 revealed: Policy: It is the facility's policy that each resident's drug regimen is free from unnecessary drugs, including unnecessary antipsychotic drugs. Procedure/Process: 1.) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record . 3.) Residents who use antipsychotic drugs will receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue use of these drugs . 6.) With the physician as the leader, and in collaboration with a pharmacist and other members of the interdisciplinary team, each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: a. Dose, b. Duration of use, c. Indications for use, d. Presence of adverse consequences which indicate the dose should be reduced or discontinued. 7.) Each resident will receive the lowest possible dose and for the shortest period of time necessary for treating his or her condition (or to improve the target symptoms being monitored) .9.) When an antipsychotic drug is initiated or used to treat an emergency situation .a. The acute treatment period will be limited to seven days or less: and b. A clinician in conjunction with the interdisciplinary team will evaluate and document the situation within seven days to identify and address any contributing and underlying causes of the acute condition and verify the continuing need for an antipsychotic drug .<BR/>Review of the website drugs.com on 07/19/22 at 10:34 AM said in part that Seroquel is an antipsychotic medicine. Seroquel is used to treat bipolar disorder (manic depression) and schizophrenia in adults.<BR/>Risperidone is an antipsychotic medicine used to treat bipolar disorder (manic depression) and schizophrenia in adults.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation.<BR/>1. <BR/>Facility Staff and Dietary Staff were not wearing hair nets or beard guards when entering or working in the kitchen. <BR/>This failure could affect residents by placing them at risk of food borne illness.<BR/>Findings include:<BR/>Observation and interview on 01/30/24 at 11:00 AM, the Maintenance Director was observed going into the kitchen without a hair net or beard guard. The Maintenance Director stated it was okay to go into the kitchen without a hair net or beard guard. In the back in the kitchen Dietary [NAME] did not have his hair net or beard guard on. The Maintenance Director stated the Dietary Manager had in-serviced all of the facility staff of what should be worn when in the kitchen. <BR/>During an interview on 01/30/24 at 11:20 AM with Dietary Cook, he stated a hair net and beard guard had to be worn. The Dietary [NAME] stated he had received training on what to wear while in the kitchen. The Dietary [NAME] stated not having a hair net or beard guard on could have hair falling into the food and contaminate it. The Dietary [NAME] stated the resident could get sick if eaten. <BR/>During an interview on 01/31/24 at 9:36 AM with the Dietary Manager, he stated everything passing the doors in the dining room was to be considered the kitchen. The Dietary Manager stated all dietary staff are to be wearing hairnets and the males would be beard guards if they have a beard. The Dietary Manager stated he had not in-serviced facility staff that were not dietary staff. The Dietary Manager stated there was a sign posted outside of the kitchen door revealing staff had to be wearing a hair net and beard guard. The Dietary Manager stated if they catch facility staff without a hairnet or beard guard, they do tell them to put one on. The Dietary Manager stated all staff have to follow the facility policy to wear hair nets and beard net and the sign posted says the something. The Dietary Manager stated the negative outcome of not wearing a hair net or beard guard would be not following facility policy of personal hygiene in which staff should be kept at all times for the safety of the residents. <BR/>During an interview on 02/01/24 at 11:18 AM with the DON, she stated she considered the kitchen area to be a clean location and sterile. The DON stated once the facility staff breach the kitchen doors in the dining area it was considered the kitchen. The DON stated facility and dietary staff have been trained and in-serviced on what the correct clothing was when entering the kitchen. The DON stated hair nets and beard guards for the males need to be warn. The DON stated the Maintenance Director stated that it was okay to enter the kitchen without hair net nor beard guard was inappropriate response and not okay. The DON stated the purpose of a hair net or beard guard was to prevent hair from falling into the food, floor, and dishes. The DON stated the risk to the residents would be infection. The DON stated it would not be appealing if she found hair in her food. <BR/>During an interview on 02/01/24 at 4:18 PM with the Administrator, she stated once facility staff cross the kitchen door in the dining room into the kitchen was consider being in the kitchen. The Administrator stated all facility staff to include dietary staff have to be wearing a hair net and for the males with facial hair a beard guard. The Administrative stated dietary staff are trained on the proper wear when being in the kitchen. The Administrator stated facility staff were trained on what to wear when entering the kitchen including the hair net and beard guard for males with facial hair. The Administrator stated the regulation says anybody working in the kitchen has to cover their hair. The Administrator stated not wearing a hair net or beard guard could be a risk of contamination. The Administrator stated she would not be okay finding hair in her food, it would be gross. <BR/>Record review of the facility Dietary Personal Hygiene policy dated 11/06 with no year revealed, Dietary employees will maintain proper food safety practices through proper personal hygiene.<BR/>- <BR/>Dietary employees shall wear, hair covering, beard restraint, and clothing that covers body hair.<BR/>- <BR/>All staff entering the kitchen must comply with hair restraints. <BR/>- <BR/>All personnel entering the kitchen to perform job functions shall follow all pertinent rules. <BR/>Record review of the facility Dietary Notice/Aviso Sign not dated revealed, Notice - Hairnets and beard covers required in this area. (Spanish) Aviso - Redecillas para el [NAME] y coberturas para la [NAME] son requeridas en areas de produccion. <BR/>Record review of facility Dietary [NAME] certification dated 08/06/21 revealed, Completion of food safety for handlers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the transfer or discharge is documented in the medical record for 1 (Resident #1) of 7 residents reviewed for clinical records.<BR/>The facility failed to complete Transfer/Discharge Form on 12/12/23 when Resident #1 was sent for Evaluation to the Emergency Room.<BR/>This failure could put residents at risk of arriving at the emergency room without information regarding their medical conditions or needs. <BR/>Findings included: <BR/>Record review of admission record dated 12/09/2023 revealed Resident #1 was a [AGE] year-old woman admitted to the facility on [DATE]. <BR/>Record review of Resident #1's Annual History and Physical 10/03/2023 revealed she was non-verbal, not alert to surroundings and on hospice care. Patient requires total assistance with ADLs (activities of daily living). Patient bed-bound, gastrostomy tube (feeding tube inserted directly through the abdominal wall into the stomach). Past Medical History: Dementia of the Alzheimer's Type, and Depression. General Examination: Elderly female, ill-appearing, thin, frail. Full range of motion to bilateral lower extremities. Contractures to bilateral upper extremities. <BR/>Record review of Resident #1's annual MDS assessment dated [DATE] revealed minimal difficulty hearing; No speech; rarely/never makes self-understood; rarely/never understand others; impaired vision; Because she was nonverbal the BIMS (Brief Interview for Mental Status) was not completed. Staff assessment for mental status revealed she had problems with both short- and long-term memory. Cognitive Skills for daily decision making, severely impaired; no symptomatic behaviors; functional limitation in range of motion impairment on both sides of upper/lower extremities; Active diagnoses included Alzheimer disease and non-Alzheimer's dementia. She was totally dependent on staff for eating, oral hygiene, toileting, bathing, dressing and personal hygiene. Incontinent of bladder and bowel. Wheelchair. Active diagnoses included Progressive Neurological Conditions, non-Alzheimer's Dementia, malnutrition, anxiety, depression, psychotic disorder, muscle spasms. No history of falls. No pain. Feeding tube. No pressure ulcers. Medications-antidepressant/antianxiety. Hospice Care.<BR/>Record review of Resident #1's care plan revised on 01/28/2021 revealed she was never to rarely understood. Care plan revised 10/13/2022 revealed she had an ADL self-care performance deficit related to cognitive impairment, limitations in range of motion, impaired balance/impaired coordination, and visual impairment. Transfers required two staff members using a Hoyer (mechanical) lift. Toileting total assistance x 2 staff. Non-ambulatory. Wheelchair total x 1 staff. Dressing, Personal Hygiene, and Bathing x 1 staff. <BR/>Review of Hospice Visit Note Report dated 12/05/23 written by Hospice CNA revealed In-House Time: 8:29 AM; Completed: 9:46 AM. ADL Services completed: Turn and position in bed, bed bath, shampoo, skin care, oral care and changed linens.<BR/>Record review of Resident #1's Nursing Note by LVN C dated 2/5/2023 revealed that the Hospice CNA provided a shower to the resident and reported discoloration to left inguinal area. Skin assessment was completed on resident, and she was noted to have a discoloration to left inguinal area. The note stated that education was provided to CNAs to not to tighten brief too much. A family member (unidentified) was at the facility and was aware. <BR/>Review of Hospital emergency room Provider Report 12/12/23 Time: 2100 (9:00 PM) <BR/>revealed [AGE] year-old female with a past medical history of dementia, bed ridden on hospice care at nursing facility presenting to the emergency room for evaluation of bruising to her pelvic region for the last week-has been evaluated by nursing home physician with imaging and labs which were negative for fracture and only very mild thrombocytopenia. The patient's [family member] was wanting further evaluation by SANE; they do have an APS case involved as they are not sure how the patient developed the bruising-she is bed ridden and contracted, nonverbal. Nursing home had contacted the hospital who stated that the patient did not qualify for a SANE exam. Chief Complaint: Bruising to pelvic region. Patient with bruising to her lower pelvic region that extends to both her hips, Foley catheter in place, bruising in healing, no new bruises noted. EXT: Bruising noted to her pelvic region, extremities are contracted. Neuro: Frail, cachectic, nonverbal at baseline. Re-Evaluation MD Notes: Patient is a [AGE] year-old female with past medical history of dementia, arthritis, bed ridden on hospice presenting to the emergency room for bruising to her pelvic region that was noted about a week ago, patient was evaluated with labs as well as imaging. Patient's [family member] was under the impression that more evaluation was needed. I spoke with the medical director of the nursing home who stated that he had already evaluated the patient's bruising, there was no evidence of a fractures to her hips or pelvis, her labs work only revealed very mild thrombocytopenia, otherwise within normal limits. Patient's [family member] was wanting a SANE evaluation however County Hospital declined this evaluation. Nursing staff spoke at length with the patient's [family member], she stated that they have no APS case, and the nursing home is who told her that she needed to come to the emergency room to have the bruising looked at further, I discussed the lab work that was obtained as well as the imaging that was obtained by the nursing home physician. Patient's [family member] would like Resident #1 to return to the nursing home. Discharge and Departure: discharged home at 2119 (9:19 PM) on 12/12/23.<BR/>In an interview on 12/09/2023 at 9:55 AM Resident #1's Family Member A revealed she visited Resident #1 every afternoon and helped with toileting, and Family Member B visited Resident #1 every morning and helped with toileting. Family Member A said she had changed Resident #1's briefs the afternoon of 12/04/2023 and saw no unusual discolorations in her pelvic area, but the afternoon of 12/05/2023 during brief changes she saw bruising on Resident #1's left inner thigh and left groin area. She described the bruising a purple and said that since the bruising was first noted it has spread across the pelvis and that there was also bruising near the resident's vagina. Family Member A said Family Member B had reported to her that the morning of 12/05/2023 Family Member B observed that Resident #1 had bruising in her pelvic area. Family Member A stated that Family Member B had reported the bruising to the Hospice CNA and the Hospice CNA had reported it to the facility LVN C. Family Member A reported resident was sent to Hospital emergency room on [DATE] on 12/12/23 at approximately 7:30 PM or 8:00 PM by ambulance. The facility staff never told me why they were sending my [family member] r to [NAME] Sol. Nothing was done at the hospital, except to pull the sheets down, look at her private area and cover her up. The hospital staff did not know why my [family member] was sent to the emergency room. They did not do anything to my [family member], not even checked her private areas. I requested they called an ambulance to return to the nursing home.<BR/>Interview and Record Review 01/03/24 1:39 PM LVN C revealed he had completed the Transfer/Discharge form on 12/12/23 when Resident #1 was sent to the Emergency Room. Nurse stated, I also remember printing a copy of the X-ray report, Ultrasound report, and labs. I handed the copies of the documents to RN I, the evening nurse because the ambulance had not arrived before the end of my shift. LVN C demonstrated to the surveyor he had completed the Transfer/Discharge form is the electronic record and was showing run date of 01/03/24. LVN C stated the computer will show the date that you access the form and will not show the actual date that the form was completed on 12/12/23. Nurse confirmed that he had not written on the Transfer/Discharge Form reason for transfer.<BR/>Interview on 01/03/24 at 3:00 PM RN I, revealed she did not remember if LVN C had printed Transfer/Discharge Form on 12/12/23 to send with Resident #1 when she was sent to Hospital emergency room by way of an Ambulance. <BR/>Interview 01/04/24 at 7:17 PM, Administrator reported she had checked with her Corporate Staff and was informed that they did not have a Policy & Procedure on completing Transfer/Discharge Form. Usual Level of Functioning was blank. Date of Transfer/Discharge, Transfer/Discharge to were blank. <BR/>Review of Transfer/Discharge Form dated 01/03/24 revealed Resident #1 Last Vital Signs 01/02/24 Blood Pressure 111/54, Pulse 65, Temperature 97.2, and Respirations 18. Chief Complaint (Reason for Transfer was blank); Relevant Information related to Behaviors, Ambulation, Bladder, Bowel, Feeding was blank. The form did not have a signature, Date or Time. <BR/>Review of email sent from hospital dated 01/05/24 at 11:21 AM, revealed they had completed a thorough of the medical record on Resident #1 and did not find the Transfer/Discharge Form from the Nursing Facility when resident was sent on 12/12/23 to the Emergency Room. <BR/>Review of Clinical Document Guideline dated 03/14/2014 revealed Policy: The patient's clinical record provides a record of the health status, including observations, measurements, history, and prognosis and serves as the primary document describing healthcare services provided to the patient. Fundamental Information: The clinical record is used by healthcare team to record, preserve, and communicate the patient's progress and current treatment. Procedure: Clinical documentation entries should be objective, information and communication that pertain to the care of the patient. Documentation: Clinical record progress notes, physician orders, flow records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #3) of seven residents reviewed for comprehensive person-centered care plans. <BR/>The facility failed to develop and implement a care plan to address Resident #3's behavior of scratching. <BR/>This failure put residents at increased risk of discomfort, impairment of skin integrity, and infection. <BR/>Findings included: <BR/>Resident #3 <BR/>Record review of Resident #3's face sheet dated 02/15/2024 revealed she was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. <BR/>Record review of Resident #3's History and Physical (H&P) dated 1/10/2024 revealed she was nonverbal and had diagnoses including Type 2 Diabetes mellitus, high blood pressure, and cerebral infarction (stroke). She was bed-bound and was non-verbal. She had no issues with her skin. The History and Physical stated right ulcer but did not specify the type or where the ulcer was located. The plan included to turn patient every 2 hours while in bed and that wound care was to evaluate and treat. <BR/>Record review of Resident #3's discharge MDS assessment dated [DATE] revealed she was nonverbal and was assessed by staff regarding her mental status. She had moderately impaired skills for daily decision making and had poor short- term memory. She was dependent on staff for toileting hygiene. She had behavioral symptoms not directed toward others. The MDS did not specify what these behaviors were. She was always incontinent of bladder and bowel. <BR/>Record review of Resident #3's Care Plan dated 06/19/2023 revealed she was incontinent of bowel and bladder. The goal was that she was to remain free from skin breakdown due to incontinence and brief use through the next review date (revised 01/26/2024). Interventions included weekly skin checks to monitor for redness, circulatory problems, breakdown, or other skin concerns and to report any new skin conditions to the physician. There was no care plan that addressed her behavior of scratching her inguinal area (where the thigh meets the front of the lower body) and abdominal fold. <BR/>Record review of Resident #3's Progress note dated 02/14/2024 revealed that a skin assessment revealed an inguinal rash (a rash where the thigh meets the front of the lower body). <BR/>Record review of progress notes for Resident #3 dated 01/15/2024 through 2/14/2024 revealed a Skin/Wound note dated 02/09/2024 that the resident had an inguinal rash. There were no notes regarding scratches. <BR/>Record review of Resident #3's physician's orders dated 2/12/2024 revealed an order to apply Nystatin power (a treatment for a yeast or fungal infection of the skin) 100000 unit/gm to her inguinal folds for a rash. <BR/>In an interview on 02/14/2024 at 12:27 PM, CNA B revealed that she provided help with ADLs to Resident #3 on 02/14/2024 and that Resident #3 had a rash in her inguinal area. The CNA said the rash was because the resident would scratch her inguinal area and her abdominal fold (the area under the stomach above the pelvis). <BR/>In an interview on 02/14/2024 at 3:10 PM, CNA C revealed that she was assigned to provide help with ADLs to Resident #3 about one week a month and had provided help to the resident on 02/14/2024. The CNA said the resident had flaky skin and scratched her inner thighs to the point she would bleed a little. The CNA stated she applied a cream that the resident's family provided and would put zinc oxide on the areas where she scratched. <BR/>In an interview on 02/14/2024 at 3:27 PM, CNA D revealed that she had provided help with ADLs to Resident #3 since the resident returned from the hospital. The CNA stated the resident had a rash between her legs and under her stomach. The CNA had no idea why the resident had a rash but said that resident did tend to scratch herself under her stomach and would also scratch her bottom. , <BR/>In an interview on 02/14/2024 at 4:13 PM, RN E revealed she was not aware that Resident #3 had a behavior of scratching her legs and under the abdomen. She stated that the CNAs should have told her if the resident had this behavior. She said that if she was aware that resident had behavior of scratching herself, she would get an order from the nurse practitioner to treat it. She said the CNAs had not indicated the resident had scratches or rashes on the shower sheets. <BR/>In an Interview on 2/14/24 at 4:25 PM, ADON G revealed she had become aware last week that Resident #3 was scratching. She said residents' skin condition was assessed weekly and the charge nurse should have been aware that the resident scratches. She stated that Resident #3's behavior of scratching should be on the care plan. The purpose of the care plan was for all nursing and management to be aware of the care the resident needed and pass along to take better care of her. The ADON said that if there was no care plan for scratching, the result was that the resident could be at risk to not accomplish goal of protecting skin. <BR/>In an interview on 02/15/2024 at 8:29 AM, CNA F revealed that had provided help with ADLs to Resident #3 two week before and the resident had a rash in her abdominal fold. The CNA said that the resident had a behavior of scratching herself was not new and had been occurring over the past six months. The CNA stated she had reported it to the charge nurse (unnamed) a while back (date unknown). The CNA said she told the resident not to scratch herself and would apply a diaper rash ointment to the scratched areas. <BR/>In an interview on 02/15/2024 at 11:14 PM, MDS Nurse H LVN revealed that Resident #3's behavior of scratching would be on care plan which had been brought to his attention a couple of days ago (date not remembered). He said the care plan's purpose was to paint a picture of the resident for staff members not familiar with the patient so they would know what to expect and how to care for them. The care plan might let someone familiar with the resident know what interventions are being used for a particular issue which was important because although a staff member might be familiar with a resident, they may not know everything about them. <BR/>In an interview on 02/15/2024 at 11:34 AM, the DON revealed she was aware of Resident #3's excoriation (raw or scraped skin) to the skin fold under abdomen and stated this should be on the resident's care plan. She stated the CNAs should have reported the excoriation and the resident's scratching behavior to the nurses. The resident's scratching behaviors and the possible causes for it should have been put on care plan. The DON said if the behavior was not on care plan, staff would not be aware of it which could lead to further skin breakdown and possible infection. <BR/>Record review of the facility policy Comprehensive Care Plans dated 02/10/2021 revealed the facility would develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical needs that are identified in the resident comprehensive assessment. The care plan process includes an assessment of the resident's needs and concerns identified by the interdisciplinary team. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 (Resident #1) of 7 residents reviewed for abuse.<BR/>-LVN C failed to immediately notify the Administrator on 12/05/23 Resident #1 had bruising left groin of unknown origin.<BR/>- Facility failed to report an injury of unknown origin to the State Survey Agency within 24 hours of being reported to Administrator on 12/05/23. <BR/>This failure could place residents at risk for abuse and neglect.<BR/>Findings Included:<BR/>Record review of admission record dated 12/09/2023 revealed Resident #1 was a [AGE] year-old woman admitted to the facility on [DATE]. <BR/>Record review of Resident #1's Annual History and Physical 10/03/2023 revealed she was non-verbal, not alert to surroundings and on hospice care. Patient requires total assistance with ADLs (activities of daily living). Patient bed-bound, gastrostomy tube (feeding tube inserted directly through the abdominal wall into the stomach). Past Medical History: Dementia of the Alzheimer's Type, and Depression. General Examination: Elderly female, ill-appearing, thin, frail. Full range of motion to bilateral lower extremities. Contractures to bilateral upper extremities. <BR/>Record review of Resident #1's annual MDS assessment dated [DATE] revealed minimal difficulty hearing; No speech; rarely/never makes self-understood; rarely/never understand others; impaired vision; Because she was nonverbal the BIMS (Brief Interview for Mental Status) was not completed. Staff assessment for mental status revealed she had problems with both short- and long-term memory. Cognitive Skills for daily decision making, severely impaired; no symptomatic behaviors; functional limitation in range of motion impairment on both sides of upper/lower extremities; Active diagnoses included Alzheimer disease and non-Alzheimer's dementia. She was totally dependent on staff for eating, oral hygiene, toileting, bathing, dressing and personal hygiene. Incontinent of bladder and bowel. Wheelchair. Active diagnoses included Progressive Neurological Conditions, non-Alzheimer's Dementia, malnutrition, anxiety, depression, psychotic disorder, muscle spasms. No history of falls. No pain. Feeding tube. No pressure ulcers. Medications-antidepressant/antianxiety. Hospice Care.<BR/>Record review of Resident #1's care plan revised on 01/28/2021 revealed she was never to rarely understood. Care plan revised 10/13/2022 revealed she had an ADL self-care performance deficit related to cognitive impairment, limitations in range of motion, impaired balance/impaired coordination, and visual impairment. Transfers required two staff members using a Hoyer (mechanical) lift. Toileting total assistance x 2 staff. Non-ambulatory. Wheelchair total x 1 staff. Dressing, Personal Hygiene, and Bathing x 1 staff. <BR/>Review of Hospice Visit Note Report dated 12/05/23 written by Hospice CNA revealed In-House Time: 8:29 AM; Completed: 9:46 AM. ADL Services completed: Turn and position in bed, bed bath, shampoo, skin care, oral care and changed linens.<BR/>Record review of Resident #1's Nursing Note by LVN C dated 2/5/2023 revealed that the Hospice CNA provided a shower to the resident and reported discoloration to left inguinal area. Skin assessment was completed on resident, and she was noted to have a discoloration to left inguinal area. The note stated that education was provided to CNAs to not to tighten brief too much. A family member (unidentified) was at the facility and was aware. <BR/>In an interview on 02/09/2024 at 9:55 AM Resident #1's Family Member A revealed she visited Resident #1 every afternoon and helped with toileting, and Family Member B visited Resident #1 every morning and helped with toileting. Family Member A said she had changed Resident #1's briefs the afternoon of 12/04/2023 and saw no unusual discolorations in her pelvic area, but the afternoon of 12/05/2023 during brief changes she saw bruising on Resident #1's left inner thigh and left groin area. She described the bruising a purple and said that since the bruising was first noted it has spread across the pelvis and that there was also bruising near the resident's vagina. Family Member A said Family Member B had reported to her that the morning of 12/05/2023 Family Member B observed that Resident #1 had bruising in her pelvic area. Family Member A stated that Family Member B had reported the bruising to the Hospice CNA and the Hospice CNA had reported it to the facility LVN C. <BR/>In an interview on 12/09/2023 at 12:42 PM with the Administrator and DON, the DON stated that Resident #1's bruising was not considered to be of unknown origin because LVN C thought the bruising was due to the resident's brief being too tight, and so was not reported to the state. The DON said the facility had gone with LVN C's assessment that the bruising was from the brief being too tight but started post-risk management such as labs and x-rays. She said the facility was looking into the bruising to try to explain it. <BR/>In an interview on 12/09/2023 at 1:17 PM LVN C revealed that the morning of 12/05/2023 the Hospice CNA asked him to come and look at a bruise on Resident #1. LVN C stated the Hospice CNA had finished bathing Resident #1 and Resident #1 was lying in bed in a gown with no brief on. LVN C stated he examined Resident #1 and found a bruise on the left groin area that extended around six inches along the groin. LVN C stated he checked the resident for pain by touching the bruise but that she did not have any grimacing or moaning. LVN C said the next day the bruising had spread across the abdomen to the right groin and on the pelvic area. He stated that because of the shape of the bruise he continued to think the bruise might have been caused by a tight brief. <BR/>In an interview on 12/09/2023 at 1:50 PM CNA E revealed she had been assigned to Resident #1 the morning of 12/05/2023 and spoke to the Hospice CNA about Resident #1 around 6:15 AM that morning. CNA E said the Hospice CNA had provided a bed bath and mentioned that the resident had a bruise. CNA E observed that Resident #1 had a light-yellow bruise in the left inguinal area. The CNA said the resident would stiffen up when her brief was being changed but that did not make it difficult to change her brief. The CNA said all care was provided to the resident in bed, and that she had never transferred the resident out of bed. <BR/>In an interview on 12/11/2023 at 9:08 AM the Hospice CNA revealed she had provided a bed bath to Resident #1 on 12/05/2023. She stated that when she began care the resident was wearing a brief which was as tight as usual. The Hospice CNA stated when she removed the resident's brief, she noticed bruising and called the nurse. The bruises were purple and in the left inguinal (where the front of the upper thigh meets the body) area extending a little in the direction of the leg. There was no bruising noted in the other areas. The Hospice CNA said she told the nurse (LVN C) and he said the bruising was from the brief because it was more in the inguinal area. She said she worked with about five residents in the facility and had never found them with tight briefs.<BR/>In an interview on 12/11/2023 at 2:15 PM the DON revealed she assessed Resident #1 the afternoon of 12/05/2023 and observed bruising to the left inguinal area, with none to the pelvic area. She was unaware that the morning of 12/05/2023 the Hospice CNA had reported the bruising LVN C. <BR/>In an interview on 12/11/1023 at 4:32 PM the Hospice Nurse revealed she received a call on 12/05/2023 at 9:21 AM from the Hospice CNA advising her that Resident #1 had a bruise in the left inguinal area. The Hospice Nurse said she was scheduled to do a visit on 12/07/2023 and decided to wait until then see the resident. <BR/>Second Interview 01/02/24 at 12:40 PM LVN C revealed Tuesday 12/05/23 at approximately 10:00 AM, Hospice CNA came to the nurse's station to report she had noted Resident #1 had a linear discoloration slightly below the fold to the left groin while giving resident a bed bath. Upon assessment Resident #1 was lying in bed on her back, without a disposable brief and noted linear reddish area below the left groin, no other discoloration was noted at time of assessment. The discoloration was on the area where the brief is placed between the folds of the legs and taped to the sides. Resident is non-verbal and requires total assistance with activities of daily living. <BR/>Second interview 01/02/24 at 1:10 PM CNA E revealed she was assigned to Resident #1 12/05/23 on the 6-2 AM shift. At approximately 6:15 AM, Hospice CNA was in the room giving Resident #1 a bed bath. I was in the room preparing the roommate to get her out of bed for breakfast. At that time the Hospice CNA asked if I had seen any bruises on resident on 12/04/23. I said no. She asked me to come and see the bruise resident had on left groin area. There was a linear bruise slightly below the fold of the left leg about 2 inches long and half the size of the width of a pen. There were no other bruises noted at that time. After lunch at approximately 12:30 PM, I was in the room attempting to explain Family Member B when she came to visit the resident what we thought had caused the bruise, when LVN C came to resident's room, and he informed Family Member B of the red area below the left groin. CNA E reported staff had been trained to immediately report abuse/neglect/any injury to the nurses. <BR/>Second interview 01/02/24 2:47 PM RN I revealed she was assigned to Resident #1 on 2-10 PM shift on 12/05/23. She stated LVN C had reported at change of shift Resident #1 had a linear bruise slightly below the groin from the brief being too tight. RN stated, Upon assessment she noted Resident #1 had a linear bruise slightly below left groin that was approximately 1-1 &frac12; inches long. The bruising was at the front of the bulk of the brief in the groin area where the tapes are tied to the sides. I have never seen residents with tight briefs. I did not recall seeing any other bruises on that day. It looked like the bruise could have been caused by brief being pulled too tight. RN I, reported resident was non-verbal and required total assistance with ADLs, had contractures to all extremities, was very rigid, unable to bend the knees and hips and had tremors to all extremities. Resident needed to be log rolled in bed with the assistance of two people to provide care. Log rolling is a technique used to turn a patient whose body must always be kept in a straight alignment. RN I, stated, they have been trained to immediately report injuries of unknow origin to the Administrator, ADON, Physician, and responsible party and document notification in electronic record.<BR/>Second interview 01/02/24 6:35 PM Family Member A reported she visits daily in the evening and Family Member A comes to visit Resident #1 during the day shift. She reported LVN C had informed Family Member B that Resident #1 had a bruise on the left groin and according to LVN C had been caused by a tight brief. Family Member A reported she took photos on her own on 12/05/23 to have records of the extent of bruising that her [family member] had on her private areas. Family Member stated, I was able to take the photos on my own, because my [family member] can relax her legs and slightly opened them for me to take the pictures of her private areas. I did not use any force to separate the legs. Family Member A stated, On 12/05/23 CNA F reported to Family Member B that my [family member] had a bruise on the groin to the left leg. I do not know who first noted the bruise to the left groin, on 12/05/23 and I do not know who reported the bruise to Family Member B. LVN C is the one who said that the bruise to the left groin was caused by the brief, and he is the one that convinced the doctors, administrator, and nursing director that the bruise was caused by tight brief. After that the physician told us the bruises had been caused by the brief. On 12/05/23 when I got here in the evening, I found her with a tight brief and told the CNAs. I did not report it to the nurses or Hospice staff. The Hospice CNA gives my [family member] a bed bath Monday-Friday, and not on the weekends.<BR/>Interview 01/03/24 4:07 PM with DON revealed Administrator was the Abuse Prohibition Coordinator. DON reported ADON O had reported Resident #1 had discoloration to the left groin on 12/05/23 via text message at 1:30 PM to the Administrator. DON stated she had assessed resident on 12/05/23 and only noted linear discoloration to left hip. No other bruises were noted at time of assessment. DON stated she did not deem bruises suspicious because LVN C had reported that bruises were caused by disposable brief. DON stated, We follow the Provider Letter related to Reporting Guidelines for reporting incidents to state office and we determine that the bruising was not considered to be of unknown origin since LVN C had reported the bruise was caused by a tight brief. <BR/>Interview 01/03/24 at 4:19 PM Administrator and DON revealed they did not know why LVN C was trying to explain what had caused the discoloration on the left groin. DON stated On 12/05/23 I went to Resident #1's room to check the discoloration to the left groin. The liner discoloration measured 5 cm x 2.5 cm was pinkish/purple color and there were parallel marks on the skin over the discoloration. DON reported that she had not documented her assessment in the resident's electronic record but had written her assessment in her personal notebook. We were trained in nursing school to document assessment in patient's clinical record. DON reported LVN C had not measured the discoloration on the left groin on 12/05/23. <BR/>Telephone interview 01/05/24 at 9:59 AM, Hospice CNA revealed 12/05/23 she had arrived at the facility at approximately 8:29 AM, to provide a bed bath to Resident #1. Resident #1 was lying in bed, when she removed the hospital gown, resident had on a disposable brief and noted linear bruise on left groin area. I immediately went to report the bruise to LVN C and both of us return to the room to show him the bruise on the left leg on the groin area. I had not provided a bed bath yet. I do not remember if the brief was tight or loose. If the brief is too tight, it will cause redness. After I completed the bed bath, I call the Hospice nurse to report the bruise to the left groin area. Resident did not have any other bruise at the time visit was completed. Hospice CNA reported that she provides a bed bath to Resident #1 Monday - Friday and the facility CNAs provide the bed bath on the weekends. Resident is not showered. <BR/>Interview 01/05/24 at 11:18 AM with Administrator revealed ADON O, had sent her a text message on 12/05/23 at 1:32 PM notifying her Resident #1 was found with discoloration to the left groin. The Administrator stated, The DON and I were not at the facility, so I immediately called the facility and talked to LVN C, and he said that he had reported to ADON O approximately 15-20 minutes ago that Resident #1 had discoloration to the left groin. Administrator reported she had not asked LVN C what time the Hospice CNA had reported to him the discoloration to the left groin on 12/05/23. Administrator reported CNA E was assigned to Resident #1on the morning shift on 12/05/23 and said Hospice CNA had reported the discoloration to LVN C after she had completed the bed bath. The Administrator stated that the discoloration to the left groin was not reported to state office because LVN C had said the discoloration had been caused by the brief. Administrator reported staff had been trained to immediately report to Administrator, DON, and ADON injuries of unknown origin and injuries of unknown source should be reported to state office according to facility's policy.<BR/>Review 01/05/24 of cell phone screen shot of Text Message provided by Administrator revealed ADON O notified Administrator on 12/05/23 at 1:32 PM Resident #1 has a discoloration to left inguinal area. [Family member] aware and hospice as well.<BR/>Review of Abuse, Neglect and Exploitation Policy & Procedure implemented 10/24/22 revealed Policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of property. Definitions: Abuse means the willful infliction of injury. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Policy Explanation and Compliance Guidelines: 1. The facility provides resident protection that include:<BR/>Prevention/prohibit resident abuse, neglect, exploitation, and misappropriation of property. Investigation of all allegations. Investigation of Alleged Abuse, Neglect and Exploitation: An immediate thorough investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Providing complete and through documentation of the investigation. Reporting/Response: Reporting of all alleged violation to the Administrator, state agency and other required agencies within specified timeframes; Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #8) of 3 residents reviewed for catheter care. <BR/>The facility failed to ensure Residents #8s catheter leg strap was in place to secure the catheter. <BR/>This failure could place residents with foley catheters at risk of catheter pulling causing pain. <BR/>Findings included:<BR/>Record review of Resident #8's face sheet dated 1/14/25 revealed a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of retention of urine and neuromuscular dysfunction of bladder. <BR/>Record review of Resident #8's significant change MDS assessment dated [DATE] revealed a BIMS score of 15, her cognition was intact and had and had indwelling catheter. <BR/>Record review of Resident #8's physician order dated 10/16/24 revealed ensure catheter strap in place and holding, every shift change as needed. <BR/>Record review of Resident #8's care plan dated 11/19/24 revealed a focus area for [Resident #8] has a Indwelling Catheter with goal of will remain free from catheter-related trauma through review date and interventions that included ensure tubing is anchored to the residents leg or linens so that tubing is not pulling on the urethra. <BR/>In an observation and interview on 1/14/25 at 11:26 am, Resident # 8 was alert and oriented to place, time, and event. While in bed, it was observed that Resident # 8's urinary catheter was positioned below the bladder and hanging over the bed, with no leg strap secured. Resident # 8 stated that the catheter strap had not been in place for two days and that she had reported the issue, though she could not recall to whom or when. Resident # 8 stated that the lack of a secured strap caused discomfort when moving, as it allowed the catheter to shift.<BR/>In an interview on 1/14/25 at 11:35 am, RN B stated that it was the responsibility of nursing aides and nurses to ensure urinary catheters were secured with leg straps and checked at least every two hours or as needed. RN B stated she had not received any communication indicating that Resident #8's catheter strap was not secured. RN B stated that she had spoken to Resident #8 that morning and asked how she was doing, but the resident had not mentioned the issue. RN B stated that during her check that morning, she only ensured the urinary catheter bag was off the floor and in a privacy bag, and she did not verify if the leg strap was in place. RN B stated that checking for the leg strap was part of her assessment, but she had forgotten to do so. RN B stated that the risk of not securing the leg strap included the catheter being tugged or pulled, potentially causing injury or trauma to the urethra. RN B stated she had received training on urinary catheter to include ensuring catheter strap was secured upon hire. <BR/>In an interview on 1/14/25 at 11:49 am, CNA A stated that she had received training on urinary catheter care upon hire and at least twice a year. CNA A explained that it was the CNA's responsibility to ensure the leg strap was secured at all times, with checks performed at least every two hours or as needed. CNA A noted that Resident #8 was verbal and able to communicate her needs. CNA A clarified that she was not the CNA assigned to the resident but had assisted with perineal care. CNA A stated that the risk of an unsecured catheter included possible discomfort, as she had been told that catheter movement when not secured could cause residents some pain.<BR/>In an interview on 1/14/25 at 3:00 pm, the DON stated that all staff, including CNAs, nurses, and nurse managers, were required to conduct rounds regularly. The DON stated nurse managers were expected to perform daily rounds, while CNAs and nurses were required to check on residents constantly and as needed throughout the day. The DON stated that nurses were expected to check catheter placement during their rounds, not just the privacy bags. The DON stated that nurses oversee the CNAs, while nurse managers oversee the nurses. The DON stated that failing to secure the catheter properly increases the risk of it being pulled out accidentally.<BR/>In an interview on 1/14/25 at 4:01 pm, the Administrator referred the question to the DON.<BR/>Record review of the facility's Cather Care policy dated 02/13/2007 read in part hold catheter tubing to one side and support against leg to avoid traction or unnecessary movement of the catheter while washing perineum.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 (Resident #1) of 7 residents reviewed for abuse.<BR/>-LVN C failed to immediately notify the Administrator on 12/05/23 Resident #1 had bruising left groin of unknown origin.<BR/>- Facility failed to report an injury of unknown origin to the State Survey Agency within 24 hours of being reported to Administrator on 12/05/23. <BR/>This failure could place residents at risk for abuse and neglect.<BR/>Findings Included:<BR/>Record review of admission record dated 12/09/2023 revealed Resident #1 was a [AGE] year-old woman admitted to the facility on [DATE]. <BR/>Record review of Resident #1's Annual History and Physical 10/03/2023 revealed she was non-verbal, not alert to surroundings and on hospice care. Patient requires total assistance with ADLs (activities of daily living). Patient bed-bound, gastrostomy tube (feeding tube inserted directly through the abdominal wall into the stomach). Past Medical History: Dementia of the Alzheimer's Type, and Depression. General Examination: Elderly female, ill-appearing, thin, frail. Full range of motion to bilateral lower extremities. Contractures to bilateral upper extremities. <BR/>Record review of Resident #1's annual MDS assessment dated [DATE] revealed minimal difficulty hearing; No speech; rarely/never makes self-understood; rarely/never understand others; impaired vision; Because she was nonverbal the BIMS (Brief Interview for Mental Status) was not completed. Staff assessment for mental status revealed she had problems with both short- and long-term memory. Cognitive Skills for daily decision making, severely impaired; no symptomatic behaviors; functional limitation in range of motion impairment on both sides of upper/lower extremities; Active diagnoses included Alzheimer disease and non-Alzheimer's dementia. She was totally dependent on staff for eating, oral hygiene, toileting, bathing, dressing and personal hygiene. Incontinent of bladder and bowel. Wheelchair. Active diagnoses included Progressive Neurological Conditions, non-Alzheimer's Dementia, malnutrition, anxiety, depression, psychotic disorder, muscle spasms. No history of falls. No pain. Feeding tube. No pressure ulcers. Medications-antidepressant/antianxiety. Hospice Care.<BR/>Record review of Resident #1's care plan revised on 01/28/2021 revealed she was never to rarely understood. Care plan revised 10/13/2022 revealed she had an ADL self-care performance deficit related to cognitive impairment, limitations in range of motion, impaired balance/impaired coordination, and visual impairment. Transfers required two staff members using a Hoyer (mechanical) lift. Toileting total assistance x 2 staff. Non-ambulatory. Wheelchair total x 1 staff. Dressing, Personal Hygiene, and Bathing x 1 staff. <BR/>Review of Hospice Visit Note Report dated 12/05/23 written by Hospice CNA revealed In-House Time: 8:29 AM; Completed: 9:46 AM. ADL Services completed: Turn and position in bed, bed bath, shampoo, skin care, oral care and changed linens.<BR/>Record review of Resident #1's Nursing Note by LVN C dated 2/5/2023 revealed that the Hospice CNA provided a shower to the resident and reported discoloration to left inguinal area. Skin assessment was completed on resident, and she was noted to have a discoloration to left inguinal area. The note stated that education was provided to CNAs to not to tighten brief too much. A family member (unidentified) was at the facility and was aware. <BR/>In an interview on 02/09/2024 at 9:55 AM Resident #1's Family Member A revealed she visited Resident #1 every afternoon and helped with toileting, and Family Member B visited Resident #1 every morning and helped with toileting. Family Member A said she had changed Resident #1's briefs the afternoon of 12/04/2023 and saw no unusual discolorations in her pelvic area, but the afternoon of 12/05/2023 during brief changes she saw bruising on Resident #1's left inner thigh and left groin area. She described the bruising a purple and said that since the bruising was first noted it has spread across the pelvis and that there was also bruising near the resident's vagina. Family Member A said Family Member B had reported to her that the morning of 12/05/2023 Family Member B observed that Resident #1 had bruising in her pelvic area. Family Member A stated that Family Member B had reported the bruising to the Hospice CNA and the Hospice CNA had reported it to the facility LVN C. <BR/>In an interview on 12/09/2023 at 12:42 PM with the Administrator and DON, the DON stated that Resident #1's bruising was not considered to be of unknown origin because LVN C thought the bruising was due to the resident's brief being too tight, and so was not reported to the state. The DON said the facility had gone with LVN C's assessment that the bruising was from the brief being too tight but started post-risk management such as labs and x-rays. She said the facility was looking into the bruising to try to explain it. <BR/>In an interview on 12/09/2023 at 1:17 PM LVN C revealed that the morning of 12/05/2023 the Hospice CNA asked him to come and look at a bruise on Resident #1. LVN C stated the Hospice CNA had finished bathing Resident #1 and Resident #1 was lying in bed in a gown with no brief on. LVN C stated he examined Resident #1 and found a bruise on the left groin area that extended around six inches along the groin. LVN C stated he checked the resident for pain by touching the bruise but that she did not have any grimacing or moaning. LVN C said the next day the bruising had spread across the abdomen to the right groin and on the pelvic area. He stated that because of the shape of the bruise he continued to think the bruise might have been caused by a tight brief. <BR/>In an interview on 12/09/2023 at 1:50 PM CNA E revealed she had been assigned to Resident #1 the morning of 12/05/2023 and spoke to the Hospice CNA about Resident #1 around 6:15 AM that morning. CNA E said the Hospice CNA had provided a bed bath and mentioned that the resident had a bruise. CNA E observed that Resident #1 had a light-yellow bruise in the left inguinal area. The CNA said the resident would stiffen up when her brief was being changed but that did not make it difficult to change her brief. The CNA said all care was provided to the resident in bed, and that she had never transferred the resident out of bed. <BR/>In an interview on 12/11/2023 at 9:08 AM the Hospice CNA revealed she had provided a bed bath to Resident #1 on 12/05/2023. She stated that when she began care the resident was wearing a brief which was as tight as usual. The Hospice CNA stated when she removed the resident's brief, she noticed bruising and called the nurse. The bruises were purple and in the left inguinal (where the front of the upper thigh meets the body) area extending a little in the direction of the leg. There was no bruising noted in the other areas. The Hospice CNA said she told the nurse (LVN C) and he said the bruising was from the brief because it was more in the inguinal area. She said she worked with about five residents in the facility and had never found them with tight briefs.<BR/>In an interview on 12/11/2023 at 2:15 PM the DON revealed she assessed Resident #1 the afternoon of 12/05/2023 and observed bruising to the left inguinal area, with none to the pelvic area. She was unaware that the morning of 12/05/2023 the Hospice CNA had reported the bruising LVN C. <BR/>In an interview on 12/11/1023 at 4:32 PM the Hospice Nurse revealed she received a call on 12/05/2023 at 9:21 AM from the Hospice CNA advising her that Resident #1 had a bruise in the left inguinal area. The Hospice Nurse said she was scheduled to do a visit on 12/07/2023 and decided to wait until then see the resident. <BR/>Second Interview 01/02/24 at 12:40 PM LVN C revealed Tuesday 12/05/23 at approximately 10:00 AM, Hospice CNA came to the nurse's station to report she had noted Resident #1 had a linear discoloration slightly below the fold to the left groin while giving resident a bed bath. Upon assessment Resident #1 was lying in bed on her back, without a disposable brief and noted linear reddish area below the left groin, no other discoloration was noted at time of assessment. The discoloration was on the area where the brief is placed between the folds of the legs and taped to the sides. Resident is non-verbal and requires total assistance with activities of daily living. <BR/>Second interview 01/02/24 at 1:10 PM CNA E revealed she was assigned to Resident #1 12/05/23 on the 6-2 AM shift. At approximately 6:15 AM, Hospice CNA was in the room giving Resident #1 a bed bath. I was in the room preparing the roommate to get her out of bed for breakfast. At that time the Hospice CNA asked if I had seen any bruises on resident on 12/04/23. I said no. She asked me to come and see the bruise resident had on left groin area. There was a linear bruise slightly below the fold of the left leg about 2 inches long and half the size of the width of a pen. There were no other bruises noted at that time. After lunch at approximately 12:30 PM, I was in the room attempting to explain Family Member B when she came to visit the resident what we thought had caused the bruise, when LVN C came to resident's room, and he informed Family Member B of the red area below the left groin. CNA E reported staff had been trained to immediately report abuse/neglect/any injury to the nurses. <BR/>Second interview 01/02/24 2:47 PM RN I revealed she was assigned to Resident #1 on 2-10 PM shift on 12/05/23. She stated LVN C had reported at change of shift Resident #1 had a linear bruise slightly below the groin from the brief being too tight. RN stated, Upon assessment she noted Resident #1 had a linear bruise slightly below left groin that was approximately 1-1 &frac12; inches long. The bruising was at the front of the bulk of the brief in the groin area where the tapes are tied to the sides. I have never seen residents with tight briefs. I did not recall seeing any other bruises on that day. It looked like the bruise could have been caused by brief being pulled too tight. RN I, reported resident was non-verbal and required total assistance with ADLs, had contractures to all extremities, was very rigid, unable to bend the knees and hips and had tremors to all extremities. Resident needed to be log rolled in bed with the assistance of two people to provide care. Log rolling is a technique used to turn a patient whose body must always be kept in a straight alignment. RN I, stated, they have been trained to immediately report injuries of unknow origin to the Administrator, ADON, Physician, and responsible party and document notification in electronic record.<BR/>Second interview 01/02/24 6:35 PM Family Member A reported she visits daily in the evening and Family Member A comes to visit Resident #1 during the day shift. She reported LVN C had informed Family Member B that Resident #1 had a bruise on the left groin and according to LVN C had been caused by a tight brief. Family Member A reported she took photos on her own on 12/05/23 to have records of the extent of bruising that her [family member] had on her private areas. Family Member stated, I was able to take the photos on my own, because my [family member] can relax her legs and slightly opened them for me to take the pictures of her private areas. I did not use any force to separate the legs. Family Member A stated, On 12/05/23 CNA F reported to Family Member B that my [family member] had a bruise on the groin to the left leg. I do not know who first noted the bruise to the left groin, on 12/05/23 and I do not know who reported the bruise to Family Member B. LVN C is the one who said that the bruise to the left groin was caused by the brief, and he is the one that convinced the doctors, administrator, and nursing director that the bruise was caused by tight brief. After that the physician told us the bruises had been caused by the brief. On 12/05/23 when I got here in the evening, I found her with a tight brief and told the CNAs. I did not report it to the nurses or Hospice staff. The Hospice CNA gives my [family member] a bed bath Monday-Friday, and not on the weekends.<BR/>Interview 01/03/24 4:07 PM with DON revealed Administrator was the Abuse Prohibition Coordinator. DON reported ADON O had reported Resident #1 had discoloration to the left groin on 12/05/23 via text message at 1:30 PM to the Administrator. DON stated she had assessed resident on 12/05/23 and only noted linear discoloration to left hip. No other bruises were noted at time of assessment. DON stated she did not deem bruises suspicious because LVN C had reported that bruises were caused by disposable brief. DON stated, We follow the Provider Letter related to Reporting Guidelines for reporting incidents to state office and we determine that the bruising was not considered to be of unknown origin since LVN C had reported the bruise was caused by a tight brief. <BR/>Interview 01/03/24 at 4:19 PM Administrator and DON revealed they did not know why LVN C was trying to explain what had caused the discoloration on the left groin. DON stated On 12/05/23 I went to Resident #1's room to check the discoloration to the left groin. The liner discoloration measured 5 cm x 2.5 cm was pinkish/purple color and there were parallel marks on the skin over the discoloration. DON reported that she had not documented her assessment in the resident's electronic record but had written her assessment in her personal notebook. We were trained in nursing school to document assessment in patient's clinical record. DON reported LVN C had not measured the discoloration on the left groin on 12/05/23. <BR/>Telephone interview 01/05/24 at 9:59 AM, Hospice CNA revealed 12/05/23 she had arrived at the facility at approximately 8:29 AM, to provide a bed bath to Resident #1. Resident #1 was lying in bed, when she removed the hospital gown, resident had on a disposable brief and noted linear bruise on left groin area. I immediately went to report the bruise to LVN C and both of us return to the room to show him the bruise on the left leg on the groin area. I had not provided a bed bath yet. I do not remember if the brief was tight or loose. If the brief is too tight, it will cause redness. After I completed the bed bath, I call the Hospice nurse to report the bruise to the left groin area. Resident did not have any other bruise at the time visit was completed. Hospice CNA reported that she provides a bed bath to Resident #1 Monday - Friday and the facility CNAs provide the bed bath on the weekends. Resident is not showered. <BR/>Interview 01/05/24 at 11:18 AM with Administrator revealed ADON O, had sent her a text message on 12/05/23 at 1:32 PM notifying her Resident #1 was found with discoloration to the left groin. The Administrator stated, The DON and I were not at the facility, so I immediately called the facility and talked to LVN C, and he said that he had reported to ADON O approximately 15-20 minutes ago that Resident #1 had discoloration to the left groin. Administrator reported she had not asked LVN C what time the Hospice CNA had reported to him the discoloration to the left groin on 12/05/23. Administrator reported CNA E was assigned to Resident #1on the morning shift on 12/05/23 and said Hospice CNA had reported the discoloration to LVN C after she had completed the bed bath. The Administrator stated that the discoloration to the left groin was not reported to state office because LVN C had said the discoloration had been caused by the brief. Administrator reported staff had been trained to immediately report to Administrator, DON, and ADON injuries of unknown origin and injuries of unknown source should be reported to state office according to facility's policy.<BR/>Review 01/05/24 of cell phone screen shot of Text Message provided by Administrator revealed ADON O notified Administrator on 12/05/23 at 1:32 PM Resident #1 has a discoloration to left inguinal area. [Family member] aware and hospice as well.<BR/>Review of Abuse, Neglect and Exploitation Policy & Procedure implemented 10/24/22 revealed Policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of property. Definitions: Abuse means the willful infliction of injury. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Policy Explanation and Compliance Guidelines: 1. The facility provides resident protection that include:<BR/>Prevention/prohibit resident abuse, neglect, exploitation, and misappropriation of property. Investigation of all allegations. Investigation of Alleged Abuse, Neglect and Exploitation: An immediate thorough investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Providing complete and through documentation of the investigation. Reporting/Response: Reporting of all alleged violation to the Administrator, state agency and other required agencies within specified timeframes; Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assure that one (Resident #5) of seven residents reviewed for enteral feeding, received appropriate treatment and services to prevent complications of enteral feeding. <BR/>-The facility failed to ensure that Resident #5's feeding tube bags were labeled with name of resident, date, and time the administration began to ensure residents maintain nutritional status within optimal parameters.<BR/>This failure could place residents receiving enteral feedings at risk of not being provided the correct enteral feeding and not receiving feeding care in a timely manner to prevent complications. <BR/>Findings included: <BR/>Record review of Resident #5's face sheet dated [DATE], revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Diagnosis included dysphagia (difficulty swallowing) and gastrostomy status (surgical procedure used to insert a tube through the abdomen and into the stomach). <BR/>Record review of Resident #5's MDS assessment dated [DATE], revealed the resident is rarely/never understood. The Swallowing/Nutritional Status section revealed a feeding tube was in place and the resident had not had weight loss or gain of 5% in the last month or 10% or more in the last 6 months. <BR/>Record review of Resident#5's weight records dated [DATE] to [DATE], revealed no significant weight loss or weight gain. <BR/>Record review of Resident #5's comprehensive care plan dated [DATE] revealed Resident #5 required the use of a feeding tube and was at risk for aspirations, weight loss, and dehydration. Feeding tube is related to not eating enough to meet daily nutritional requirements., significant weight loss. Interventions in place included administer tube feeding and water flushes as ordered.<BR/>Record review of Resident #5's physician order dated [DATE] revealed Enteral Feed Order in the evening Enteral Feeding Continuously: Formula: Jevity 1.2, Rate: 60 ml/hr.<BR/>Observation on [DATE] at 2:03 p.m., of Resident #5 revealed the tube feeding container was infusing via pump and into the resident. The feeding tube was set at 60 ml/hr. The enteral feeding bag was not labeled with the feeding formula name, resident's name, the date, the time it was hung, the initials of who had hung it, and tube feeding order information. The hanging water bag had a label that read Jevity 1.2 at 55 ml.hr. <BR/>During an interview and observation on [DATE] at 2:09 p.m., LVN C said she changed Resident #5's feeding bag on [DATE] at 7:00 p.m. LVN C said she used a sticker type label and that the label must have fallen off. Label not located through search of room. LVN C said she did not know what happened to the label. LVN C said the setting of 60 m/hr was correct but the sticker label on water bag was wrong. LVN C said that it was her mistake when she placed the sticker label on the water bag with incorrect information. LVN C said Resident #5's automatic feeding machine was at the correct setting per orders.<BR/>During an interview on [DATE] at 9:30 a.m., the DON said Resident #5 had not experienced any significant weight loss or weight gain or any complications with tube feeding. The DON said the risk of failing to label an enteral feeding bag was possibility of not knowing if the feeding is at the appropriate rate, speed and how old the formula was. The DON said the risk could be using an expired product or the wrong product. <BR/>Record review of facility policy titled Gastrostomy Tube Care dated 2007, reads in part Labeling/Dating - formula and or feedings should be labeled with at least the date and time the administration begun.

Based on observation, interview, and record review, the facility failed to maintain an a safe, clean, comfortable, and homelike environment for 5 of 5 confidential residents. <BR/>The facility failed to ensure SCA was sanitized after each use with residents.<BR/>This failure could place residents at risk for being in an unclean environment, cross contamination and the spread of infection.<BR/>The findings included: <BR/>During a confidential group interview on 07/18/22 beginning at 10:30 AM, 5 of 5 residents complained of issues of the shower chairs not being cleaned. <BR/>During observation and interview on 07/19/22 at 4:50 PM of the Men's shower room on Hall B, with ADON D, revealed a reclining shower chair (SCA) that appeared to not have been cleaned. The seat of the SCA had a brown smear on the top of the seat cushion. The back of the SCA seat cushion had a line of brown substance along the bottom, the back mesh had a brown film along the edge, the white PCP pipe at the seat had brown substance that looked to have ran down the pipe from the seat. ADON D stated the SCA looked to be soiled and unclean . ADON D stated aides are to clean shower chairs with disinfectant after each shower. ADON D stated she would not want to be showered in the SCA and residents should not be showered in the SCA. ADON D stated not cleaning shower chairs properly could cause residents to have received skin infections. ADON D stated she was responsible for ensuring CNA's clean shower chairs. <BR/>During an interview on 07/20/22 at 12:25 PM with the DON , she stated shower chairs need to be cleaned between each resident. The DON stated she looked at the SCA and she could not say the residue was or was not BM, but it could have been mixture of soap, dirt, and skin. The DON stated the failure of chairs not being cleaned was staff not being detailed when they cleaned the shower chairs.<BR/>Record review of policy titled, Clinical practice Guideline: Cleaning and Disinfecting Portable Equipment, dated 05/04/21 revealed: It is the policy of this facility to follow infection control principles to prevent spread and infection through contact with portable equipment in the resident's care environment . Staff shall follow environmental infection control principles for cleaning and disinfecting the equipment. Each user is responsible for routine cleaning and disinfection. Cleaning shall be performed daily and between residents.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 1 of 2 treatment carts (North Side) checked for medication storage. <BR/>1. The facility failed to ensure Santyl Ointments stored in treatment cart had a prescription label. <BR/>2. The facility failed to store prescribed and over the counter external ointments separately and labeled with resident's name. <BR/>3. The facility failed to ensure oral swabs were not stored with external ointments in the treatment cart. <BR/>4. The facility failed to remove medications from treatment carts after residents were discharged from the facility. <BR/>These failures could affect residents that received treatments at the facility by placing them at risk of not having prescribed medications and cross contamination. <BR/>Findings include: <BR/>Observation and interview on 02/12/24 at 11:08 AM, with the Treatment Nurse revealed facility had two treatment carts. An observation of Treatment Cart #1 (North Side) revealed multiple tubes of MediHoney, Santyl, Mupirocin ointment was stored together in a square plastic box in the top drawer. The nurse stated, We have been trained to store the ointments in a sealed plastic bag with the resident's name. We buy MediHoney ointment over the counter, and each resident should have a tube for individual use and stored in a plastic bag with the resident's name. It was observed that the Santyl ointment tubes were not labeled. There was a wound vac stored in the treatment cart in the third drawer. The nurse stated, It belongs to one of the residents, it was discontinued two weeks ago. We stored the wound vac in the treatment cart because we did not know if we had to return it to the vendor. It should not be stored in the cart with the clean supplies. The wound vac was immediately removed by nurse from the treatment cart. The nurse reported there were a couple of ointments still stored in the treatment cart for residents that had been discharged home . The nurses had been trained to give all the medicines including ointments to the residents upon discharge and remove discontinued ointments from treatment carts. It was observed that oral care swabs were stored in the treatment cart with gauze bandages packets and rolls of self-adherent wrap. The self-adherent wrap was not stored in sealed bags. <BR/>Review of the facility's policy on Medication Storage dated 01/20/21 revealed policy: It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, and security. Policy Explanation and Compliance Guidelines: The medication carts are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed in accordance with the facility policy. <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 received adequate supervison and assistance devices to prevent accidents for 1 of 5 (Resident #4) residents reviewed for repositioning. <BR/>The facility failed to ensure Resident #4 was repositioned using a drawsheet, CNA E grabbed Resident #4 right elbow to assist with scooting up to bed of head. <BR/>This failure could place residents at risk of bruising, pain, or possible injury. <BR/>Findings include: <BR/>Record review of Resident #4's face sheet dated 08/22/2023 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of anoxic brain damage, dysphagia, muscle wasting ad atrophy. <BR/>Record review of Resident #4's MDS quarterly assessment dated [DATE] revealed BIMS score of 0, he as severely cognitive impaired. <BR/>Record review of Resident #4's care plan dated 07/17/2023 revealed focus care for ADLs with interventions of bed mobility required total assistance of 2 staff .<BR/>During observation and interview on 08/22/2023 at 11:10 am, Resident #4 was in bed, he was nonverbal. CNA E and CNA F had finished proving perineal care and Resident #4 needed to be repositioned in bed. CNA E and CNA F both agreed to scoot Resident #4 up to head of bed, drawsheet was noted under Resident #4. CNA F was on Resident #4 right side of bed and held on to drawsheet and CNA E was on left side of bed did not grab the drawsheet. CNA E and CNA F pulled Resident #4 up to head of bed, CNA E grabbed on to Resident #4 left elbow while CNA F used to drawsheet to pull him up. No distress noted to Resident #4 after he was repositioned. CNA E stated she had been trained to use the drawsheet to repositioned residents and did not have reason for grabbing Resident #4 let elbow to reposition. CNA E stated she should have used the drawsheet to reposition Resident #4 instead of grabbing his left elbow. CNA E stated she could have injured him. LVN G was at bedside and assessed Resident #4 left elbow and stated there was no redness note to his left elbow and no sign of pain during assessment. <BR/>During interview on 08/22/2023 at 12:56 pm, the DON stated all CNAs had been trained on repositioning upon hire, annually and as needed thru competency check off. DON stated when repositioning a resident wo required total sist with 2 staff required to use a draw sheet while in bed. DON stated it was expected for CNAs to use drawsheet to reposition to side to side or up to head of the bed. DON stated CNAs were never to hold on to resident arms and/or elbows to assist up to head of bed because there was risk of bruising, injury and/or possible dislocation.

Based on observation, interview, and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for 1 (02/10/2024) of 6 days reviewed for nurse staffing information. <BR/> The facility failed to post the required staffing information for 02/10/2024. <BR/> This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census. <BR/> Finding include: <BR/> During observation and record review on 02/10/2024 at 9:50 a.m. of the public access area nursing station located outside of the DON office, revealed a Daily Staffing Hours sheet posting information which included facility name, census, total hours for RNs, LVNs, CNAs, MAs, and shift times that was dated 02/09/2024. <BR/>In an interview on 02/13/2024 at 11:20 AM, the Administrator revealed that anyone in nursing administration was responsible for posting the nurse staffing data [Daily Staffing Hours] as soon as possible each day, as soon as staff started coming in which was usually at 8:00 AM. The Administrator stated for weekends, the Daily Staffing Hours sheet was left ready based on the planned schedule, and nursing staff were expected to post the sheet unless there was a last-minute call from staff resulting in the need to update the staffing sheet. She said the staffing sheets were important for families so they could know how many CNAs and nurses were assigned to provide patient care. The Administrator said the staffing sheets were also important for the continuity of care so families would know that care was consistent, and families could be comfortable knowing the facility was taking care of loved ones. She said no one was in charge Saturday morning [02/10/2024] to post the Daily Staffing Hours sheet. She said the facility did not have a policy regarding posting daily nurse staffing information and that the facility followed state guidelines. <BR/>In an interview on 02/13/2024 at 11:30 AM, the DON revealed that, on weekends, the weekend receptionist was responsible for posting the Daily Staffing Hours sheet. She said the Daily Staffing Hours sheet was supposed to be posted by 8:30 AM or 9:00 AM at the latest. The DON said the Daily Staffing Hours sheet needed to be available to let anyone know the ratio of staff to provide care to residents. The DON said that managers were aware they should look for Daily Staffing Hours sheet when they arrived at the facility, including the nurse on weekends. She said that when she arrived at the facility on Saturday (02/10/2024) at about 10:55 AM, she saw the Daily Staffing Hours was not correct and changed it when she arrived. She said she spoke with the receptionist about the Daily Staffing Hours sheet not being changed and showed him how to do it. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assure that one (Resident #5) of seven residents reviewed for enteral feeding, received appropriate treatment and services to prevent complications of enteral feeding. <BR/>-The facility failed to ensure that Resident #5's feeding tube bags were labeled with name of resident, date, and time the administration began to ensure residents maintain nutritional status within optimal parameters.<BR/>This failure could place residents receiving enteral feedings at risk of not being provided the correct enteral feeding and not receiving feeding care in a timely manner to prevent complications. <BR/>Findings included: <BR/>Record review of Resident #5's face sheet dated [DATE], revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Diagnosis included dysphagia (difficulty swallowing) and gastrostomy status (surgical procedure used to insert a tube through the abdomen and into the stomach). <BR/>Record review of Resident #5's MDS assessment dated [DATE], revealed the resident is rarely/never understood. The Swallowing/Nutritional Status section revealed a feeding tube was in place and the resident had not had weight loss or gain of 5% in the last month or 10% or more in the last 6 months. <BR/>Record review of Resident#5's weight records dated [DATE] to [DATE], revealed no significant weight loss or weight gain. <BR/>Record review of Resident #5's comprehensive care plan dated [DATE] revealed Resident #5 required the use of a feeding tube and was at risk for aspirations, weight loss, and dehydration. Feeding tube is related to not eating enough to meet daily nutritional requirements., significant weight loss. Interventions in place included administer tube feeding and water flushes as ordered.<BR/>Record review of Resident #5's physician order dated [DATE] revealed Enteral Feed Order in the evening Enteral Feeding Continuously: Formula: Jevity 1.2, Rate: 60 ml/hr.<BR/>Observation on [DATE] at 2:03 p.m., of Resident #5 revealed the tube feeding container was infusing via pump and into the resident. The feeding tube was set at 60 ml/hr. The enteral feeding bag was not labeled with the feeding formula name, resident's name, the date, the time it was hung, the initials of who had hung it, and tube feeding order information. The hanging water bag had a label that read Jevity 1.2 at 55 ml.hr. <BR/>During an interview and observation on [DATE] at 2:09 p.m., LVN C said she changed Resident #5's feeding bag on [DATE] at 7:00 p.m. LVN C said she used a sticker type label and that the label must have fallen off. Label not located through search of room. LVN C said she did not know what happened to the label. LVN C said the setting of 60 m/hr was correct but the sticker label on water bag was wrong. LVN C said that it was her mistake when she placed the sticker label on the water bag with incorrect information. LVN C said Resident #5's automatic feeding machine was at the correct setting per orders.<BR/>During an interview on [DATE] at 9:30 a.m., the DON said Resident #5 had not experienced any significant weight loss or weight gain or any complications with tube feeding. The DON said the risk of failing to label an enteral feeding bag was possibility of not knowing if the feeding is at the appropriate rate, speed and how old the formula was. The DON said the risk could be using an expired product or the wrong product. <BR/>Record review of facility policy titled Gastrostomy Tube Care dated 2007, reads in part Labeling/Dating - formula and or feedings should be labeled with at least the date and time the administration begun.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assure that one (Resident #5) of seven residents reviewed for enteral feeding, received appropriate treatment and services to prevent complications of enteral feeding. <BR/>-The facility failed to ensure that Resident #5's feeding tube bags were labeled with name of resident, date, and time the administration began to ensure residents maintain nutritional status within optimal parameters.<BR/>This failure could place residents receiving enteral feedings at risk of not being provided the correct enteral feeding and not receiving feeding care in a timely manner to prevent complications. <BR/>Findings included: <BR/>Record review of Resident #5's face sheet dated [DATE], revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Diagnosis included dysphagia (difficulty swallowing) and gastrostomy status (surgical procedure used to insert a tube through the abdomen and into the stomach). <BR/>Record review of Resident #5's MDS assessment dated [DATE], revealed the resident is rarely/never understood. The Swallowing/Nutritional Status section revealed a feeding tube was in place and the resident had not had weight loss or gain of 5% in the last month or 10% or more in the last 6 months. <BR/>Record review of Resident#5's weight records dated [DATE] to [DATE], revealed no significant weight loss or weight gain. <BR/>Record review of Resident #5's comprehensive care plan dated [DATE] revealed Resident #5 required the use of a feeding tube and was at risk for aspirations, weight loss, and dehydration. Feeding tube is related to not eating enough to meet daily nutritional requirements., significant weight loss. Interventions in place included administer tube feeding and water flushes as ordered.<BR/>Record review of Resident #5's physician order dated [DATE] revealed Enteral Feed Order in the evening Enteral Feeding Continuously: Formula: Jevity 1.2, Rate: 60 ml/hr.<BR/>Observation on [DATE] at 2:03 p.m., of Resident #5 revealed the tube feeding container was infusing via pump and into the resident. The feeding tube was set at 60 ml/hr. The enteral feeding bag was not labeled with the feeding formula name, resident's name, the date, the time it was hung, the initials of who had hung it, and tube feeding order information. The hanging water bag had a label that read Jevity 1.2 at 55 ml.hr. <BR/>During an interview and observation on [DATE] at 2:09 p.m., LVN C said she changed Resident #5's feeding bag on [DATE] at 7:00 p.m. LVN C said she used a sticker type label and that the label must have fallen off. Label not located through search of room. LVN C said she did not know what happened to the label. LVN C said the setting of 60 m/hr was correct but the sticker label on water bag was wrong. LVN C said that it was her mistake when she placed the sticker label on the water bag with incorrect information. LVN C said Resident #5's automatic feeding machine was at the correct setting per orders.<BR/>During an interview on [DATE] at 9:30 a.m., the DON said Resident #5 had not experienced any significant weight loss or weight gain or any complications with tube feeding. The DON said the risk of failing to label an enteral feeding bag was possibility of not knowing if the feeding is at the appropriate rate, speed and how old the formula was. The DON said the risk could be using an expired product or the wrong product. <BR/>Record review of facility policy titled Gastrostomy Tube Care dated 2007, reads in part Labeling/Dating - formula and or feedings should be labeled with at least the date and time the administration begun.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #8) of 3 residents reviewed for catheter care. <BR/>The facility failed to ensure Residents #8s catheter leg strap was in place to secure the catheter. <BR/>This failure could place residents with foley catheters at risk of catheter pulling causing pain. <BR/>Findings included:<BR/>Record review of Resident #8's face sheet dated 1/14/25 revealed a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of retention of urine and neuromuscular dysfunction of bladder. <BR/>Record review of Resident #8's significant change MDS assessment dated [DATE] revealed a BIMS score of 15, her cognition was intact and had and had indwelling catheter. <BR/>Record review of Resident #8's physician order dated 10/16/24 revealed ensure catheter strap in place and holding, every shift change as needed. <BR/>Record review of Resident #8's care plan dated 11/19/24 revealed a focus area for [Resident #8] has a Indwelling Catheter with goal of will remain free from catheter-related trauma through review date and interventions that included ensure tubing is anchored to the residents leg or linens so that tubing is not pulling on the urethra. <BR/>In an observation and interview on 1/14/25 at 11:26 am, Resident # 8 was alert and oriented to place, time, and event. While in bed, it was observed that Resident # 8's urinary catheter was positioned below the bladder and hanging over the bed, with no leg strap secured. Resident # 8 stated that the catheter strap had not been in place for two days and that she had reported the issue, though she could not recall to whom or when. Resident # 8 stated that the lack of a secured strap caused discomfort when moving, as it allowed the catheter to shift.<BR/>In an interview on 1/14/25 at 11:35 am, RN B stated that it was the responsibility of nursing aides and nurses to ensure urinary catheters were secured with leg straps and checked at least every two hours or as needed. RN B stated she had not received any communication indicating that Resident #8's catheter strap was not secured. RN B stated that she had spoken to Resident #8 that morning and asked how she was doing, but the resident had not mentioned the issue. RN B stated that during her check that morning, she only ensured the urinary catheter bag was off the floor and in a privacy bag, and she did not verify if the leg strap was in place. RN B stated that checking for the leg strap was part of her assessment, but she had forgotten to do so. RN B stated that the risk of not securing the leg strap included the catheter being tugged or pulled, potentially causing injury or trauma to the urethra. RN B stated she had received training on urinary catheter to include ensuring catheter strap was secured upon hire. <BR/>In an interview on 1/14/25 at 11:49 am, CNA A stated that she had received training on urinary catheter care upon hire and at least twice a year. CNA A explained that it was the CNA's responsibility to ensure the leg strap was secured at all times, with checks performed at least every two hours or as needed. CNA A noted that Resident #8 was verbal and able to communicate her needs. CNA A clarified that she was not the CNA assigned to the resident but had assisted with perineal care. CNA A stated that the risk of an unsecured catheter included possible discomfort, as she had been told that catheter movement when not secured could cause residents some pain.<BR/>In an interview on 1/14/25 at 3:00 pm, the DON stated that all staff, including CNAs, nurses, and nurse managers, were required to conduct rounds regularly. The DON stated nurse managers were expected to perform daily rounds, while CNAs and nurses were required to check on residents constantly and as needed throughout the day. The DON stated that nurses were expected to check catheter placement during their rounds, not just the privacy bags. The DON stated that nurses oversee the CNAs, while nurse managers oversee the nurses. The DON stated that failing to secure the catheter properly increases the risk of it being pulled out accidentally.<BR/>In an interview on 1/14/25 at 4:01 pm, the Administrator referred the question to the DON.<BR/>Record review of the facility's Cather Care policy dated 02/13/2007 read in part hold catheter tubing to one side and support against leg to avoid traction or unnecessary movement of the catheter while washing perineum.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of one (Resident #2) of seven residents reviewed for availability of medications. <BR/>The facility failed to obtain and administer Lyrica (pain medication) nine time between 12/01/23 and 12/05/2023 as per physician's orders to Resident #2. <BR/>This failure puts residents at risk of not receiving prescribed medications and experiencing pain or other symptoms of diagnosed conditions. <BR/>Findings included:<BR/>Record review of Resident #2's face sheet dated 12/12/2023 revealed he was [AGE] years old, was initially 06/30/2023 and readmitted on [DATE]. <BR/>Record review of Resident #2's History and physical dated 07/03/2023 revealed he had bilateral foot deformities with osteomyelitis (swelling in the bones usually due to an infection), and amputation of his left big toe and other left toes. He was prescribed 5 MG of Eliquis (a pain medication) twice a day. <BR/>Record review of Resident #2's 5-day MDS assessment dated [DATE] he had a BIMS of 15 (cognitively intact). He had not signs or symptoms of delirium or psychosis. He had no symptomatic behaviors. He received both scheduled pain medication and PRN medications during the five day look back period. At the time of the MDS assessment he had no pain over the previous five days. He had taken opioids twice during the past seven days. <BR/>Record review of Resident #2's care plan initiated 09/26/2023 revealed he was on a pain management regimen and took analgesics routinely or as needed.<BR/>Record review of Resident #2's physicians orders revealed an order dated 08/17/2023 for 150 MG of Lyrica to be administered twice a day for pain. Medications were to be administered as ordered. <BR/>In an interview on 12/12/2023 at 3:40 PM Resident #2 revealed that two weekends prior the facility had run out of his medicine for nerve pain [Lyrica). He said it was because the facility had to wait for a new prescription. He said he also received Tylenol 3 (pain medication - acetaminophen) if he needed it. He said that staff did not consistently assess or reassess his pain. <BR/>Record review of Resident #2's December 2023 MAR revealed that he did not receive the physician-ordered two doses of Lyrica 150 MG on 12/01/23 (Friday), 12/02/23, 12/03/23, 12/4/24 or the prescribed dose of Lyrica 150 MG the morning of 12/05/2023 for a total of 9 missed doses. During that time period he received Tylenol 3 nine times. All times it was recorded as having been effective. <BR/>In an interview on 12/12/2023 at 3:53 RN J revealed Resident #2 was administered Lyrica twice a day for nerve pain. RN J said he worked Monday through Friday and twice when he returned from the weekend, the facility was out of Resident #2's Lyrica. He said the morning nurse was responsible for calling in refills, and if a new prescription was needed, getting a medication could take a little longer. RN J said RN K ordered Resident #2's Lyrica on a Wednesday, they ran out of the medication on Thursday, and then did not get more until the next Monday because of a physician delay. RN J said if there is a refill for a medication, the nurse can get code from pharmacy to get it from the NexSys (a system that stores medications for emergencies), but if a new prescription is needed there can be a delay in getting medications, and that was what happened with Resident #2's Lyrica. <BR/>In an interview on 12/12/2023 at 3:59 PM the DON revealed she was not aware Resident #2 had run out of Lyrica. She said the staff member responsible for administering a medication was also responsible for refills and new prescriptions and in this situation that would be RN K. The DON stated that refills can take 8 days for short-term residents to 2 weeks for long term residents. If there are refills a medication can be pulled from the NexSys (a system that stores medications for emergencies)but that was not the case if a prescription refill was needed. She said that the risk to the resident was that he could have pain that was not adequately controlled. She stated that pain was assessed each shift and documented for PRN pain medications. <BR/>In an interview on 12/12/2023 at 4:12 PM RN K revealed she was responsible to calling in refills for medications and they are usually delivered the next day. She said that one of the problem with the system for refills was that the pharmacy does not tell her if a resident was out of refills for a medication. She said that was what happened with Resident #2. She had called in a refill for Resident #2's Lyrica the morning of 11/30/23 and was told would be in on Friday. Friday morning the Lyrica did not arrive in the morning delivery so she called the pharmacy again and was told it would arrive on Saturday. She did not work over the weekend and when she arrived on Monday (12/04/2023) the Lyrica still had not come in. She called the pharmacy she was told they needed a new prescription. She said she was a designated representative for the physician so can call in prescriptions which she did, and the Lyrica arrived the next day from the pharmacy which was located in Houston. RN K said she was not able to pull Lyrica out of the system for Resident #2 because the machine did not have the strength of the medications that were required by Resident #2, and the NexSys will not dispense partial does. She said the risk to the resident of not having his pain medication was that he might be in pain. She said if the resident had pain, he could request Tylenol 3.<BR/>Record review of the facility policy Receiving Controlled Substances effective 09/2018 revealed that controlled substances were requested when a 5- day supply remained to allow for transmission of the required written prescription to the pharmacy

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assure that one (Resident #5) of seven residents reviewed for enteral feeding, received appropriate treatment and services to prevent complications of enteral feeding. <BR/>-The facility failed to ensure that Resident #5's feeding tube bags were labeled with name of resident, date, and time the administration began to ensure residents maintain nutritional status within optimal parameters.<BR/>This failure could place residents receiving enteral feedings at risk of not being provided the correct enteral feeding and not receiving feeding care in a timely manner to prevent complications. <BR/>Findings included: <BR/>Record review of Resident #5's face sheet dated [DATE], revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Diagnosis included dysphagia (difficulty swallowing) and gastrostomy status (surgical procedure used to insert a tube through the abdomen and into the stomach). <BR/>Record review of Resident #5's MDS assessment dated [DATE], revealed the resident is rarely/never understood. The Swallowing/Nutritional Status section revealed a feeding tube was in place and the resident had not had weight loss or gain of 5% in the last month or 10% or more in the last 6 months. <BR/>Record review of Resident#5's weight records dated [DATE] to [DATE], revealed no significant weight loss or weight gain. <BR/>Record review of Resident #5's comprehensive care plan dated [DATE] revealed Resident #5 required the use of a feeding tube and was at risk for aspirations, weight loss, and dehydration. Feeding tube is related to not eating enough to meet daily nutritional requirements., significant weight loss. Interventions in place included administer tube feeding and water flushes as ordered.<BR/>Record review of Resident #5's physician order dated [DATE] revealed Enteral Feed Order in the evening Enteral Feeding Continuously: Formula: Jevity 1.2, Rate: 60 ml/hr.<BR/>Observation on [DATE] at 2:03 p.m., of Resident #5 revealed the tube feeding container was infusing via pump and into the resident. The feeding tube was set at 60 ml/hr. The enteral feeding bag was not labeled with the feeding formula name, resident's name, the date, the time it was hung, the initials of who had hung it, and tube feeding order information. The hanging water bag had a label that read Jevity 1.2 at 55 ml.hr. <BR/>During an interview and observation on [DATE] at 2:09 p.m., LVN C said she changed Resident #5's feeding bag on [DATE] at 7:00 p.m. LVN C said she used a sticker type label and that the label must have fallen off. Label not located through search of room. LVN C said she did not know what happened to the label. LVN C said the setting of 60 m/hr was correct but the sticker label on water bag was wrong. LVN C said that it was her mistake when she placed the sticker label on the water bag with incorrect information. LVN C said Resident #5's automatic feeding machine was at the correct setting per orders.<BR/>During an interview on [DATE] at 9:30 a.m., the DON said Resident #5 had not experienced any significant weight loss or weight gain or any complications with tube feeding. The DON said the risk of failing to label an enteral feeding bag was possibility of not knowing if the feeding is at the appropriate rate, speed and how old the formula was. The DON said the risk could be using an expired product or the wrong product. <BR/>Record review of facility policy titled Gastrostomy Tube Care dated 2007, reads in part Labeling/Dating - formula and or feedings should be labeled with at least the date and time the administration begun.

Based on observation, interview, and record review the facility failed to ensure each resident receives and the facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature for 3 of 3 sample trays sampled. <BR/>A. <BR/>Food was served cold for breakfast. <BR/>This failure could have placed residents at risk for foodborne illnesses. <BR/>Findings include:<BR/>Interview on 07/18/22 at 11:39 AM during confidential group meeting, resident's complaint about cold food served for meals. <BR/>Interview on 07/18/22 at 3:15 PM surveyor requested to Dietary Manager for 3 test trays (regular, mechanical, and puree) for breakfast on 7/19/22.<BR/>Observation on 07/19/22 at 7:52 AM breakfast plates for F hall, last hall to be served, were being prepared and placed on food cart. <BR/>Observation on 07/19/22 at 8:05 AM 3 test trays surveyor requested were the last to be served and placed in food cart. <BR/>Observation on 07/19/22 at 8:06 AM food cart was dropped off in F hall, 2 staff on the floor observed passing out food trays to residents. 1 staff was at nurses' station on the computer and 1 staff at end of hall by med cart.<BR/>Observation on 07/19/22 at 8:15 AM last food tray to resident was served. <BR/>Observation and interview on 07/19/22 at 8:16 AM test trays were ready for surveyors. Dietary Manager took temperatures on all test trays and they revealed: mechanical cereal 135 degrees, mechanical sausage 90 degrees, mechanical egg 96.8 degrees; puree cereal 130 degrees, puree egg 98 degrees, puree sausage 102.9 degrees; regular scrambled eggs 90 degrees, regular hot cereal 136 degrees, and regular crispy bacon was not able to take temperature. Dietary Manager stated food temperatures at holding table were above 135 degrees. The delay in serving food trays had an impact on food temperatures. Dietary Manager stated food should be served for resident to eat at 135 degrees. <BR/>Observation and interview on 7/19/22 at 8:23 AM surveyors tasted a spoon full of each test tray and confirmed food was cold except for the hot cereal on all 3 consistencies. <BR/>Observation and interview on 7/19/22 at 8:30 AM Dietary Manager tasted puree muffin and stated it was cold and should have been served at 135 degrees or higher. <BR/>Interview on 07/19/22 at 11:15 AM Administrator stated she had not received recent complaints about food been served cold. Administrator stated there had been past grievances about cold food. Administrator stated it was expected for staff to immediately start passing out food trays when food cart arrived at their hall. Administrator stated it was expected for more than one staff member to assist with passing out trays. Administrator stated any staff that are seen in the hall could assist in delivering food trays to residents. Administrator stated the longer food sat in the food cart the food was bound to get cold. Administrator stated there were at least 4 CNA's, 2 charge nurses, 1 med aide, and 1 ADON on each side, enough staff to help each other to deliver food trays quickly. Administrator stated by food been served cold could put the residents at risk of foodborne illness. Administrator stated food should be served at least at 135 degrees. Administrator did not have answer for this failure. <BR/>Record review of Food Safety and Sanitation Plan policy dated 11/2017 did not specify temperatures food should be served at.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #3) of seven residents reviewed for comprehensive person-centered care plans. <BR/>The facility failed to develop and implement a care plan to address Resident #3's behavior of scratching. <BR/>This failure put residents at increased risk of discomfort, impairment of skin integrity, and infection. <BR/>Findings included: <BR/>Resident #3 <BR/>Record review of Resident #3's face sheet dated 02/15/2024 revealed she was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. <BR/>Record review of Resident #3's History and Physical (H&P) dated 1/10/2024 revealed she was nonverbal and had diagnoses including Type 2 Diabetes mellitus, high blood pressure, and cerebral infarction (stroke). She was bed-bound and was non-verbal. She had no issues with her skin. The History and Physical stated right ulcer but did not specify the type or where the ulcer was located. The plan included to turn patient every 2 hours while in bed and that wound care was to evaluate and treat. <BR/>Record review of Resident #3's discharge MDS assessment dated [DATE] revealed she was nonverbal and was assessed by staff regarding her mental status. She had moderately impaired skills for daily decision making and had poor short- term memory. She was dependent on staff for toileting hygiene. She had behavioral symptoms not directed toward others. The MDS did not specify what these behaviors were. She was always incontinent of bladder and bowel. <BR/>Record review of Resident #3's Care Plan dated 06/19/2023 revealed she was incontinent of bowel and bladder. The goal was that she was to remain free from skin breakdown due to incontinence and brief use through the next review date (revised 01/26/2024). Interventions included weekly skin checks to monitor for redness, circulatory problems, breakdown, or other skin concerns and to report any new skin conditions to the physician. There was no care plan that addressed her behavior of scratching her inguinal area (where the thigh meets the front of the lower body) and abdominal fold. <BR/>Record review of Resident #3's Progress note dated 02/14/2024 revealed that a skin assessment revealed an inguinal rash (a rash where the thigh meets the front of the lower body). <BR/>Record review of progress notes for Resident #3 dated 01/15/2024 through 2/14/2024 revealed a Skin/Wound note dated 02/09/2024 that the resident had an inguinal rash. There were no notes regarding scratches. <BR/>Record review of Resident #3's physician's orders dated 2/12/2024 revealed an order to apply Nystatin power (a treatment for a yeast or fungal infection of the skin) 100000 unit/gm to her inguinal folds for a rash. <BR/>In an interview on 02/14/2024 at 12:27 PM, CNA B revealed that she provided help with ADLs to Resident #3 on 02/14/2024 and that Resident #3 had a rash in her inguinal area. The CNA said the rash was because the resident would scratch her inguinal area and her abdominal fold (the area under the stomach above the pelvis). <BR/>In an interview on 02/14/2024 at 3:10 PM, CNA C revealed that she was assigned to provide help with ADLs to Resident #3 about one week a month and had provided help to the resident on 02/14/2024. The CNA said the resident had flaky skin and scratched her inner thighs to the point she would bleed a little. The CNA stated she applied a cream that the resident's family provided and would put zinc oxide on the areas where she scratched. <BR/>In an interview on 02/14/2024 at 3:27 PM, CNA D revealed that she had provided help with ADLs to Resident #3 since the resident returned from the hospital. The CNA stated the resident had a rash between her legs and under her stomach. The CNA had no idea why the resident had a rash but said that resident did tend to scratch herself under her stomach and would also scratch her bottom. , <BR/>In an interview on 02/14/2024 at 4:13 PM, RN E revealed she was not aware that Resident #3 had a behavior of scratching her legs and under the abdomen. She stated that the CNAs should have told her if the resident had this behavior. She said that if she was aware that resident had behavior of scratching herself, she would get an order from the nurse practitioner to treat it. She said the CNAs had not indicated the resident had scratches or rashes on the shower sheets. <BR/>In an Interview on 2/14/24 at 4:25 PM, ADON G revealed she had become aware last week that Resident #3 was scratching. She said residents' skin condition was assessed weekly and the charge nurse should have been aware that the resident scratches. She stated that Resident #3's behavior of scratching should be on the care plan. The purpose of the care plan was for all nursing and management to be aware of the care the resident needed and pass along to take better care of her. The ADON said that if there was no care plan for scratching, the result was that the resident could be at risk to not accomplish goal of protecting skin. <BR/>In an interview on 02/15/2024 at 8:29 AM, CNA F revealed that had provided help with ADLs to Resident #3 two week before and the resident had a rash in her abdominal fold. The CNA said that the resident had a behavior of scratching herself was not new and had been occurring over the past six months. The CNA stated she had reported it to the charge nurse (unnamed) a while back (date unknown). The CNA said she told the resident not to scratch herself and would apply a diaper rash ointment to the scratched areas. <BR/>In an interview on 02/15/2024 at 11:14 PM, MDS Nurse H LVN revealed that Resident #3's behavior of scratching would be on care plan which had been brought to his attention a couple of days ago (date not remembered). He said the care plan's purpose was to paint a picture of the resident for staff members not familiar with the patient so they would know what to expect and how to care for them. The care plan might let someone familiar with the resident know what interventions are being used for a particular issue which was important because although a staff member might be familiar with a resident, they may not know everything about them. <BR/>In an interview on 02/15/2024 at 11:34 AM, the DON revealed she was aware of Resident #3's excoriation (raw or scraped skin) to the skin fold under abdomen and stated this should be on the resident's care plan. She stated the CNAs should have reported the excoriation and the resident's scratching behavior to the nurses. The resident's scratching behaviors and the possible causes for it should have been put on care plan. The DON said if the behavior was not on care plan, staff would not be aware of it which could lead to further skin breakdown and possible infection. <BR/>Record review of the facility policy Comprehensive Care Plans dated 02/10/2021 revealed the facility would develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical needs that are identified in the resident comprehensive assessment. The care plan process includes an assessment of the resident's needs and concerns identified by the interdisciplinary team. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #8) of 3 residents reviewed for catheter care. <BR/>The facility failed to ensure Residents #8s catheter leg strap was in place to secure the catheter. <BR/>This failure could place residents with foley catheters at risk of catheter pulling causing pain. <BR/>Findings included:<BR/>Record review of Resident #8's face sheet dated 1/14/25 revealed a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of retention of urine and neuromuscular dysfunction of bladder. <BR/>Record review of Resident #8's significant change MDS assessment dated [DATE] revealed a BIMS score of 15, her cognition was intact and had and had indwelling catheter. <BR/>Record review of Resident #8's physician order dated 10/16/24 revealed ensure catheter strap in place and holding, every shift change as needed. <BR/>Record review of Resident #8's care plan dated 11/19/24 revealed a focus area for [Resident #8] has a Indwelling Catheter with goal of will remain free from catheter-related trauma through review date and interventions that included ensure tubing is anchored to the residents leg or linens so that tubing is not pulling on the urethra. <BR/>In an observation and interview on 1/14/25 at 11:26 am, Resident # 8 was alert and oriented to place, time, and event. While in bed, it was observed that Resident # 8's urinary catheter was positioned below the bladder and hanging over the bed, with no leg strap secured. Resident # 8 stated that the catheter strap had not been in place for two days and that she had reported the issue, though she could not recall to whom or when. Resident # 8 stated that the lack of a secured strap caused discomfort when moving, as it allowed the catheter to shift.<BR/>In an interview on 1/14/25 at 11:35 am, RN B stated that it was the responsibility of nursing aides and nurses to ensure urinary catheters were secured with leg straps and checked at least every two hours or as needed. RN B stated she had not received any communication indicating that Resident #8's catheter strap was not secured. RN B stated that she had spoken to Resident #8 that morning and asked how she was doing, but the resident had not mentioned the issue. RN B stated that during her check that morning, she only ensured the urinary catheter bag was off the floor and in a privacy bag, and she did not verify if the leg strap was in place. RN B stated that checking for the leg strap was part of her assessment, but she had forgotten to do so. RN B stated that the risk of not securing the leg strap included the catheter being tugged or pulled, potentially causing injury or trauma to the urethra. RN B stated she had received training on urinary catheter to include ensuring catheter strap was secured upon hire. <BR/>In an interview on 1/14/25 at 11:49 am, CNA A stated that she had received training on urinary catheter care upon hire and at least twice a year. CNA A explained that it was the CNA's responsibility to ensure the leg strap was secured at all times, with checks performed at least every two hours or as needed. CNA A noted that Resident #8 was verbal and able to communicate her needs. CNA A clarified that she was not the CNA assigned to the resident but had assisted with perineal care. CNA A stated that the risk of an unsecured catheter included possible discomfort, as she had been told that catheter movement when not secured could cause residents some pain.<BR/>In an interview on 1/14/25 at 3:00 pm, the DON stated that all staff, including CNAs, nurses, and nurse managers, were required to conduct rounds regularly. The DON stated nurse managers were expected to perform daily rounds, while CNAs and nurses were required to check on residents constantly and as needed throughout the day. The DON stated that nurses were expected to check catheter placement during their rounds, not just the privacy bags. The DON stated that nurses oversee the CNAs, while nurse managers oversee the nurses. The DON stated that failing to secure the catheter properly increases the risk of it being pulled out accidentally.<BR/>In an interview on 1/14/25 at 4:01 pm, the Administrator referred the question to the DON.<BR/>Record review of the facility's Cather Care policy dated 02/13/2007 read in part hold catheter tubing to one side and support against leg to avoid traction or unnecessary movement of the catheter while washing perineum.

Based on observation, interview, and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for 1 (02/10/2024) of 6 days reviewed for nurse staffing information. <BR/> The facility failed to post the required staffing information for 02/10/2024. <BR/> This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census. <BR/> Finding include: <BR/> During observation and record review on 02/10/2024 at 9:50 a.m. of the public access area nursing station located outside of the DON office, revealed a Daily Staffing Hours sheet posting information which included facility name, census, total hours for RNs, LVNs, CNAs, MAs, and shift times that was dated 02/09/2024. <BR/>In an interview on 02/13/2024 at 11:20 AM, the Administrator revealed that anyone in nursing administration was responsible for posting the nurse staffing data [Daily Staffing Hours] as soon as possible each day, as soon as staff started coming in which was usually at 8:00 AM. The Administrator stated for weekends, the Daily Staffing Hours sheet was left ready based on the planned schedule, and nursing staff were expected to post the sheet unless there was a last-minute call from staff resulting in the need to update the staffing sheet. She said the staffing sheets were important for families so they could know how many CNAs and nurses were assigned to provide patient care. The Administrator said the staffing sheets were also important for the continuity of care so families would know that care was consistent, and families could be comfortable knowing the facility was taking care of loved ones. She said no one was in charge Saturday morning [02/10/2024] to post the Daily Staffing Hours sheet. She said the facility did not have a policy regarding posting daily nurse staffing information and that the facility followed state guidelines. <BR/>In an interview on 02/13/2024 at 11:30 AM, the DON revealed that, on weekends, the weekend receptionist was responsible for posting the Daily Staffing Hours sheet. She said the Daily Staffing Hours sheet was supposed to be posted by 8:30 AM or 9:00 AM at the latest. The DON said the Daily Staffing Hours sheet needed to be available to let anyone know the ratio of staff to provide care to residents. The DON said that managers were aware they should look for Daily Staffing Hours sheet when they arrived at the facility, including the nurse on weekends. She said that when she arrived at the facility on Saturday (02/10/2024) at about 10:55 AM, she saw the Daily Staffing Hours was not correct and changed it when she arrived. She said she spoke with the receptionist about the Daily Staffing Hours sheet not being changed and showed him how to do it. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #3) of seven residents reviewed for comprehensive person-centered care plans. <BR/>The facility failed to develop and implement a care plan to address Resident #3's behavior of scratching. <BR/>This failure put residents at increased risk of discomfort, impairment of skin integrity, and infection. <BR/>Findings included: <BR/>Resident #3 <BR/>Record review of Resident #3's face sheet dated 02/15/2024 revealed she was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. <BR/>Record review of Resident #3's History and Physical (H&P) dated 1/10/2024 revealed she was nonverbal and had diagnoses including Type 2 Diabetes mellitus, high blood pressure, and cerebral infarction (stroke). She was bed-bound and was non-verbal. She had no issues with her skin. The History and Physical stated right ulcer but did not specify the type or where the ulcer was located. The plan included to turn patient every 2 hours while in bed and that wound care was to evaluate and treat. <BR/>Record review of Resident #3's discharge MDS assessment dated [DATE] revealed she was nonverbal and was assessed by staff regarding her mental status. She had moderately impaired skills for daily decision making and had poor short- term memory. She was dependent on staff for toileting hygiene. She had behavioral symptoms not directed toward others. The MDS did not specify what these behaviors were. She was always incontinent of bladder and bowel. <BR/>Record review of Resident #3's Care Plan dated 06/19/2023 revealed she was incontinent of bowel and bladder. The goal was that she was to remain free from skin breakdown due to incontinence and brief use through the next review date (revised 01/26/2024). Interventions included weekly skin checks to monitor for redness, circulatory problems, breakdown, or other skin concerns and to report any new skin conditions to the physician. There was no care plan that addressed her behavior of scratching her inguinal area (where the thigh meets the front of the lower body) and abdominal fold. <BR/>Record review of Resident #3's Progress note dated 02/14/2024 revealed that a skin assessment revealed an inguinal rash (a rash where the thigh meets the front of the lower body). <BR/>Record review of progress notes for Resident #3 dated 01/15/2024 through 2/14/2024 revealed a Skin/Wound note dated 02/09/2024 that the resident had an inguinal rash. There were no notes regarding scratches. <BR/>Record review of Resident #3's physician's orders dated 2/12/2024 revealed an order to apply Nystatin power (a treatment for a yeast or fungal infection of the skin) 100000 unit/gm to her inguinal folds for a rash. <BR/>In an interview on 02/14/2024 at 12:27 PM, CNA B revealed that she provided help with ADLs to Resident #3 on 02/14/2024 and that Resident #3 had a rash in her inguinal area. The CNA said the rash was because the resident would scratch her inguinal area and her abdominal fold (the area under the stomach above the pelvis). <BR/>In an interview on 02/14/2024 at 3:10 PM, CNA C revealed that she was assigned to provide help with ADLs to Resident #3 about one week a month and had provided help to the resident on 02/14/2024. The CNA said the resident had flaky skin and scratched her inner thighs to the point she would bleed a little. The CNA stated she applied a cream that the resident's family provided and would put zinc oxide on the areas where she scratched. <BR/>In an interview on 02/14/2024 at 3:27 PM, CNA D revealed that she had provided help with ADLs to Resident #3 since the resident returned from the hospital. The CNA stated the resident had a rash between her legs and under her stomach. The CNA had no idea why the resident had a rash but said that resident did tend to scratch herself under her stomach and would also scratch her bottom. , <BR/>In an interview on 02/14/2024 at 4:13 PM, RN E revealed she was not aware that Resident #3 had a behavior of scratching her legs and under the abdomen. She stated that the CNAs should have told her if the resident had this behavior. She said that if she was aware that resident had behavior of scratching herself, she would get an order from the nurse practitioner to treat it. She said the CNAs had not indicated the resident had scratches or rashes on the shower sheets. <BR/>In an Interview on 2/14/24 at 4:25 PM, ADON G revealed she had become aware last week that Resident #3 was scratching. She said residents' skin condition was assessed weekly and the charge nurse should have been aware that the resident scratches. She stated that Resident #3's behavior of scratching should be on the care plan. The purpose of the care plan was for all nursing and management to be aware of the care the resident needed and pass along to take better care of her. The ADON said that if there was no care plan for scratching, the result was that the resident could be at risk to not accomplish goal of protecting skin. <BR/>In an interview on 02/15/2024 at 8:29 AM, CNA F revealed that had provided help with ADLs to Resident #3 two week before and the resident had a rash in her abdominal fold. The CNA said that the resident had a behavior of scratching herself was not new and had been occurring over the past six months. The CNA stated she had reported it to the charge nurse (unnamed) a while back (date unknown). The CNA said she told the resident not to scratch herself and would apply a diaper rash ointment to the scratched areas. <BR/>In an interview on 02/15/2024 at 11:14 PM, MDS Nurse H LVN revealed that Resident #3's behavior of scratching would be on care plan which had been brought to his attention a couple of days ago (date not remembered). He said the care plan's purpose was to paint a picture of the resident for staff members not familiar with the patient so they would know what to expect and how to care for them. The care plan might let someone familiar with the resident know what interventions are being used for a particular issue which was important because although a staff member might be familiar with a resident, they may not know everything about them. <BR/>In an interview on 02/15/2024 at 11:34 AM, the DON revealed she was aware of Resident #3's excoriation (raw or scraped skin) to the skin fold under abdomen and stated this should be on the resident's care plan. She stated the CNAs should have reported the excoriation and the resident's scratching behavior to the nurses. The resident's scratching behaviors and the possible causes for it should have been put on care plan. The DON said if the behavior was not on care plan, staff would not be aware of it which could lead to further skin breakdown and possible infection. <BR/>Record review of the facility policy Comprehensive Care Plans dated 02/10/2021 revealed the facility would develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical needs that are identified in the resident comprehensive assessment. The care plan process includes an assessment of the resident's needs and concerns identified by the interdisciplinary team. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #3) of seven residents reviewed for comprehensive person-centered care plans. <BR/>The facility failed to develop and implement a care plan to address Resident #3's behavior of scratching. <BR/>This failure put residents at increased risk of discomfort, impairment of skin integrity, and infection. <BR/>Findings included: <BR/>Resident #3 <BR/>Record review of Resident #3's face sheet dated 02/15/2024 revealed she was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. <BR/>Record review of Resident #3's History and Physical (H&P) dated 1/10/2024 revealed she was nonverbal and had diagnoses including Type 2 Diabetes mellitus, high blood pressure, and cerebral infarction (stroke). She was bed-bound and was non-verbal. She had no issues with her skin. The History and Physical stated right ulcer but did not specify the type or where the ulcer was located. The plan included to turn patient every 2 hours while in bed and that wound care was to evaluate and treat. <BR/>Record review of Resident #3's discharge MDS assessment dated [DATE] revealed she was nonverbal and was assessed by staff regarding her mental status. She had moderately impaired skills for daily decision making and had poor short- term memory. She was dependent on staff for toileting hygiene. She had behavioral symptoms not directed toward others. The MDS did not specify what these behaviors were. She was always incontinent of bladder and bowel. <BR/>Record review of Resident #3's Care Plan dated 06/19/2023 revealed she was incontinent of bowel and bladder. The goal was that she was to remain free from skin breakdown due to incontinence and brief use through the next review date (revised 01/26/2024). Interventions included weekly skin checks to monitor for redness, circulatory problems, breakdown, or other skin concerns and to report any new skin conditions to the physician. There was no care plan that addressed her behavior of scratching her inguinal area (where the thigh meets the front of the lower body) and abdominal fold. <BR/>Record review of Resident #3's Progress note dated 02/14/2024 revealed that a skin assessment revealed an inguinal rash (a rash where the thigh meets the front of the lower body). <BR/>Record review of progress notes for Resident #3 dated 01/15/2024 through 2/14/2024 revealed a Skin/Wound note dated 02/09/2024 that the resident had an inguinal rash. There were no notes regarding scratches. <BR/>Record review of Resident #3's physician's orders dated 2/12/2024 revealed an order to apply Nystatin power (a treatment for a yeast or fungal infection of the skin) 100000 unit/gm to her inguinal folds for a rash. <BR/>In an interview on 02/14/2024 at 12:27 PM, CNA B revealed that she provided help with ADLs to Resident #3 on 02/14/2024 and that Resident #3 had a rash in her inguinal area. The CNA said the rash was because the resident would scratch her inguinal area and her abdominal fold (the area under the stomach above the pelvis). <BR/>In an interview on 02/14/2024 at 3:10 PM, CNA C revealed that she was assigned to provide help with ADLs to Resident #3 about one week a month and had provided help to the resident on 02/14/2024. The CNA said the resident had flaky skin and scratched her inner thighs to the point she would bleed a little. The CNA stated she applied a cream that the resident's family provided and would put zinc oxide on the areas where she scratched. <BR/>In an interview on 02/14/2024 at 3:27 PM, CNA D revealed that she had provided help with ADLs to Resident #3 since the resident returned from the hospital. The CNA stated the resident had a rash between her legs and under her stomach. The CNA had no idea why the resident had a rash but said that resident did tend to scratch herself under her stomach and would also scratch her bottom. , <BR/>In an interview on 02/14/2024 at 4:13 PM, RN E revealed she was not aware that Resident #3 had a behavior of scratching her legs and under the abdomen. She stated that the CNAs should have told her if the resident had this behavior. She said that if she was aware that resident had behavior of scratching herself, she would get an order from the nurse practitioner to treat it. She said the CNAs had not indicated the resident had scratches or rashes on the shower sheets. <BR/>In an Interview on 2/14/24 at 4:25 PM, ADON G revealed she had become aware last week that Resident #3 was scratching. She said residents' skin condition was assessed weekly and the charge nurse should have been aware that the resident scratches. She stated that Resident #3's behavior of scratching should be on the care plan. The purpose of the care plan was for all nursing and management to be aware of the care the resident needed and pass along to take better care of her. The ADON said that if there was no care plan for scratching, the result was that the resident could be at risk to not accomplish goal of protecting skin. <BR/>In an interview on 02/15/2024 at 8:29 AM, CNA F revealed that had provided help with ADLs to Resident #3 two week before and the resident had a rash in her abdominal fold. The CNA said that the resident had a behavior of scratching herself was not new and had been occurring over the past six months. The CNA stated she had reported it to the charge nurse (unnamed) a while back (date unknown). The CNA said she told the resident not to scratch herself and would apply a diaper rash ointment to the scratched areas. <BR/>In an interview on 02/15/2024 at 11:14 PM, MDS Nurse H LVN revealed that Resident #3's behavior of scratching would be on care plan which had been brought to his attention a couple of days ago (date not remembered). He said the care plan's purpose was to paint a picture of the resident for staff members not familiar with the patient so they would know what to expect and how to care for them. The care plan might let someone familiar with the resident know what interventions are being used for a particular issue which was important because although a staff member might be familiar with a resident, they may not know everything about them. <BR/>In an interview on 02/15/2024 at 11:34 AM, the DON revealed she was aware of Resident #3's excoriation (raw or scraped skin) to the skin fold under abdomen and stated this should be on the resident's care plan. She stated the CNAs should have reported the excoriation and the resident's scratching behavior to the nurses. The resident's scratching behaviors and the possible causes for it should have been put on care plan. The DON said if the behavior was not on care plan, staff would not be aware of it which could lead to further skin breakdown and possible infection. <BR/>Record review of the facility policy Comprehensive Care Plans dated 02/10/2021 revealed the facility would develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical needs that are identified in the resident comprehensive assessment. The care plan process includes an assessment of the resident's needs and concerns identified by the interdisciplinary team. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of one (Resident #2) of seven residents reviewed for availability of medications. <BR/>The facility failed to obtain and administer Lyrica (pain medication) nine time between 12/01/23 and 12/05/2023 as per physician's orders to Resident #2. <BR/>This failure puts residents at risk of not receiving prescribed medications and experiencing pain or other symptoms of diagnosed conditions. <BR/>Findings included:<BR/>Record review of Resident #2's face sheet dated 12/12/2023 revealed he was [AGE] years old, was initially 06/30/2023 and readmitted on [DATE]. <BR/>Record review of Resident #2's History and physical dated 07/03/2023 revealed he had bilateral foot deformities with osteomyelitis (swelling in the bones usually due to an infection), and amputation of his left big toe and other left toes. He was prescribed 5 MG of Eliquis (a pain medication) twice a day. <BR/>Record review of Resident #2's 5-day MDS assessment dated [DATE] he had a BIMS of 15 (cognitively intact). He had not signs or symptoms of delirium or psychosis. He had no symptomatic behaviors. He received both scheduled pain medication and PRN medications during the five day look back period. At the time of the MDS assessment he had no pain over the previous five days. He had taken opioids twice during the past seven days. <BR/>Record review of Resident #2's care plan initiated 09/26/2023 revealed he was on a pain management regimen and took analgesics routinely or as needed.<BR/>Record review of Resident #2's physicians orders revealed an order dated 08/17/2023 for 150 MG of Lyrica to be administered twice a day for pain. Medications were to be administered as ordered. <BR/>In an interview on 12/12/2023 at 3:40 PM Resident #2 revealed that two weekends prior the facility had run out of his medicine for nerve pain [Lyrica). He said it was because the facility had to wait for a new prescription. He said he also received Tylenol 3 (pain medication - acetaminophen) if he needed it. He said that staff did not consistently assess or reassess his pain. <BR/>Record review of Resident #2's December 2023 MAR revealed that he did not receive the physician-ordered two doses of Lyrica 150 MG on 12/01/23 (Friday), 12/02/23, 12/03/23, 12/4/24 or the prescribed dose of Lyrica 150 MG the morning of 12/05/2023 for a total of 9 missed doses. During that time period he received Tylenol 3 nine times. All times it was recorded as having been effective. <BR/>In an interview on 12/12/2023 at 3:53 RN J revealed Resident #2 was administered Lyrica twice a day for nerve pain. RN J said he worked Monday through Friday and twice when he returned from the weekend, the facility was out of Resident #2's Lyrica. He said the morning nurse was responsible for calling in refills, and if a new prescription was needed, getting a medication could take a little longer. RN J said RN K ordered Resident #2's Lyrica on a Wednesday, they ran out of the medication on Thursday, and then did not get more until the next Monday because of a physician delay. RN J said if there is a refill for a medication, the nurse can get code from pharmacy to get it from the NexSys (a system that stores medications for emergencies), but if a new prescription is needed there can be a delay in getting medications, and that was what happened with Resident #2's Lyrica. <BR/>In an interview on 12/12/2023 at 3:59 PM the DON revealed she was not aware Resident #2 had run out of Lyrica. She said the staff member responsible for administering a medication was also responsible for refills and new prescriptions and in this situation that would be RN K. The DON stated that refills can take 8 days for short-term residents to 2 weeks for long term residents. If there are refills a medication can be pulled from the NexSys (a system that stores medications for emergencies)but that was not the case if a prescription refill was needed. She said that the risk to the resident was that he could have pain that was not adequately controlled. She stated that pain was assessed each shift and documented for PRN pain medications. <BR/>In an interview on 12/12/2023 at 4:12 PM RN K revealed she was responsible to calling in refills for medications and they are usually delivered the next day. She said that one of the problem with the system for refills was that the pharmacy does not tell her if a resident was out of refills for a medication. She said that was what happened with Resident #2. She had called in a refill for Resident #2's Lyrica the morning of 11/30/23 and was told would be in on Friday. Friday morning the Lyrica did not arrive in the morning delivery so she called the pharmacy again and was told it would arrive on Saturday. She did not work over the weekend and when she arrived on Monday (12/04/2023) the Lyrica still had not come in. She called the pharmacy she was told they needed a new prescription. She said she was a designated representative for the physician so can call in prescriptions which she did, and the Lyrica arrived the next day from the pharmacy which was located in Houston. RN K said she was not able to pull Lyrica out of the system for Resident #2 because the machine did not have the strength of the medications that were required by Resident #2, and the NexSys will not dispense partial does. She said the risk to the resident of not having his pain medication was that he might be in pain. She said if the resident had pain, he could request Tylenol 3.<BR/>Record review of the facility policy Receiving Controlled Substances effective 09/2018 revealed that controlled substances were requested when a 5- day supply remained to allow for transmission of the required written prescription to the pharmacy

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #3) of seven residents reviewed for comprehensive person-centered care plans. <BR/>The facility failed to develop and implement a care plan to address Resident #3's behavior of scratching. <BR/>This failure put residents at increased risk of discomfort, impairment of skin integrity, and infection. <BR/>Findings included: <BR/>Resident #3 <BR/>Record review of Resident #3's face sheet dated 02/15/2024 revealed she was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. <BR/>Record review of Resident #3's History and Physical (H&P) dated 1/10/2024 revealed she was nonverbal and had diagnoses including Type 2 Diabetes mellitus, high blood pressure, and cerebral infarction (stroke). She was bed-bound and was non-verbal. She had no issues with her skin. The History and Physical stated right ulcer but did not specify the type or where the ulcer was located. The plan included to turn patient every 2 hours while in bed and that wound care was to evaluate and treat. <BR/>Record review of Resident #3's discharge MDS assessment dated [DATE] revealed she was nonverbal and was assessed by staff regarding her mental status. She had moderately impaired skills for daily decision making and had poor short- term memory. She was dependent on staff for toileting hygiene. She had behavioral symptoms not directed toward others. The MDS did not specify what these behaviors were. She was always incontinent of bladder and bowel. <BR/>Record review of Resident #3's Care Plan dated 06/19/2023 revealed she was incontinent of bowel and bladder. The goal was that she was to remain free from skin breakdown due to incontinence and brief use through the next review date (revised 01/26/2024). Interventions included weekly skin checks to monitor for redness, circulatory problems, breakdown, or other skin concerns and to report any new skin conditions to the physician. There was no care plan that addressed her behavior of scratching her inguinal area (where the thigh meets the front of the lower body) and abdominal fold. <BR/>Record review of Resident #3's Progress note dated 02/14/2024 revealed that a skin assessment revealed an inguinal rash (a rash where the thigh meets the front of the lower body). <BR/>Record review of progress notes for Resident #3 dated 01/15/2024 through 2/14/2024 revealed a Skin/Wound note dated 02/09/2024 that the resident had an inguinal rash. There were no notes regarding scratches. <BR/>Record review of Resident #3's physician's orders dated 2/12/2024 revealed an order to apply Nystatin power (a treatment for a yeast or fungal infection of the skin) 100000 unit/gm to her inguinal folds for a rash. <BR/>In an interview on 02/14/2024 at 12:27 PM, CNA B revealed that she provided help with ADLs to Resident #3 on 02/14/2024 and that Resident #3 had a rash in her inguinal area. The CNA said the rash was because the resident would scratch her inguinal area and her abdominal fold (the area under the stomach above the pelvis). <BR/>In an interview on 02/14/2024 at 3:10 PM, CNA C revealed that she was assigned to provide help with ADLs to Resident #3 about one week a month and had provided help to the resident on 02/14/2024. The CNA said the resident had flaky skin and scratched her inner thighs to the point she would bleed a little. The CNA stated she applied a cream that the resident's family provided and would put zinc oxide on the areas where she scratched. <BR/>In an interview on 02/14/2024 at 3:27 PM, CNA D revealed that she had provided help with ADLs to Resident #3 since the resident returned from the hospital. The CNA stated the resident had a rash between her legs and under her stomach. The CNA had no idea why the resident had a rash but said that resident did tend to scratch herself under her stomach and would also scratch her bottom. , <BR/>In an interview on 02/14/2024 at 4:13 PM, RN E revealed she was not aware that Resident #3 had a behavior of scratching her legs and under the abdomen. She stated that the CNAs should have told her if the resident had this behavior. She said that if she was aware that resident had behavior of scratching herself, she would get an order from the nurse practitioner to treat it. She said the CNAs had not indicated the resident had scratches or rashes on the shower sheets. <BR/>In an Interview on 2/14/24 at 4:25 PM, ADON G revealed she had become aware last week that Resident #3 was scratching. She said residents' skin condition was assessed weekly and the charge nurse should have been aware that the resident scratches. She stated that Resident #3's behavior of scratching should be on the care plan. The purpose of the care plan was for all nursing and management to be aware of the care the resident needed and pass along to take better care of her. The ADON said that if there was no care plan for scratching, the result was that the resident could be at risk to not accomplish goal of protecting skin. <BR/>In an interview on 02/15/2024 at 8:29 AM, CNA F revealed that had provided help with ADLs to Resident #3 two week before and the resident had a rash in her abdominal fold. The CNA said that the resident had a behavior of scratching herself was not new and had been occurring over the past six months. The CNA stated she had reported it to the charge nurse (unnamed) a while back (date unknown). The CNA said she told the resident not to scratch herself and would apply a diaper rash ointment to the scratched areas. <BR/>In an interview on 02/15/2024 at 11:14 PM, MDS Nurse H LVN revealed that Resident #3's behavior of scratching would be on care plan which had been brought to his attention a couple of days ago (date not remembered). He said the care plan's purpose was to paint a picture of the resident for staff members not familiar with the patient so they would know what to expect and how to care for them. The care plan might let someone familiar with the resident know what interventions are being used for a particular issue which was important because although a staff member might be familiar with a resident, they may not know everything about them. <BR/>In an interview on 02/15/2024 at 11:34 AM, the DON revealed she was aware of Resident #3's excoriation (raw or scraped skin) to the skin fold under abdomen and stated this should be on the resident's care plan. She stated the CNAs should have reported the excoriation and the resident's scratching behavior to the nurses. The resident's scratching behaviors and the possible causes for it should have been put on care plan. The DON said if the behavior was not on care plan, staff would not be aware of it which could lead to further skin breakdown and possible infection. <BR/>Record review of the facility policy Comprehensive Care Plans dated 02/10/2021 revealed the facility would develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical needs that are identified in the resident comprehensive assessment. The care plan process includes an assessment of the resident's needs and concerns identified by the interdisciplinary team. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #3) of seven residents reviewed for comprehensive person-centered care plans. <BR/>The facility failed to develop and implement a care plan to address Resident #3's behavior of scratching. <BR/>This failure put residents at increased risk of discomfort, impairment of skin integrity, and infection. <BR/>Findings included: <BR/>Resident #3 <BR/>Record review of Resident #3's face sheet dated 02/15/2024 revealed she was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. <BR/>Record review of Resident #3's History and Physical (H&P) dated 1/10/2024 revealed she was nonverbal and had diagnoses including Type 2 Diabetes mellitus, high blood pressure, and cerebral infarction (stroke). She was bed-bound and was non-verbal. She had no issues with her skin. The History and Physical stated right ulcer but did not specify the type or where the ulcer was located. The plan included to turn patient every 2 hours while in bed and that wound care was to evaluate and treat. <BR/>Record review of Resident #3's discharge MDS assessment dated [DATE] revealed she was nonverbal and was assessed by staff regarding her mental status. She had moderately impaired skills for daily decision making and had poor short- term memory. She was dependent on staff for toileting hygiene. She had behavioral symptoms not directed toward others. The MDS did not specify what these behaviors were. She was always incontinent of bladder and bowel. <BR/>Record review of Resident #3's Care Plan dated 06/19/2023 revealed she was incontinent of bowel and bladder. The goal was that she was to remain free from skin breakdown due to incontinence and brief use through the next review date (revised 01/26/2024). Interventions included weekly skin checks to monitor for redness, circulatory problems, breakdown, or other skin concerns and to report any new skin conditions to the physician. There was no care plan that addressed her behavior of scratching her inguinal area (where the thigh meets the front of the lower body) and abdominal fold. <BR/>Record review of Resident #3's Progress note dated 02/14/2024 revealed that a skin assessment revealed an inguinal rash (a rash where the thigh meets the front of the lower body). <BR/>Record review of progress notes for Resident #3 dated 01/15/2024 through 2/14/2024 revealed a Skin/Wound note dated 02/09/2024 that the resident had an inguinal rash. There were no notes regarding scratches. <BR/>Record review of Resident #3's physician's orders dated 2/12/2024 revealed an order to apply Nystatin power (a treatment for a yeast or fungal infection of the skin) 100000 unit/gm to her inguinal folds for a rash. <BR/>In an interview on 02/14/2024 at 12:27 PM, CNA B revealed that she provided help with ADLs to Resident #3 on 02/14/2024 and that Resident #3 had a rash in her inguinal area. The CNA said the rash was because the resident would scratch her inguinal area and her abdominal fold (the area under the stomach above the pelvis). <BR/>In an interview on 02/14/2024 at 3:10 PM, CNA C revealed that she was assigned to provide help with ADLs to Resident #3 about one week a month and had provided help to the resident on 02/14/2024. The CNA said the resident had flaky skin and scratched her inner thighs to the point she would bleed a little. The CNA stated she applied a cream that the resident's family provided and would put zinc oxide on the areas where she scratched. <BR/>In an interview on 02/14/2024 at 3:27 PM, CNA D revealed that she had provided help with ADLs to Resident #3 since the resident returned from the hospital. The CNA stated the resident had a rash between her legs and under her stomach. The CNA had no idea why the resident had a rash but said that resident did tend to scratch herself under her stomach and would also scratch her bottom. , <BR/>In an interview on 02/14/2024 at 4:13 PM, RN E revealed she was not aware that Resident #3 had a behavior of scratching her legs and under the abdomen. She stated that the CNAs should have told her if the resident had this behavior. She said that if she was aware that resident had behavior of scratching herself, she would get an order from the nurse practitioner to treat it. She said the CNAs had not indicated the resident had scratches or rashes on the shower sheets. <BR/>In an Interview on 2/14/24 at 4:25 PM, ADON G revealed she had become aware last week that Resident #3 was scratching. She said residents' skin condition was assessed weekly and the charge nurse should have been aware that the resident scratches. She stated that Resident #3's behavior of scratching should be on the care plan. The purpose of the care plan was for all nursing and management to be aware of the care the resident needed and pass along to take better care of her. The ADON said that if there was no care plan for scratching, the result was that the resident could be at risk to not accomplish goal of protecting skin. <BR/>In an interview on 02/15/2024 at 8:29 AM, CNA F revealed that had provided help with ADLs to Resident #3 two week before and the resident had a rash in her abdominal fold. The CNA said that the resident had a behavior of scratching herself was not new and had been occurring over the past six months. The CNA stated she had reported it to the charge nurse (unnamed) a while back (date unknown). The CNA said she told the resident not to scratch herself and would apply a diaper rash ointment to the scratched areas. <BR/>In an interview on 02/15/2024 at 11:14 PM, MDS Nurse H LVN revealed that Resident #3's behavior of scratching would be on care plan which had been brought to his attention a couple of days ago (date not remembered). He said the care plan's purpose was to paint a picture of the resident for staff members not familiar with the patient so they would know what to expect and how to care for them. The care plan might let someone familiar with the resident know what interventions are being used for a particular issue which was important because although a staff member might be familiar with a resident, they may not know everything about them. <BR/>In an interview on 02/15/2024 at 11:34 AM, the DON revealed she was aware of Resident #3's excoriation (raw or scraped skin) to the skin fold under abdomen and stated this should be on the resident's care plan. She stated the CNAs should have reported the excoriation and the resident's scratching behavior to the nurses. The resident's scratching behaviors and the possible causes for it should have been put on care plan. The DON said if the behavior was not on care plan, staff would not be aware of it which could lead to further skin breakdown and possible infection. <BR/>Record review of the facility policy Comprehensive Care Plans dated 02/10/2021 revealed the facility would develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical needs that are identified in the resident comprehensive assessment. The care plan process includes an assessment of the resident's needs and concerns identified by the interdisciplinary team. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of one (Resident #2) of seven residents reviewed for availability of medications. <BR/>The facility failed to obtain and administer Lyrica (pain medication) nine time between 12/01/23 and 12/05/2023 as per physician's orders to Resident #2. <BR/>This failure puts residents at risk of not receiving prescribed medications and experiencing pain or other symptoms of diagnosed conditions. <BR/>Findings included:<BR/>Record review of Resident #2's face sheet dated 12/12/2023 revealed he was [AGE] years old, was initially 06/30/2023 and readmitted on [DATE]. <BR/>Record review of Resident #2's History and physical dated 07/03/2023 revealed he had bilateral foot deformities with osteomyelitis (swelling in the bones usually due to an infection), and amputation of his left big toe and other left toes. He was prescribed 5 MG of Eliquis (a pain medication) twice a day. <BR/>Record review of Resident #2's 5-day MDS assessment dated [DATE] he had a BIMS of 15 (cognitively intact). He had not signs or symptoms of delirium or psychosis. He had no symptomatic behaviors. He received both scheduled pain medication and PRN medications during the five day look back period. At the time of the MDS assessment he had no pain over the previous five days. He had taken opioids twice during the past seven days. <BR/>Record review of Resident #2's care plan initiated 09/26/2023 revealed he was on a pain management regimen and took analgesics routinely or as needed.<BR/>Record review of Resident #2's physicians orders revealed an order dated 08/17/2023 for 150 MG of Lyrica to be administered twice a day for pain. Medications were to be administered as ordered. <BR/>In an interview on 12/12/2023 at 3:40 PM Resident #2 revealed that two weekends prior the facility had run out of his medicine for nerve pain [Lyrica). He said it was because the facility had to wait for a new prescription. He said he also received Tylenol 3 (pain medication - acetaminophen) if he needed it. He said that staff did not consistently assess or reassess his pain. <BR/>Record review of Resident #2's December 2023 MAR revealed that he did not receive the physician-ordered two doses of Lyrica 150 MG on 12/01/23 (Friday), 12/02/23, 12/03/23, 12/4/24 or the prescribed dose of Lyrica 150 MG the morning of 12/05/2023 for a total of 9 missed doses. During that time period he received Tylenol 3 nine times. All times it was recorded as having been effective. <BR/>In an interview on 12/12/2023 at 3:53 RN J revealed Resident #2 was administered Lyrica twice a day for nerve pain. RN J said he worked Monday through Friday and twice when he returned from the weekend, the facility was out of Resident #2's Lyrica. He said the morning nurse was responsible for calling in refills, and if a new prescription was needed, getting a medication could take a little longer. RN J said RN K ordered Resident #2's Lyrica on a Wednesday, they ran out of the medication on Thursday, and then did not get more until the next Monday because of a physician delay. RN J said if there is a refill for a medication, the nurse can get code from pharmacy to get it from the NexSys (a system that stores medications for emergencies), but if a new prescription is needed there can be a delay in getting medications, and that was what happened with Resident #2's Lyrica. <BR/>In an interview on 12/12/2023 at 3:59 PM the DON revealed she was not aware Resident #2 had run out of Lyrica. She said the staff member responsible for administering a medication was also responsible for refills and new prescriptions and in this situation that would be RN K. The DON stated that refills can take 8 days for short-term residents to 2 weeks for long term residents. If there are refills a medication can be pulled from the NexSys (a system that stores medications for emergencies)but that was not the case if a prescription refill was needed. She said that the risk to the resident was that he could have pain that was not adequately controlled. She stated that pain was assessed each shift and documented for PRN pain medications. <BR/>In an interview on 12/12/2023 at 4:12 PM RN K revealed she was responsible to calling in refills for medications and they are usually delivered the next day. She said that one of the problem with the system for refills was that the pharmacy does not tell her if a resident was out of refills for a medication. She said that was what happened with Resident #2. She had called in a refill for Resident #2's Lyrica the morning of 11/30/23 and was told would be in on Friday. Friday morning the Lyrica did not arrive in the morning delivery so she called the pharmacy again and was told it would arrive on Saturday. She did not work over the weekend and when she arrived on Monday (12/04/2023) the Lyrica still had not come in. She called the pharmacy she was told they needed a new prescription. She said she was a designated representative for the physician so can call in prescriptions which she did, and the Lyrica arrived the next day from the pharmacy which was located in Houston. RN K said she was not able to pull Lyrica out of the system for Resident #2 because the machine did not have the strength of the medications that were required by Resident #2, and the NexSys will not dispense partial does. She said the risk to the resident of not having his pain medication was that he might be in pain. She said if the resident had pain, he could request Tylenol 3.<BR/>Record review of the facility policy Receiving Controlled Substances effective 09/2018 revealed that controlled substances were requested when a 5- day supply remained to allow for transmission of the required written prescription to the pharmacy

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of one (Resident #2) of seven residents reviewed for availability of medications. <BR/>The facility failed to obtain and administer Lyrica (pain medication) nine time between 12/01/23 and 12/05/2023 as per physician's orders to Resident #2. <BR/>This failure puts residents at risk of not receiving prescribed medications and experiencing pain or other symptoms of diagnosed conditions. <BR/>Findings included:<BR/>Record review of Resident #2's face sheet dated 12/12/2023 revealed he was [AGE] years old, was initially 06/30/2023 and readmitted on [DATE]. <BR/>Record review of Resident #2's History and physical dated 07/03/2023 revealed he had bilateral foot deformities with osteomyelitis (swelling in the bones usually due to an infection), and amputation of his left big toe and other left toes. He was prescribed 5 MG of Eliquis (a pain medication) twice a day. <BR/>Record review of Resident #2's 5-day MDS assessment dated [DATE] he had a BIMS of 15 (cognitively intact). He had not signs or symptoms of delirium or psychosis. He had no symptomatic behaviors. He received both scheduled pain medication and PRN medications during the five day look back period. At the time of the MDS assessment he had no pain over the previous five days. He had taken opioids twice during the past seven days. <BR/>Record review of Resident #2's care plan initiated 09/26/2023 revealed he was on a pain management regimen and took analgesics routinely or as needed.<BR/>Record review of Resident #2's physicians orders revealed an order dated 08/17/2023 for 150 MG of Lyrica to be administered twice a day for pain. Medications were to be administered as ordered. <BR/>In an interview on 12/12/2023 at 3:40 PM Resident #2 revealed that two weekends prior the facility had run out of his medicine for nerve pain [Lyrica). He said it was because the facility had to wait for a new prescription. He said he also received Tylenol 3 (pain medication - acetaminophen) if he needed it. He said that staff did not consistently assess or reassess his pain. <BR/>Record review of Resident #2's December 2023 MAR revealed that he did not receive the physician-ordered two doses of Lyrica 150 MG on 12/01/23 (Friday), 12/02/23, 12/03/23, 12/4/24 or the prescribed dose of Lyrica 150 MG the morning of 12/05/2023 for a total of 9 missed doses. During that time period he received Tylenol 3 nine times. All times it was recorded as having been effective. <BR/>In an interview on 12/12/2023 at 3:53 RN J revealed Resident #2 was administered Lyrica twice a day for nerve pain. RN J said he worked Monday through Friday and twice when he returned from the weekend, the facility was out of Resident #2's Lyrica. He said the morning nurse was responsible for calling in refills, and if a new prescription was needed, getting a medication could take a little longer. RN J said RN K ordered Resident #2's Lyrica on a Wednesday, they ran out of the medication on Thursday, and then did not get more until the next Monday because of a physician delay. RN J said if there is a refill for a medication, the nurse can get code from pharmacy to get it from the NexSys (a system that stores medications for emergencies), but if a new prescription is needed there can be a delay in getting medications, and that was what happened with Resident #2's Lyrica. <BR/>In an interview on 12/12/2023 at 3:59 PM the DON revealed she was not aware Resident #2 had run out of Lyrica. She said the staff member responsible for administering a medication was also responsible for refills and new prescriptions and in this situation that would be RN K. The DON stated that refills can take 8 days for short-term residents to 2 weeks for long term residents. If there are refills a medication can be pulled from the NexSys (a system that stores medications for emergencies)but that was not the case if a prescription refill was needed. She said that the risk to the resident was that he could have pain that was not adequately controlled. She stated that pain was assessed each shift and documented for PRN pain medications. <BR/>In an interview on 12/12/2023 at 4:12 PM RN K revealed she was responsible to calling in refills for medications and they are usually delivered the next day. She said that one of the problem with the system for refills was that the pharmacy does not tell her if a resident was out of refills for a medication. She said that was what happened with Resident #2. She had called in a refill for Resident #2's Lyrica the morning of 11/30/23 and was told would be in on Friday. Friday morning the Lyrica did not arrive in the morning delivery so she called the pharmacy again and was told it would arrive on Saturday. She did not work over the weekend and when she arrived on Monday (12/04/2023) the Lyrica still had not come in. She called the pharmacy she was told they needed a new prescription. She said she was a designated representative for the physician so can call in prescriptions which she did, and the Lyrica arrived the next day from the pharmacy which was located in Houston. RN K said she was not able to pull Lyrica out of the system for Resident #2 because the machine did not have the strength of the medications that were required by Resident #2, and the NexSys will not dispense partial does. She said the risk to the resident of not having his pain medication was that he might be in pain. She said if the resident had pain, he could request Tylenol 3.<BR/>Record review of the facility policy Receiving Controlled Substances effective 09/2018 revealed that controlled substances were requested when a 5- day supply remained to allow for transmission of the required written prescription to the pharmacy

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of one (Resident #2) of seven residents reviewed for availability of medications. <BR/>The facility failed to obtain and administer Lyrica (pain medication) nine time between 12/01/23 and 12/05/2023 as per physician's orders to Resident #2. <BR/>This failure puts residents at risk of not receiving prescribed medications and experiencing pain or other symptoms of diagnosed conditions. <BR/>Findings included:<BR/>Record review of Resident #2's face sheet dated 12/12/2023 revealed he was [AGE] years old, was initially 06/30/2023 and readmitted on [DATE]. <BR/>Record review of Resident #2's History and physical dated 07/03/2023 revealed he had bilateral foot deformities with osteomyelitis (swelling in the bones usually due to an infection), and amputation of his left big toe and other left toes. He was prescribed 5 MG of Eliquis (a pain medication) twice a day. <BR/>Record review of Resident #2's 5-day MDS assessment dated [DATE] he had a BIMS of 15 (cognitively intact). He had not signs or symptoms of delirium or psychosis. He had no symptomatic behaviors. He received both scheduled pain medication and PRN medications during the five day look back period. At the time of the MDS assessment he had no pain over the previous five days. He had taken opioids twice during the past seven days. <BR/>Record review of Resident #2's care plan initiated 09/26/2023 revealed he was on a pain management regimen and took analgesics routinely or as needed.<BR/>Record review of Resident #2's physicians orders revealed an order dated 08/17/2023 for 150 MG of Lyrica to be administered twice a day for pain. Medications were to be administered as ordered. <BR/>In an interview on 12/12/2023 at 3:40 PM Resident #2 revealed that two weekends prior the facility had run out of his medicine for nerve pain [Lyrica). He said it was because the facility had to wait for a new prescription. He said he also received Tylenol 3 (pain medication - acetaminophen) if he needed it. He said that staff did not consistently assess or reassess his pain. <BR/>Record review of Resident #2's December 2023 MAR revealed that he did not receive the physician-ordered two doses of Lyrica 150 MG on 12/01/23 (Friday), 12/02/23, 12/03/23, 12/4/24 or the prescribed dose of Lyrica 150 MG the morning of 12/05/2023 for a total of 9 missed doses. During that time period he received Tylenol 3 nine times. All times it was recorded as having been effective. <BR/>In an interview on 12/12/2023 at 3:53 RN J revealed Resident #2 was administered Lyrica twice a day for nerve pain. RN J said he worked Monday through Friday and twice when he returned from the weekend, the facility was out of Resident #2's Lyrica. He said the morning nurse was responsible for calling in refills, and if a new prescription was needed, getting a medication could take a little longer. RN J said RN K ordered Resident #2's Lyrica on a Wednesday, they ran out of the medication on Thursday, and then did not get more until the next Monday because of a physician delay. RN J said if there is a refill for a medication, the nurse can get code from pharmacy to get it from the NexSys (a system that stores medications for emergencies), but if a new prescription is needed there can be a delay in getting medications, and that was what happened with Resident #2's Lyrica. <BR/>In an interview on 12/12/2023 at 3:59 PM the DON revealed she was not aware Resident #2 had run out of Lyrica. She said the staff member responsible for administering a medication was also responsible for refills and new prescriptions and in this situation that would be RN K. The DON stated that refills can take 8 days for short-term residents to 2 weeks for long term residents. If there are refills a medication can be pulled from the NexSys (a system that stores medications for emergencies)but that was not the case if a prescription refill was needed. She said that the risk to the resident was that he could have pain that was not adequately controlled. She stated that pain was assessed each shift and documented for PRN pain medications. <BR/>In an interview on 12/12/2023 at 4:12 PM RN K revealed she was responsible to calling in refills for medications and they are usually delivered the next day. She said that one of the problem with the system for refills was that the pharmacy does not tell her if a resident was out of refills for a medication. She said that was what happened with Resident #2. She had called in a refill for Resident #2's Lyrica the morning of 11/30/23 and was told would be in on Friday. Friday morning the Lyrica did not arrive in the morning delivery so she called the pharmacy again and was told it would arrive on Saturday. She did not work over the weekend and when she arrived on Monday (12/04/2023) the Lyrica still had not come in. She called the pharmacy she was told they needed a new prescription. She said she was a designated representative for the physician so can call in prescriptions which she did, and the Lyrica arrived the next day from the pharmacy which was located in Houston. RN K said she was not able to pull Lyrica out of the system for Resident #2 because the machine did not have the strength of the medications that were required by Resident #2, and the NexSys will not dispense partial does. She said the risk to the resident of not having his pain medication was that he might be in pain. She said if the resident had pain, he could request Tylenol 3.<BR/>Record review of the facility policy Receiving Controlled Substances effective 09/2018 revealed that controlled substances were requested when a 5- day supply remained to allow for transmission of the required written prescription to the pharmacy

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 1 of 2 treatment carts (North Side) checked for medication storage. <BR/>1. The facility failed to ensure Santyl Ointments stored in treatment cart had a prescription label. <BR/>2. The facility failed to store prescribed and over the counter external ointments separately and labeled with resident's name. <BR/>3. The facility failed to ensure oral swabs were not stored with external ointments in the treatment cart. <BR/>4. The facility failed to remove medications from treatment carts after residents were discharged from the facility. <BR/>These failures could affect residents that received treatments at the facility by placing them at risk of not having prescribed medications and cross contamination. <BR/>Findings include: <BR/>Observation and interview on 02/12/24 at 11:08 AM, with the Treatment Nurse revealed facility had two treatment carts. An observation of Treatment Cart #1 (North Side) revealed multiple tubes of MediHoney, Santyl, Mupirocin ointment was stored together in a square plastic box in the top drawer. The nurse stated, We have been trained to store the ointments in a sealed plastic bag with the resident's name. We buy MediHoney ointment over the counter, and each resident should have a tube for individual use and stored in a plastic bag with the resident's name. It was observed that the Santyl ointment tubes were not labeled. There was a wound vac stored in the treatment cart in the third drawer. The nurse stated, It belongs to one of the residents, it was discontinued two weeks ago. We stored the wound vac in the treatment cart because we did not know if we had to return it to the vendor. It should not be stored in the cart with the clean supplies. The wound vac was immediately removed by nurse from the treatment cart. The nurse reported there were a couple of ointments still stored in the treatment cart for residents that had been discharged home . The nurses had been trained to give all the medicines including ointments to the residents upon discharge and remove discontinued ointments from treatment carts. It was observed that oral care swabs were stored in the treatment cart with gauze bandages packets and rolls of self-adherent wrap. The self-adherent wrap was not stored in sealed bags. <BR/>Review of the facility's policy on Medication Storage dated 01/20/21 revealed policy: It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, and security. Policy Explanation and Compliance Guidelines: The medication carts are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed in accordance with the facility policy. <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 received adequate supervison and assistance devices to prevent accidents for 1 of 5 (Resident #4) residents reviewed for repositioning. <BR/>The facility failed to ensure Resident #4 was repositioned using a drawsheet, CNA E grabbed Resident #4 right elbow to assist with scooting up to bed of head. <BR/>This failure could place residents at risk of bruising, pain, or possible injury. <BR/>Findings include: <BR/>Record review of Resident #4's face sheet dated 08/22/2023 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of anoxic brain damage, dysphagia, muscle wasting ad atrophy. <BR/>Record review of Resident #4's MDS quarterly assessment dated [DATE] revealed BIMS score of 0, he as severely cognitive impaired. <BR/>Record review of Resident #4's care plan dated 07/17/2023 revealed focus care for ADLs with interventions of bed mobility required total assistance of 2 staff .<BR/>During observation and interview on 08/22/2023 at 11:10 am, Resident #4 was in bed, he was nonverbal. CNA E and CNA F had finished proving perineal care and Resident #4 needed to be repositioned in bed. CNA E and CNA F both agreed to scoot Resident #4 up to head of bed, drawsheet was noted under Resident #4. CNA F was on Resident #4 right side of bed and held on to drawsheet and CNA E was on left side of bed did not grab the drawsheet. CNA E and CNA F pulled Resident #4 up to head of bed, CNA E grabbed on to Resident #4 left elbow while CNA F used to drawsheet to pull him up. No distress noted to Resident #4 after he was repositioned. CNA E stated she had been trained to use the drawsheet to repositioned residents and did not have reason for grabbing Resident #4 let elbow to reposition. CNA E stated she should have used the drawsheet to reposition Resident #4 instead of grabbing his left elbow. CNA E stated she could have injured him. LVN G was at bedside and assessed Resident #4 left elbow and stated there was no redness note to his left elbow and no sign of pain during assessment. <BR/>During interview on 08/22/2023 at 12:56 pm, the DON stated all CNAs had been trained on repositioning upon hire, annually and as needed thru competency check off. DON stated when repositioning a resident wo required total sist with 2 staff required to use a draw sheet while in bed. DON stated it was expected for CNAs to use drawsheet to reposition to side to side or up to head of the bed. DON stated CNAs were never to hold on to resident arms and/or elbows to assist up to head of bed because there was risk of bruising, injury and/or possible dislocation.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 1 of 2 treatment carts (North Side) checked for medication storage. <BR/>1. The facility failed to ensure Santyl Ointments stored in treatment cart had a prescription label. <BR/>2. The facility failed to store prescribed and over the counter external ointments separately and labeled with resident's name. <BR/>3. The facility failed to ensure oral swabs were not stored with external ointments in the treatment cart. <BR/>4. The facility failed to remove medications from treatment carts after residents were discharged from the facility. <BR/>These failures could affect residents that received treatments at the facility by placing them at risk of not having prescribed medications and cross contamination. <BR/>Findings include: <BR/>Observation and interview on 02/12/24 at 11:08 AM, with the Treatment Nurse revealed facility had two treatment carts. An observation of Treatment Cart #1 (North Side) revealed multiple tubes of MediHoney, Santyl, Mupirocin ointment was stored together in a square plastic box in the top drawer. The nurse stated, We have been trained to store the ointments in a sealed plastic bag with the resident's name. We buy MediHoney ointment over the counter, and each resident should have a tube for individual use and stored in a plastic bag with the resident's name. It was observed that the Santyl ointment tubes were not labeled. There was a wound vac stored in the treatment cart in the third drawer. The nurse stated, It belongs to one of the residents, it was discontinued two weeks ago. We stored the wound vac in the treatment cart because we did not know if we had to return it to the vendor. It should not be stored in the cart with the clean supplies. The wound vac was immediately removed by nurse from the treatment cart. The nurse reported there were a couple of ointments still stored in the treatment cart for residents that had been discharged home . The nurses had been trained to give all the medicines including ointments to the residents upon discharge and remove discontinued ointments from treatment carts. It was observed that oral care swabs were stored in the treatment cart with gauze bandages packets and rolls of self-adherent wrap. The self-adherent wrap was not stored in sealed bags. <BR/>Review of the facility's policy on Medication Storage dated 01/20/21 revealed policy: It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, and security. Policy Explanation and Compliance Guidelines: The medication carts are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed in accordance with the facility policy. <BR/>

Based on observation, interview, and record review the facility failed to ensure each resident receives and the facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature for 3 of 3 sample trays sampled. <BR/>A. <BR/>Food was served cold for breakfast. <BR/>This failure could have placed residents at risk for foodborne illnesses. <BR/>Findings include:<BR/>Interview on 07/18/22 at 11:39 AM during confidential group meeting, resident's complaint about cold food served for meals. <BR/>Interview on 07/18/22 at 3:15 PM surveyor requested to Dietary Manager for 3 test trays (regular, mechanical, and puree) for breakfast on 7/19/22.<BR/>Observation on 07/19/22 at 7:52 AM breakfast plates for F hall, last hall to be served, were being prepared and placed on food cart. <BR/>Observation on 07/19/22 at 8:05 AM 3 test trays surveyor requested were the last to be served and placed in food cart. <BR/>Observation on 07/19/22 at 8:06 AM food cart was dropped off in F hall, 2 staff on the floor observed passing out food trays to residents. 1 staff was at nurses' station on the computer and 1 staff at end of hall by med cart.<BR/>Observation on 07/19/22 at 8:15 AM last food tray to resident was served. <BR/>Observation and interview on 07/19/22 at 8:16 AM test trays were ready for surveyors. Dietary Manager took temperatures on all test trays and they revealed: mechanical cereal 135 degrees, mechanical sausage 90 degrees, mechanical egg 96.8 degrees; puree cereal 130 degrees, puree egg 98 degrees, puree sausage 102.9 degrees; regular scrambled eggs 90 degrees, regular hot cereal 136 degrees, and regular crispy bacon was not able to take temperature. Dietary Manager stated food temperatures at holding table were above 135 degrees. The delay in serving food trays had an impact on food temperatures. Dietary Manager stated food should be served for resident to eat at 135 degrees. <BR/>Observation and interview on 7/19/22 at 8:23 AM surveyors tasted a spoon full of each test tray and confirmed food was cold except for the hot cereal on all 3 consistencies. <BR/>Observation and interview on 7/19/22 at 8:30 AM Dietary Manager tasted puree muffin and stated it was cold and should have been served at 135 degrees or higher. <BR/>Interview on 07/19/22 at 11:15 AM Administrator stated she had not received recent complaints about food been served cold. Administrator stated there had been past grievances about cold food. Administrator stated it was expected for staff to immediately start passing out food trays when food cart arrived at their hall. Administrator stated it was expected for more than one staff member to assist with passing out trays. Administrator stated any staff that are seen in the hall could assist in delivering food trays to residents. Administrator stated the longer food sat in the food cart the food was bound to get cold. Administrator stated there were at least 4 CNA's, 2 charge nurses, 1 med aide, and 1 ADON on each side, enough staff to help each other to deliver food trays quickly. Administrator stated by food been served cold could put the residents at risk of foodborne illness. Administrator stated food should be served at least at 135 degrees. Administrator did not have answer for this failure. <BR/>Record review of Food Safety and Sanitation Plan policy dated 11/2017 did not specify temperatures food should be served at.

Based on interview, and record review the facility failed to treat residents with respect, dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 5 of 13 residents in the confidential group interview.<BR/>The facility failed to provide privacy by conducting care plan meetings in resident rooms. <BR/>These failures could place residents at risk of decreased feelings of self-worth and decreased quality of life.<BR/>Findings included: <BR/>In a confidential interview during the Resident Group revealed Care Plan reviews were being done in the residents' rooms in the presence of their roommates and staff members and/or visitors were able to go into the room and hear everything that was being discussed. The residents said this made them feel embarrassed and was a violation of their privacy. <BR/>In an interview on 11/19/24 at 4:53 PM, with LVN MDS Nurse revealed resident care plans were conducted in resident room's and she was not aware if residents had voiced any concerns about this practice. <BR/>In an interview with the Administrator on 11/20/2024 at 10:13 AM, revealed she was not aware Care Plan reviews were being done in the resident rooms. She said the residents had not reported any concerns regarding staff discussing care plans in their room in front of other residents and/or visitors. She stated, The care plans should be discussed individually and in private with the residents. <BR/>Record review of the Nursing Facility Residents' Rights dated November 2021 documented, Nursing Facility Resident Rights: Privacy and Confidentiality - You have the right to: Privacy, including privacy during visits, phone calls and while attending to personal needs. Have facility information about you maintained as confidential.