FOCUSED CARE AT LINDEN

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to provide or obtain radiology and other diagnostic services to meet the needs of its residents for 1 of 4 (Resident #1) residents reviewed for radiology services. The facility failed to ensure Resident #1's STAT x-ray results were obtained and reported to the physician in a timely manner. Resident #1's x-ray results were not reviewed by the facility until 10/20/25, which was 4 days after the STAT x-ray was performed. This failure could result in a delay in treatment of broken bones, increased pain, and a decreased quality of life. The findings included: Record review of the face sheet, dated 10/30/25, reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of dementia (memory loss) without behaviors, pressure ulcer of sacral region, stage 4 (wound that exposes muscle, bone, or tendon to the sacrum [triangular bone in the lower back formed from fused vertebrae and situated between the two hip bones of the pelvis] caused from pressure), Multiple Sclerosis (a progressive disease that damages the protective cover around nerves called myelin in your central nervous system, which can cause muscle weakness, vision changes, numbness and memory issues), and Arnold Chiari Syndrome (a condition in which brain tissue extends into the spinal canal). Record review of the quarterly MDS assessment, dated 05/03/25, reflected Resident #1 had clear speech, was understood by others, and was able to understand others. Resident #1 had a BIMS score of 8, which indicated moderately impaired cognition. Resident #1 had no behaviors or refusal of care. The MDS reflected Resident #1 had an impairment to both sides of her lower extremities that interfered with daily functions or placed resident at risk of injury. Record review of the comprehensive care plan, initiated on 10/15/25, reflected Resident #1 complained of pain to her right knee. Resident #1 denied falling or injuries. Resident #1 had a nondisplaced lateral plateau fracture (break or crack in the shin bone or tibia). The interventions were as follows:1. On 10/15/25 - Obtain x-ray to right knee per the physician's orders.2. On 10/15/25 - Mechanical lift when transferred.3. On 10/22/25 - Administer pain medication per physician orders.4. On 10/22/25 - Check skin every shift under brace for redness, irritation, or breakdown.5. On 10/22/25 - May remove brace for showers.6. On 10/22/25 - Referral to the orthopedic (specialist bone doctor).7. On 10/22/25 - Straight leg brace to right lower extremity as the resident allows. Record review of Resident #1's progress notes, dated 10/15/25 at 10:32 PM, RN A documented While moving [Resident #1] from room [ROOM NUMBER] to 116, [Resident #1] complained of knee pain and swelling. Upon assessment, [Resident #1's] knee was very swollen. No redness or warmth noted. Contacted NP about getting [x-ray] for right knee. Awaiting response. [Resident #1] in bed at this time. [Call light] and [by mouth] fluids at bedside. Record review of the SBAR Communication Form, dated 10/16/25, reflected Resident #1 had new onset pain, swelling, and warmth of the right knee. Orders were obtained for a STAT x-ray for the right lower extremity. Record review of Resident #1's order details, dated 10/16/25, reflected the Nurse Practitioner ordered the following x-rays with an urgency of STAT:1. Left femur (upper leg), 2 views2. Right knee, 2 views3. Right Tibia and fibula (lower leg), 2 viewsThe order details reflected it was sent to the radiology provider. Record review of Resident #1's radiology report reflected the right knee x-ray was completed on 10/16/25 at 12:24 PM and was read by the radiologist and reported to the facility on [DATE] at 5:25 PM. The impression was findings concerning for a nondisplaced lateral plateau fracture [break or crack in the shin bone or tibia] Record review of Resident #1's radiology report reflected the right tibia and fibula x-ray was completed on 10/16/25 at 12:22 PM and was read by the radiologist and reported to the facility on [DATE] at 5:26 PM. The impression was findings of an age-indeterminate distal fibular fracture [fracture of the fibula bone near the ankle, unable to determine the age of the injury] . Record review of Resident #1's radiology report reflected the right femur x-ray was completed on 10/16/25 at 12:26 PM and was read by the radiologist and reported to the facility on [DATE] at 5:27 PM. The impression was no acute osseous abnormality [bone structure changes]. Record review of the follow-up note, dated 10/19/25, reflected Resident #1 had pain in her right knee with swelling and pain during movement. The follow-up note did not reflect any information on the x-ray results. Record review of Resident #1's radiology report reflected a right ankle x-ray was completed on 10/20/25 at 1:09 PM and was read by the radiologist and reported to the facility on [DATE] at 2:18 AM. The impression was osteopenia (bones are weaker than normal) and no fracture noted. Record review of the in-service education record, dated 10/20/25, reflected education was provided on osteopenia for nurses only. There were 4 nurse signatures. Record review of the in-service education record, dated 10/20/25, reflected education was provided on the pain management policy and procedures for nurses only. There were 3 nurse signatures. Record review of the witness statement, signed and dated 10/20/25 at 2:00 PM by CNA B, reflected the following: [Resident #1] was transferred to shower chair by 2 staff, given a shower then transferred back to bed in 116. I never heard anything pop and she never said anything hurt. Record review of the witness statement, signed and dated 10/21/25 at 12:00 PM by RN A, reflected the following: On 10/15/25 [Resident #1] was being transferred to shower chair prior to room change. [Resident #1] informed staff her right knee was swollen. Upon assessment right knee was swollen but no redness, warmth, or pain noted. [Resident #1] was transferred without incident to shower chair then after shower transferred to bed in 116. [NP] notified of swelling and pain management regimen continued per [Resident #1's] baseline. I never heard anything pop and she never complained of increased pain. Record review of Resident #1's progress notes, dated 10/21/25 at 1:14 PM, the DON documented Spoke with [Resident #1's family member] regarding fracture of right leg in 2 places, [new order] for straight leg brace, [non-weight bearing] to right leg and [orthopedic] referral. Record review of the 24-hour report sheets, dated 10/15/25 to 10/25/25, reflected the following:1. On 10/15/25, Resident #1 moved to 304. The 24 report sheet did not address Resident #1's right knee.2. On 10/16/25, Resident #1 moved to 116 and STAT [right lower extremity] x-ray for swelling/pain/warmth.3. On 10/17/25, Resident #1 pending x-ray results.4. On 10/18/25, Resident #1 was not listed.5. On 10/19/25, Resident #1 was not listed.6. On 10/20/25, the 24 hour report sheet did not address Resident #1's right knee or x-ray. During an observation and interview on 10/30/25 at 9:33 AM, Resident #1 was lying in the bed with the head of her bed elevated slightly. Resident #1's hair was pulled back, and she appeared neat and clean. Resident #1 was pleasant and calm during the interview. Resident #1 stated she was having some pain this morning, but the nurse had just given her some pain medication. Resident #1 stated she took pain medication regularly and her pain was well-controlled. Resident #1 stated her pain was from her right knee and leg. Resident #1 said she recently found out she had a fracture. Resident #1 stated it was an accident and happened during a transfer. Resident #1 stated she did not remember everything about the incident because her memory was not that good. Resident #1 stated she had no complications or increased pain from the fracture in her leg. During an interview on 10/30/25 at 10:56 AM, LVN C stated Resident #1 had first complained about pain in her right knee during the night of 10/15/25 when they were moving her room. LVN C stated RN A had contacted her when she was driving to work and informed her the NP had ordered an x-ray for Resident #1's right leg. LVN C stated when she arrived at work, she placed the x-ray order into the computer system as STAT and it was automatically sent over to the radiology company. LVN C stated she was unable to remember when the x-ray was performed or if she received the results. LVN C stated she was unsure what the time frames were for STAT orders on radiology. LVN C stated when STAT orders were ordered by the doctor, she normally received the results the same day. LVN C stated Resident #1 had pain medications scheduled, which were effective at controlling her pain. LVN C stated she did not work at the facility again until 10/20/25 but had to leave early for a family emergency. LVN C stated 10/20/25 was her last day working at the facility. During an interview on 10/30/25 at 11:24 AM, the DON stated Resident #1 had diagnoses of multiple sclerosis and osteopenia. She stated on 10/15/25 prior to the transfer and room change, Resident #1 had reported to the staff her right knee was swollen but denied any pain. She stated the staff transferred Resident #1 to the shower chair, provided a shower, then transferred her back to bed. The DON stated Resident #1 was a stand and pivot transfer with a gait belt and 2 staff assistance. She stated Resident #1 was usually weak but was able to bear some weight. She said the next morning, on 10/16/25, LVN C noticed Resident #1 had new onset of pain, swelling, and warmth to her right knee. The DON stated LVN C completed the change of condition assessment and notified the NP. She stated the x-rays were ordered and completed the same day. She stated on 10/17/25 she received a text message from the radiology representative that the order was missing diagnosis codes. The DON stated she was out of town and was not going to be able to provide the diagnosis codes until she returned. The DON stated she did not hear back from the radiology representative, so she assumed he got in touch with the staff at the facility. She stated the facility did not obtain the radiology results until 10/20/25 when she checked the portal. The DON stated she notified the doctor, family, and obtained new orders for a brace and orthopedic consult. The DON said she initiated in- service education on osteopenia and pain management. She stated she expected the facility staff to ensure STAT orders were followed up on. She stated all the nurses had access to the radiology results portal. The DON stated the radiology company did not call the facility to notify them that Resident #1 had a fracture. She said the radiology representative only mentioned the diagnosis code when he called on 10/17/25 but did not mention Resident #1 had a fracture. During an interview on 10/30/25 at 11:58 AM the ADON stated he has been the ADON for the last week and prior to that he worked the floor. The ADON stated he was working the floor on 10/17/25 and 10/18/25. The ADON stated he got a stomach bug the evening of 10/18/25, went home early, and called in 10/19/25. He said normally when STAT x-rays were ordered, the order was placed in the computer and submitted to the radiology company. He stated the company would have come out, completed the x-ray, and posted the imaging results under diagnostic results. He stated the company would have posted the results online and did not usually fax them. He said he was not made aware the x-rays were ordered and obtained on Resident #1 on the 17th or 18th when he worked. He said Resident #1 had no complaints of pain or discomfort during that weekend and was always in a good mood. He stated he was in Resident #1's room daily because he had to perform wound care. He stated if he was aware Resident #1 had x-rays completed, he would have looked for the results or followed up with x-ray company for the results. He stated he had no issues with the radiology company prior to the incident. He stated he was under the impression a STAT radiology or lab order could be completed within 24 hours. He stated it was important to ensure x-ray results were obtained timely to prevent further injuries to the resident. He stated it was important to ensure issues or concerns or pending results were passed on in report so follow up could happen timely with no delays in treatment. During an interview on 10/30/25 at 12:25 PM, CNA B stated nothing significant happened during the transfer with Resident #1 on 10/15/25. She said Resident #1 was complaining of pain to her right knee before they moved or transferred her. She stated when she placed Resident #1 back in bed she was still complaining of pain, so she notified the nurse. CNA B stated her knees were always big and nothing looked abnormal. She said she heard no popping noises or anything that would have indicated Resident #1 had an injury. She stated she transferred Resident #1 using a gait belt. She stated Resident #1 was able to bear weight. During an interview on 10/30/25 at 2:50 PM, The Administrator stated she was first notified of Resident #1's fracture on 10/20/25 during the stand-up clinical meeting. She said that was when the facility obtained the results for her x-rays. The Administrator stated the IDT met to try and determine the cause of the injury, but she had no falls or injuries reported. The Administrator stated she submitted the report to HHSC and completed her investigation. She stated she had no reason to believe her injuries were intentionally caused by the facility staff. The Administrator stated during her investigation it was determined that Resident #1 had been complaining of pain during the evening of 10/15/25 prior to any transfers. She said Resident #1 reported she heard a popping noise during the transfer, but the staff denied any popping noises. The Administrator stated it was discovered she had osteopenia and was at risk for fractures. She said she was unsure if there had been any issues or concerns with the radiology company. The Administrator stated she expected the nursing staff to follow up with STAT orders. She stated they should have been looking for the results and noting them on the 24 hour report sheet. She stated it was important to ensure radiology results were received timely to prevent a delay in treatment or decreased quality of care. She stated Resident #1 was well-managed while the results were pending and developed no complications. During an interview on 10/30/25 at 2:38 PM, the NP stated she expected the facility to ensure results were obtained from STAT x-ray orders. The NP stated if the facility did not have the results from a STAT order, they should have followed up with the radiology company for the results. She said at the minimum it should have been passed on during report for continued follow up. The NP stated it was important to ensure that radiology results were received timely to ensure treatment and services were implemented to prevent further injuries. The NP stated Resident #1 was stable and developed no complications. She stated Resident #1 was bed bound and her pain was managed with her current pain regimen. During an interview on 10/30/25 at 2:57 PM, the Director of Radiology stated the technicians tried to perform STAT orders within 4 hours of receiving the orders. He stated the time in which the STAT order was completed, depended on the territory and where the technicians were in relation to where the test was ordered. He stated the average time it took for the radiologist to read the x-rays was 1 hour, but it depended on the day and what was going on. He stated the x-ray results were submitted to the facilities in real time, as the results were sent straight into the portal and into their electronic charting system. He stated the facility should have access to the results as soon as it was read by the radiologist. During an interview on 10/31/25 at 2:01 PM, the Radiology Compliance Officer stated Resident #1's x-ray orders were completed on 10/16/25 at 12:06 PM, which was the same day they were ordered. He stated the radiologist read them on 10/17/25. He stated the orders were not put into the system as a STAT order. Record review of the imaging services agreement, dated 01/06/25, reflected .Company will use reasonable efforts to dispatch STAT x-ray services as soon as possible after receipt of the STAT order. STAT (emergency) service is provided for life-threatening and/or critical situations requiring rapid images. Record review of the Lab/Radiology Management policy, revised 04/21/21, reflected .provide or obtain laboratory services to meet the needs of its residents.the community is responsible for the timeliness of the services.the community must notify the attending physician of the lab results.ensure all labs ordered have been collected with results communicated to doctor and family in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 7 reviewed for abuse. (Resident #1) The facility failed to ensure Resident #1 was free from abuse when RCP A told Resident #1, You better get out of my face and get back in your room. on 07/05/25 as witnessed by LVN B and LVN C. This failure could place residents at risk for verbal abuse and emotional harm.Findings included:Record review of a face sheet dated 07/14/25 revealed Resident #1 was [AGE] years old and was initially admitted on [DATE] with diagnoses including congestive heart failure (chronic condition where the heart cannot pump enough blood to meet the body's needs), bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), and anxiety disorder. Record review of an annual MDS dated [DATE] revealed Resident #1 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #1 required supervision to moderate assistance with most ADLs. Record review of a care plan last reviewed on 07/14/25 revealed Resident #1 had a behavior problem related to low frustration tolerance. The care plan indicated Resident #1 got angry with other residents and would yell at them or staff. The care plan indicated Resident #1 made false allegations against staff and other residents. There was an intervention for caregivers to provide opportunity for positive interaction and attention. Record review of a typed statement indicated Resident #1 was interviewed by the DCO and the EDO on 07/07/25. The statement indicated the date of the incident was 07/05/25. The statement indicated, .A while after lunch I had gone to my room and found my roommate, in bed with the lift pad pulled over her face and her left fingers in the straps on the side and she was pulling on them. I went to (RCP A) who was standing in the hallway and told her, and she said that she would come fix it. After a few minutes, I went to see where she was, and she was still standing in the hall. I went to the nurses' station and was telling (LVN B), but I was so upset I couldn't get my words out, so she pushed me down to my room. When we got back to my room, (RCP A) was in there. (LVN B) went into the room, and I stayed in the hallway. They both came out and started walking back towards the nurses station. (RCP A) got about halfway up the hall and turned around and smiled at me. I said loudly (RCP A) its not funny. And she said (Resident #1, that's why we don't get along. You need to shut up and let me do my job. (LVN B) came to my room later and told me that she reported (RCP A) to the DCO because she can't talk to me that way and that it was abuse. The statement was not signed. Record review of a typed statement indicated RCP A was interviewed by the DCO and ADCO on 07/07/25. The statement indicated the date of the incident was 07/05/25. The statement indicated, .After lunch I had put (Resident #1's roommate) in bed from her geri-chair and then walked out of the room to go get my resident out of the dining room and tend to their needs. (Resident #1) came to me while I was pushing another resident to her room and asked me to move (Resident #1's roommate's) chair and told me that (the roommate) had pulled her lift pad over her face and that her hand was tangled up in straps, so I went in there and took care of that then went and changed a couple more residents that were asking for help then came back to (the roommate's) room to change her. As I was finishing with her, (LVN B) came into the room and asked what was going on, being rude to me. So, I told her what happened, and she said I was rude, so I just walked out of the room. I stopped to get my linen barrel, and (Resident #1) was behind me talking about me and saying things under her breath and being confrontational, so I said, (Resident #1) go in your room and leave me alone. The statement was not signed. Record review of a typed statement indicated LVN B was interviewed by the DCO and ADCO on 07/07/25. The statement indicated the date of the incident was 07/05/25. The statement indicated, .After lunch I was sitting at the nurses' station with the other nurse and (Resident #1) came up to the nurses' station and told the other nurse she needed to report something. The other nurse told her that was sitting right there, and (Resident #1) said she wanted (LVN C) to be witness in case something didn't get done about it. She then started telling me that her roommate was in bed with a lift pad over her face. When we got there the door was closed and she said, Well I guess she is in there fixing it now. I entered the room, and (RCP A) was in there finishing her incontinent care. I asked her what was going on and she started telling me that the resident had pulled the lift pad over her face and that her hand was kind of tangle up in it but it was fixed now. As we walked out of the room, (RCP A) was behind me and I heard her say You need to get out of my face and go back to your room. I informed (RCP A) that she can not talk to residents like that. (RCP A) walked away and I spoke with (Resident #1) who was not in any distress afterwards and told her that I would report the incident to the DCO, which I did but I never said anything about it being abuse. If I felt like it was abuse, I would have reported it right away to (the EDO). The statement was not signed.Record review of a typed statement by the Business Office Manager dated 07/07/25 indicated, (Resident #1) approached me.at my office door around 10:10 a.m. She then asked me if I heard about her and (RCP A). I replied, No ma'am. She then told me that (Resident #1's roommate) was in the lift pad with it over her head and her arms were through the hole in the pad. She then told (RCP A) Why did you leave (Resident #1's roommate) like that? She said (RCP A) smiled at her, and (Resident #1) went down to the nurses station to tell (LVN B). She stated she was upset and couldn't get her words out, and (LVN B) pushed her down the room to see what she was upset about. (RCP A) was in there and everything was then normal with the lift pad. (Resident #1) said (RCP A) laughed at her, and (Resident #1) said something to her (unsure of what exact words were) and (RCP A) then told her to Shut up and let me do my job. (Resident #1) said (LVN B) approached her after this statement and told her that was abuse and she was going to report it. The statement was signed by the Business Office Manager.Record review of an In-Service and Education Record dated 07/07/25 indicated the ADCO educated 23 staff members on Types of Verbal Abuse and the Effects It Can Have on our Residents and Families. RCP A was not in attendance. The in-service indicated, .Verbal abuse is the use of spoken words to cause emotional harm or anguish to the victim. It includes both the words that are spoken and the way they are spoken.Includes any use of speech that is meant to accomplish any of the following against an individual.scare.undermine.belittle.humiliate.discredit.Perpetrators may us manipulation to convince victims they deserve the abuse.Judging - The use of you statements for the purpose of casting judgement on the victim's character or person.Blaming - Statements that claim the victim is a fault for negative occurrences that are beyond the victim's control.Record review of a Disciplinary Action Record dated 07/10/25 indicated RCP A was given a Final warning. The facts regarding the incident indicated, Rudeness to resident and coworkers. Unprofessional behavior towards charge nurses when asked to complete task. Expectations for team member behavior indicated, Employee will remain professional towards residents and co-workers. Employee will treat everyone with dignity and respect. Corrective action to be taken indicated, Final write up. Further customer service issues will lead to termination. The record indicated RCP A refused to sign. The record was signed by the DCO and EDO. Record review of an undated Provider Response indicated, (Resident #1) made an allegation that the CNA providing care to her roommate told her to shut up and let me do my job. The CNA named in the allegation was asked to provide and statement and suspended pending the outcome of the investigation. The CNA said she told (Resident #1) go in your room and leave me alone. The investigation did not confirm the allegation of abuse. The investigation did confirm an incident of very poor customer service. The employee received disciplinary action for this incident as her statement to the resident was unprofessional and represented poor customer service. The employee will no longer be assigned to provide care to that resident.During an interview on 07/14/25 at 3:03 p.m., Resident #1 said on 07/05/25 she had come back to her room after lunch. She said her roommate had her arm tangled into her lift pad. She said she left out of her room to tell RCP A that her roommate needed help. She said RCP A was just down the hall near the linen cart. Resident #1 said she told RCP A that her roommate needed help and RCP A did not respond. She said she waited awhile, and RCP A never came. She said she peeped out the door and RCP A was still by the linen cart. She said she headed to the nurse's station to get LVN B. She said she had a hard time telling LVN B what was going on. She said LVN B came back to her room with her. Resident #1 said when they got back to the room, RCP A was in the room and had her roommate back like she was supposed to be. She said LVN B went in the room and closed the door. She said she did not know what was said between them. She said when they came out of the room RCP A looked at her and laughed at her. Resident #1 said she raised her voice and told RCP A it was not funny. The resident said RCP A told her, That's why we can't get along because you won't mind your own business and let me do my job. She said RCP A then told her, Shut up and go back to your room. She said LVN B told her RCP A could not talk to her that way because it was verbal abuse. She said later LVN B came to her and told her that she had reported the way RCP A talked to her. She said she had not seen RCP A since the incident. When Resident #1 was asked about what RCP A had said to her, Resident #1 said, absolutely it was abusive. Resident #1 said, I don't want her on this hall. During an attempted interview on 07/15/25 at 9:50 a.m., a call was placed to RCP A. There was a recording, The subscriber you have dialed is not in service.During an interview on 07/15/25 at 10:56 a.m., LVN B said on 07/05/25 Resident #1 came to the nurse's station. Resident #1 said her roommate was in the bed with the lift pad stuck over her head and her hand was stuck in the pad. LVN B said she went to the room with Resident #1. LVN B said when she got there the door was closed. She said RCP A was in the room. LVN B said RCP A had an attitude with her. She said when she walked out, Resident #1 said something to RCP A. She said she could not hear what Resident #1 said. LVN B said she was walking up the hall when she heard RCP A say, you better get out of my face and get back in your room. She said she was approximately four doors away. LVN B said she told RCP A she could not talk to Resident #1 like that. LVN B said RCP A said, did you not hear what she said to me?. LVN B said she told RCP A, I don't care what she said to you, this her home and you cannot talk to her like that. LVN B said she never told Resident #1 it was verbal abuse. LVN B said she just told Resident #1 that RCP A could not talk to her like that and it had been reported to the DCO. LVN B said what RCP A said was rude and she felt like it was abuse. LVN B said RCP A's tone was hateful. She said she would not want RCP A to talk to her grandmother like that. She said if RCP A had talked to her grandmother that way, she would have a mugshot. During an attempted interview on 07/15/25 at 11:40 a.m., RCP A was called at a different number provided by the Business Office Manager. There was no answer. The surveyor was unable to leave a message. During an interview 07/15/25 at 12:15 p.m., the DCO said the incident between Resident #1 and RCP A was reported to her immediately. She said the incident happened on 07/05/25 at the end of RCP A's shift. She said RCP A was suspended on the morning of 07/07/25 and it was reported to the state on the 07/07/25. She said there were several versions of what happened and all that was told to her on the 07/05/25 was that RCP A told Resident #1, just let me do my job. She said she felt this was a customer service issue. She said Resident #1 did not say she felt abused until 07/07/25. She said RCP A did not return to work until 7/10/25. She said this was the only shift RCP A had worked since the incident on 07/05/25. The DCO said she had attempted to call RCP A and there was no answer.During an interview on 07/15/25 at 12:54 p.m., LVN B said on 07/05/25, RCP A's tone was very strong. LVN B said staff had to respect their residents. She said the typed statement dated 07/07/25 was given over the telephone. LVN B said the statement was correct except for the last sentence. LVN B said she never stated, If I felt like it was abuse, I would have reported it right away to (the EDO). During an interview on 07/15/25 at 1:10 p.m., the EDO said she was contacted on the afternoon of 07/05/25. She said the DCO reported to her that Resident #1 was upset and RCP A had said something to the effect of let me do my job. She felt it was rude but not an abuse allegation. The EDO said she was not in the building on the 07/05/25. She said the DCO was in the building. She said things changed on the morning of 07/07/25 when Resident #1 reported the incident to the Business Office Manager. She said that was when it was reported to the state because of what was reported to the Business Office Manager was an allegation of abuse, because she said something different to her than what LVN B said on Saturday, 07/05/25.During an interview on 07/15/25 at 3:12 p.m., Resident #1 said she had not seen RCP A again since the incident on 07/05/25. Resident #1 said she was not afraid of being out of her room. She said if she saw RCP A, she would not be afraid of her, but it would cause her some anxiety.During an interview on 07/15/25 at 3:18 p.m., LVN C said Resident #1 came to the nurse's station on 07/05/25. She said LVN B went down to the room to check on the roommate. She said when they were coming back out into the hallway Resident #1 said something to RCP A, but she could not hear what she said. She said she then heard RCP A say, get out of my face and go back to your room. She said her tone was harsh. LVN C said Resident #1 did not seem afraid or anxious. She said she was present when LVN B called the DCO. She said LVN B explained in detail what had happened. She said she told the DCO that RCP A said, get out of my face and go back to your room. LVN C said LVN B was upset. During an interview on 07/16/25 at 8:15 a.m., the Activity Director said she had seen RCP A have an attitude with other staff but never to any residents. She said since the incident on 07/05/25 between RCP A and Resident #1, Resident #1 had still been attending activities. She said she had not been anxious or afraid. She said, She has not changed a bit.During an interview on 07/16/25 at 8:58 a.m., the Business Office Manager said Resident #1 came into her office on 07/07/25 and asked if she had heard what happened between her and RCP A. She said Resident #1 told her on 07/05/25 her roommate was tangled in her lift pad. She said Resident #1 told her she went to RCP A to ask for assistance and RCP A just brushed her off and continued doing her work. She said Resident #1 told her she went to LVN B. She said Resident #1 told her that LVN B went down to the room and RCP A was in the room. She said Resident #1 told her she said, (RCP A) you know what you did. She said Resident #1 told her RCP A said, Shut up and let me do my job. The Business Office Manager said she gave a statement on what Resident #1 had told her. She said that was not an appropriate thing to say to a resident. She said Resident #1 told her that LVN B heard what was said and told Resident #1 it was verbal abuse, and she would be reporting it. She said she reported what Resident #1 told her to the EDO. She said she felt like what Resident #1 told her was verbal abuse. She said Resident #1 said she did not want RCP A to be her aide anymore. She said since 07/07/25 Resident #1 had gone about her normal activities and had not been upset. She said she had not seen RCP A again since the incident. She said RCP A was very stand offish, not friendly, and can be rude. She said she had never seen her be rude to residents.During an interview on 07/16/25 at 12:06 p.m., the ADCO said she did not witness the incident between RCP A and Resident #1. She said it happened before she came into work on 07/05/25. She said she saw Resident #1 on 07/07/25. She said Resident #1 told her RCP A had said to her, That's why we can't get along because you won't mind your own business and let me do my job. She said RCP A then told her, To shut up and go back to her room. The ADCO said she was also on the phone with the DCO when RCP A gave her statement over the phone. The ADCO said RCP A said she was in the next room changing a resident and Resident #1 had come to tell her what happened. She said RCP A admitted to telling Resident #1 to go back to her room. She said if RCP A said Get out of my face and go back to your room in a hateful or harsh tone it was verbal abuse. She said she started in-services on Customer Service and Verbal Abuse on 07/07/25. The ADCO said RCP A could be difficult with other staff. During an interview on 07/16/25 at 2:09 p.m., the DCO said when LVN B called her on 7/5/25 she tried to clarify exactly what words RCP A used toward Resident #1 and it was told to her that RCP A said, leave me alone and let me do my job. She said at the time she did not feel it was abuse. She said that was different than telling the resident to shut up and go to their room. She said she was going to deal with it as a customer service issue until the morning of 07/07/25 when the story had changed and sounded more like abuse. She said that was when Resident #1 made the statement that RCP A had told her to shut up and go back to her room. She said since the incident Resident #1 has been absolutely fine. She said there has been no adverse psychological effects. She said she preferred not to speculate on a negative outcome for the resident. She said RCP A has been reassigned and would not be providing care to Resident #1.During an interview on 07/16/2025 at 2:55 p.m., the EDO said on 07/05/25 she was notified about the incident between RCP A and Resident #1. She said she felt one thing was told to herself and the DCO on 07/05/25 and then something different was reported on Monday, 07/07/25. She said then she felt like what was said on 07/07/25 was reportable. She said if the nurses were saying it was abuse now, they should have been saying in was abuse at the time and it would have been handled differently. She said the situation was not reported to her as abuse. She said as the EDO you can only make a decision on the facts that have been presented to you. She said RCP A was not suspended until Monday because of what was presented to her on Saturday. She used what was presented to her on Saturday to make the judgement call. She said she talked to Resident #1 almost every day. She said she had not said anything else to her about the incident. She said she has not been upset or distraught. She said DCO was in the building on 7/5/25 during the time the two charge nurses were on duty and nothing additional was shared with her. She said Resident #1 had a history of making her concerns and needs known to the DCO and she did not say anything to her on 07/05/25. She said RCP A has been reassigned and would not provide care to the Resident #1.Record review of a facility Abuse Policy last revised on 01/27/20 indicated, .The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure.Residents will not be subjected to abuse by anyone, including, but not limited to community staff.This includes physical, verbal, sexual, physical/chemical restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents for 1 of 7 residents reviewed for abuse and neglect.The facility failed to prevent Resident #1 from being abused when RCP A told Resident #1 You better get out of my face and get back in your room. on 07/05/25 as witnessed by LVN B and LVN C.The facility failed to immediately suspend RCP A. The facility staff failed to immediately interview Resident #1 concerning the allegations. These failures could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the allegations of abuse timely. Findings included:Record review of a face sheet dated 07/14/25 revealed Resident #1 was [AGE] years old and was initially admitted on [DATE] with diagnoses including congestive heart failure (chronic condition where the heart cannot pump enough blood to meet the body's needs), bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), and anxiety disorder. Record review of an annual MDS dated [DATE] revealed Resident #1 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #1 required supervision to moderate assistance with most ADLs. Record review of a care plan last reviewed on 07/14/25 revealed Resident #1 had a behavior problem related to low frustration tolerance. The care plan indicated Resident #1 got angry with other residents and would yell at them or staff. The care plan indicated Resident #1 made false allegations against staff and other residents. There was an intervention for caregivers to provide opportunity for positive interaction and attention. Record review of a typed statement indicated Resident #1 was interviewed by the DCO and the EDO on 07/07/25. The statement indicated the date of the incident was 07/05/25. The statement indicated, .A while after lunch I had gone to my room and found my roommate, in bed with the lift pad pulled over her face and her left fingers in the straps on the side and she was pulling on them. I went to (RCP A) who was standing in the hallway and told her, and she said that she would come fix it. After a few minutes, I went to see where she was, and she was still standing in the hall. I went to the nurses' station and was telling (LVN B), but I was so upset I couldn't get my words out, so she pushed me down to my room. When we got back to my room, (RCP A) was in there. (LVN B) went into the room, and I stayed in the hallway. They both came out and started walking back towards the nurses station. (RCP A) got about halfway up the hall and turned around and smiled at me. I said loudly (RCP A) its not funny. And she said (Resident #1, that's why we don't get along. You need to shut up and let me do my job. (LVN B) came to my room later and told me that she reported (RCP A) to the DCO because she can't talk to me that way and that it was abuse. The statement was not signed. Record review of a typed statement indicated RCP A was interviewed by the DCO and ADCO on 07/07/25. The statement indicated the date of the incident was 07/05/25. The statement indicated, .After lunch I had put (Resident #1's roommate) in bed from her geri-chair and then walked out of the room to go get my resident out of the dining room and tend to their needs. (Resident #1) came to me while I was pushing another resident to her room and asked me to move (Resident #1's roommate's) chair and told me that (the roommate) had pulled her lift pad over her face and that her hand was tangled up in straps, so I went in there and took care of that then went and changed a couple more residents that were asking for help then came back to (the roommate's) room to change her. As I was finishing with her, (LVN B) came into the room and asked what was going on, being rude to me. So, I told her what happened, and she said I was rude, so I just walked out of the room. I stopped to get my linen barrel, and (Resident #1) was behind me talking about me and saying things under her breath and being confrontational, so I said, (Resident #1) go in your room and leave me alone. The statement was not signed. Record review of a typed statement indicated LVN B was interviewed by the DCO and ADCO on 07/07/25. The statement indicated the date of the incident was 07/05/25. The statement indicated, .After lunch I was sitting at the nurses' station with the other nurse and (Resident #1) came up to the nurses' station and told the other nurse she needed to report something. The other nurse told her that was sitting right there, and (Resident #1) said she wanted (LVN C) to be witness in case something didn't get done about it. She then started telling me that her roommate was in bed with a lift pad over her face. When we got there the door was closed and she said, Well I guess she is in there fixing it now. I entered the room, and (RCP A) was in there finishing her incontinent care. I asked her what was going on and she started telling me that the resident had pulled the lift pad over her face and that her hand was kind of tangle up in it but it was fixed now. As we walked out of the room, (RCP A) was behind me and I heard her say You need to get out of my face and go back to your room. I informed (RCP A) that she can not talk to residents like that. (RCP A) walked away and I spoke with (Resident #1) who was not in any distress afterwards and told her that I would report the incident to the DCO, which I did but I never said anything about it being abuse. If I felt like it was abuse, I would have reported it right away to (the EDO). The statement was not signed.Record review of a typed statement by the Business Office Manager dated 07/07/25 indicated, (Resident #1) approached me.at my office door around 10:10 a.m. She then asked me if I heard about her and (RCP A). I replied, No ma'am. She then told me that (Resident #1's roommate) was in the lift pad with it over her head and her arms were through the hole in the pad. She then told (RCP A) Why did you leave (Resident #1's roommate) like that? She said (RCP A) smiled at her, and (Resident #1) went down to the nurses station to tell (LVN B). She stated she was upset and couldn't get her words out, and (LVN B) pushed her down the room to see what she was upset about. (RCP A) was in there and everything was then normal with the lift pad. (Resident #1) said (RCP A) laughed at her, and (Resident #1) said something to her (unsure of what exact words were) and (RCP A) then told her to Shut up and let me do my job. (Resident #1) said (LVN B) approached her after this statement and told her that was abuse and she was going to report it. The statement was signed by the Business Office Manager.Record review of an In-Service and Education Record dated 07/07/25 indicated the ADCO educated 23 staff members on Types of Verbal Abuse and the Effects It Can Have on our Residents and Families. RCP A was not in attendance. The in-service indicated, .Verbal abuse is the use of spoken words to cause emotional harm or anguish to the victim. It includes both the words that are spoken and the way they are spoken.Includes any use of speech that is meant to accomplish any of the following against an individual.scare.undermine.belittle.humiliate.discredit.Perpetrators may us manipulation to convince victims they deserve the abuse.Judging - The use of you statements for the purpose of casting judgement on the victim's character or person.Blaming - Statements that claim the victim is a fault for negative occurrences that are beyond the victim's control.Record review of a Disciplinary Action Record dated 07/07/25 indicated RCP A was suspended after an occurrence that happened on 07/05/25. The occurrence was an allegation of verbal abuse made by a resident. The record indicated RCP A was suspended pending an investigation. The record indicated RCP A was suspended via telephone at 11:50 a.m. The record was signed by the DCO and the ADCO. Record review of a Disciplinary Action Record dated 07/10/25 indicated RCP A was given a Final warning. The facts regarding the incident indicated, Rudeness to resident and coworkers. Unprofessional behavior towards charge nurses when asked to complete task. Expectations for team member behavior indicated, Employee will remain professional towards residents and co-workers. Employee will treat everyone with dignity and respect. Corrective action to be taken indicated, Final write up. Further customer service issues will lead to termination. The record indicated RCP A refused to sign. The record was signed by the DCO and EDO.Record review of an undated Provider Response indicated, (Resident #1) made an allegation that the CNA providing care to her roommate told her to shut up and let me do my job. The CNA named in the allegation was asked to provide and statement and suspended pending the outcome of the investigation. The CNA said she told (Resident #1) go in your room and leave me alone. The investigation did not confirm the allegation of abuse. The investigation did confirm an incident of very poor customer service. The employee received disciplinary action for this incident as her statement to the resident was unprofessional and represented poor customer service. The employee will no longer be assigned to provide care to that resident. During an interview on 07/14/25 at 3:03 p.m., Resident #1 said on 07/05/25 she had come back to her room after lunch. She said her roommate had her arm tangled into her lift pad. She said she left out of her room to tell RCP A that her roommate needed help. She said RCP A was just down the hall near the linen cart. Resident #1 said she told RCP A that her roommate needed help and RCP A did not respond. She said she waited awhile, and RCP A never came. She said she peeped out the door and RCP A was still by the linen cart. She said she headed to the nurse's station to get LVN B. She said she had a hard time telling LVN B what was going on. She said LVN B came back to her room with her. Resident #1 said when they got back to the room, RCP A was in the room and had her roommate back like she was supposed to be. She said LVN B went in the room and closed the door. She said she did not know what was said between them. She said when they came out of the room RCP A looked at her and laughed at her. Resident #1 said she raised her voice and told RCP A it was not funny. The resident said RCP A told her, That's why we can't get along because you won't mind your own business and let me do my job. She said RCP A then told her, Shut up and go back to your room. She said LVN B told her RCP A could not talk to her that way because it was verbal abuse. She said later LVN B came to her and told her that she had reported the way RCP A talked to her. She said she had not seen RCP A since the incident. When Resident #1 was asked about what RCP A had said to her, Resident #1 said, absolutely it was abusive. Resident #1 said, I don't want her on this hall.During an attempted interview on 07/15/25 at 9:50 a.m., a call was placed to RCP A. There was a recording, The subscriber you have dialed is not in service.During an interview on 07/15/25 at 10:56 a.m., LVN B said on 07/05/25 Resident #1 came to the nurse's station. Resident #1 said her roommate was in the bed with the lift pad stuck over her head and her hand was stuck in the pad. LVN B said she went to the room with Resident #1. LVN B said when she got there the door was closed. She said RCP A was in the room. LVN B said RCP A had an attitude with her. She said when she walked out, Resident #1 said something to RCP A. She said she could not hear what Resident #1 said. LVN B said she was walking up the hall when she heard RCP A say, you better get out of my face and get back in your room. She said she was approximately four doors away. LVN B said she told RCP A she could not talk to Resident #1 like that. LVN B said RCP A said, did you not hear what she said to me?. LVN B said she told RCP A, I don't care what she said to you this her home and you cannot talk to her like that. LVN B said she never told Resident #1 it was verbal abuse. LVN B said she just told Resident #1 that RCP A could not talk to her like that and it had been reported to the DCO. LVN B said what RCP A said was rude and she felt like it was abuse. LVN B said RCP A's tone was hateful. She said she would not want RCP A to talk to her grandmother like that. She said if RCP A had talked to her grandmother that way, she would have a mugshot. She said the incident happened around 1:40 p.m. She said she reported it immediately to the DCO. She said she called the DCO to talk to her about the incident. She said the DCO told her she would call the EDO. She said she waited for the DCO to call her back, but she never did. She said the incident happened at the end of RCP A's shift and she left right after the incident.During an attempted interview on 07/15/25 at 11:40 a.m., RCP A was called at a different number provided by the Business Office Manager. There was no answer. The surveyor was unable to leave a message.During an interview on 07/15/25 at 12:15 p.m., the DCO said the incident between Resident #1 and RCP A was reported to her immediately. She said the incident happened on 7/5/25 at the end of RCP A's shift. She said RCP A was suspended on the morning of 07/07/25 and it was reported to the state on the 07/07/25. She said there were several versions of what happened and all that was told to her on the 07/05/25 was that RCP A told Resident #1, just let me do my job. She said she felt this was a customer service issue. She said Resident #1 did not say she felt abused until 07/07/25. She said RCP A did not return to work until 7/10/25. She said this was the only shift RCP A had worked since the incident on 07/05/25. The DCO said she attempted to call RCP A and there was no answer.During an interview on 07/15/25 at 12:54 p.m., LVN B said on 07/05/25, RCP A's tone was very strong. LVN B said staff had to respect their residents. She said the typed statement dated 07/07/25 was given over the telephone. LVN B said the statement was correct except for the last sentence. LVN B said she never stated, If I felt like it was abuse, I would have reported it right away to (the EDO).During an interview on 07/15/25 at 1:10 p.m., the EDO said she was contacted on the afternoon of 07/05/25. She said the DCO reported to her that Resident #1 was upset and RCP A had said something to the effect of let me do my job. She felt it was rude but not an abuse allegation. The EDO said she was not in the building on the 07/05/25. She said she did not interview the resident on 07/05/25. She said the DCO was in the building. She said things changed on the morning of 07/07/25 when Resident #1 reported the incident to the Business Office Manager. She said that was when it was reported to the state because of what was reported to the Business Office Manager was an allegation of abuse, because she said something different to her than what LVN B said on Saturday, 07/05/25.During an interview on 07/15/25 at 3:18 p.m., LVN C said Resident #1 came to the nurse's station on 07/05/25. She said LVN B went down to the room to check on the roommate. She said when they were coming back out into the hallway Resident #1 said something to RCP A, but she could not hear what she said. She said she then heard RCP A say, get out of my face and go back to your room. She said her tone was harsh. LVN C said Resident #1 did not seem afraid or anxious. She said as a charge nurse they do have the authority to send someone home. She said LVN B called the DCO to clarify what she should do. She said she was present when LVN B called the DCO. She said LVN B explained in detail what had happened. She said she told the DCO that RCP A said, get out of my face and go back to your room. LVN C said LVN B was upset.During an interview on 07/16/25 at 8:15 a.m., the Activity Director said she had seen RCP A have an attitude with other staff but never to any residents. She said since the incident on 07/05/25 between RCP A and Resident #1, Resident #1 had still been attending activities. She said she had not been anxious or afraid. She said, She has not changed a bit.During an interview on 07/16/25 at 8:58 a.m., the Business Office Manager said Resident #1 came into her office on 07/07/25 and asked if she had heard what happened between her and RCP A. She said Resident #1 told her on 07/05/25 her roommate was tangled in her lift pad. She said Resident #1 told her she went to RCP A to ask for assistance and RCP A just brushed her off and continued doing her work. She said Resident #1 told her she went to LVN B. She said Resident #1 told her that LVN B went down to the room and RCP A was in the room. She said Resident #1 told her she said, (RCP A) you know what you did. She said Resident #1 told her RCP A said, Shut up and let me do my job. The Business Office Manager said she gave a statement on what Resident #1 had told her. She said that was not an appropriate thing to say to a resident. She said Resident #1 told her that LVN B heard what was said and told Resident #1 it was verbal abuse, and she would be reporting it. She said she reported what Resident #1 told her to the EDO. She said she felt like what Resident #1 told her was verbal abuse. She said Resident #1 said she did not want RCP A to be her aide anymore. She said since 07/07/25 Resident #1 had gone about her normal activities and had not been upset. She said she had not seen RCP A again since the incident. She said RCP A was very stand offish, not friendly, and can be rude. She said she had never seen her be rude to residents.During an interview on 07/16/25 at 12:06 p.m., the ADCO said she did not witness the incident between RCP A and Resident #1. She said it happened before she came into work on 07/05/25. She said she saw Resident #1 on 07/07/25. She said Resident #1 told her RCP A had said to her, That's why we can't get along because you won't mind your own business and let me do my job. She said RCP A then told her, To shut up and go back to her room. The ADCO said she was also on the phone with the DCO when RCP A gave her statement over the phone. The ADCO said RCP A said she was in the next room changing a resident and Resident #1 had come to tell her what happened. She said RCP A admitted to telling Resident #1 to go back to her room. She said if RCP A said Get out of my face and go back to your room in a hateful or harsh tone it was verbal abuse. She said she started in-services on Customer Service and Verbal Abuse on 07/07/25. The ADCO said RCP A could be difficult with other staff.During an interview on 07/16/25 at 2:09 p.m., the DCO said when LVN B called her on 7/5/25 she tried to clarify exactly what words RCP A used toward Resident #1 and it was told to her that RCP A said, leave me alone and let me do my job. She said at the time she did not feel it was abuse. She said that was different than telling the resident to shut up and go to their room. She said she did not interview the resident on 07/05/25. She said she was going to deal with it as a customer service issue until the morning of 07/07/25 when the story had changed and sounded more like abuse. She said that was when Resident #1 made the statement that RCP A had told her to shut up and go back to her room. She said RCP A was suspended on 07/07/25. She said since the incident Resident #1 has been absolutely fine. She said there had been no adverse psychological effects. She said she preferred not to speculate on a negative outcome for the resident. She said RCP A has been reassigned and would not be providing care to Resident #1. During an interview on 07/16/2025 at 2:55 p.m., the EDO said on 07/05/25 she was notified about the incident between RCP A and Resident #1. She said she felt one thing was told to herself and the DCO on 07/05/25 and then something different was reported on Monday, 07/07/25. She said then she felt like what was said on 07/07/25 was reportable. She said if the nurses were saying it was abuse now, they should have been saying in was abuse at the time and it would have been handled differently. She said the situation was not reported to her as abuse. She said as the EDO you can only make a decision on the facts that have been presented to you. She said RCP A was not suspended until Monday because of what was presented to her on Saturday. She used what was presented to her on Saturday to make the judgement call. She said she talked to Resident #1 almost every day. She said she had not said anything else to her about the incident. She said she has not been upset or distraught. She said DCO was in the building on 7/5/25 during the time the two charge nurses were on duty and nothing additional was shared with her. She said Resident #1 had a history of making her concerns and needs known to the DCO and she did not say anything to her on 07/05/25. She said RCP A has been reassigned and would not provide care to the Resident #1.Record review of a facility Abuse Policy last revised on 01/27/20 indicated, .The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure.Residents will not be subjected to abuse by anyone, including, but not limited to community staff.This includes physical, verbal, sexual, physical/chemical restraint.The administrator and/or designee are responsible for maintaining ALL facility policies that prohibit abuse, neglect, and misappropriation of funds/personal belongings, involuntary seclusion, or corporation punishment.Identification of possible problems that need investigation.Investigating allegations.Reporting incidents, investigations, and facility response to results of investigation within mandated time frames.Protecting residents during investigation.Upon notification of an allegation of physical or mental abuse, neglect or involuntary seclusion, the facility will conduct interviews that include documented statement summaries from the alleged perpetrator, the alleged victim, .and any staff who worked prior to and during the time of the incident.Investigations will focus on determining if the abuse occurred, the extent of the abuse, and potential cause(s).All events that involve an allegation of abuse.must be reported immediately or not later than 2 hours of alleged violation.Protection: It is utmost important that resident(s) suspected of being abused, and all other resident must be protected during the initial identification, and investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. Upon notification of allegation, the Abuse Coordinator or designee will perform the following.Identify the perpetrator that is identified by eyewitness or during the investigation and remove the perpetrator from further contact with the resident pending outcome of the investigation.When there is no resolution to the suspected abuse, but there is indication that the abuse occurred, the facility will immediately conduct an in-service on abuse, and will notify staff that there is strong suspicion of abuse occurring, and it will not be tolerated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 15 resident reviewed for ADLs. (Resident #19)<BR/>The facility failed remove Resident #19's unwanted facial hair.<BR/>The facility failed to provide Resident #19 her schedule bath/showers.<BR/>These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.<BR/>Findings included:<BR/>Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side and muscle weakness.<BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene.<BR/>Record review of Resident #19's care plan dated 04/10/23 indicated Resident #19 had limited physical mobility related to stroke and weakness. Intervention included Resident #19 was non-weight bearing. The care plan did not address ADL care and intervention. <BR/>Record review of Resident #19's ADL bathing report dated 12/11/23-01/08/24 indicated no documentation for Resident #19 for 6 out of 13 scheduled bath/showers. The ADL bathing report indicated Resident #19's shower days were Mondays, Wednesdays, and Fridays. <BR/>Record review of Resident #19's shower sheets from 12/11/23-01/08/24 indicated 12/11/23 (bed bath), 12/13/23 (refused shower, received bed bath, shaved), 12/18/23, 12/22/23 (bed bath), 12/28/23 (bed bath), 01/03/24 (showered, shampoo), 01/05/24, 01/08/24 (bed bath). <BR/>During an interview and observation on 01/08/24 at 1:04 p.m., Resident #19 was lying in her bed in a hospital gown with food on her hand and the bed. Resident #19 said she did not get enough baths. She said her baths were on Mondays, Wednesdays, and Fridays but she only got them once or twice a week. Resident #19 had small amount of black, curly hair on both side of her mouth. Resident #19 said she wanted it (facial hair) off. <BR/>During an observation on 01/09/24 at 11:30 a.m., Resident #19 was lying in her bed in a hospital gown with a small amount of black, curly hair on both side of her mouth. <BR/>During an observation on 01/09/24 at 1:15 p.m., Resident #19 was lying in her bed in a hospital gown with a small amount of black, curly hair on both side of her mouth. <BR/>During an interview on 01/10/24 at 12:22 p.m., RCP O said RCPs were responsible for giving residents bath or showers and removing facial hair. She said Resident #19 refused showers at least once a shift when she worked. She said Resident #19 let the RCPs remove her facial hair. She said ADL care was charted on the facility's charting system. She said the ADCO and DCO decided the shower scheduled. She said the shower schedule was posted at the nurse's station with the resident's day and which shift. She said the facility just started using shower sheets also to document resident's showers. She said ADL care was important for hygiene. She said sometimes if the facility only had 2 RCPs on the floor, things did not get done like resident's shower and baths. <BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said RCPs were responsible for ADL care of residents. She said if the resident refused, the RCP was supposed to notify the nurse and the nurse was supposed to also ask then document if the resident still refused. She said Resident #19 refused to get up for showers but would get a bed bath instead. She said Resident #19 rarely refused to have her facial hair removed. She said refusals were documented on shower sheets. She said ADL care was important for the resident's dignity and to smell good. <BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said the RCP was responsible for ADL care. She said residents should get bed bath daily and showers three times a week. She said she was not sure when women were shaved. She said ADL care was documented in the facility's charting system. She said she was not sure if Resident #19 refused to have her facial hair removed but she refused showers but would do bed baths. She said bed baths and showers were supposed to be charted in the facility's charting system. She said shower sheets were supposed to be done for all bath and showers. She said shower/baths were important to promote cleanliness. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said RCP was responsible for ADL care. She said she expected the staff to follow the shower schedule unless the resident refused. She said facial hair should be removed as needed. She said nurses and nursing management should make rounds to ensure resident were be provided ADL care. A policy regarding ADL for shower/bath and facial hair was requested at this time, the policy was not received before or after exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment are reported immediately or not later than 2 hours for 1 of 6 residents reviewed for abuse and neglect. (Resident #1)<BR/>The facility staff (RCP A, LVN B, and the Social Worker) failed to report an allegation of abuse immediately to the Abuse Coordinator after Resident #1 alleged that RCP D threw a blanket on her face and told her to shut the hell up.<BR/>This failure could place residents at risk for abuse and neglect. <BR/>Findings included:<BR/>Record review of a face sheet dated 04/09/25 revealed Resident #1 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including schizoaffective disorder bipolar type (combines symptoms of both schizophrenia (like hallucinations and delusions) and bipolar disorder (like mania and depression), diabetes, and high blood pressure. <BR/>Record review of a quarterly MDS dated [DATE] revealed Resident #1 was understood and understood others. The MDS revealed a BIMS score of 9, indicating moderate cognitive impairment. The MDS indicated Resident #1 required substantial to maximal assistance with most ADLs. <BR/>Record review of a care plan last revised on 04/10/25 revealed Resident #1 was verbally aggressive related to schizoaffective disorder and mental/emotional illness, ineffective coping skill and poor impulse control with past history of verbal disruption, screaming, cursing, making accusations, telling family untruths about staff and other residents. This focus area of the care plan was last revised on 04/17/23. <BR/>Record review of an undated and untimed written statement of LVN B indicated, On 4/1/25 the 6-2 RCP (RCP A) told me that (Resident #1) had a complaint against (RCP D), the 10-6 rcp from the previous night. I went to speak with (Resident #1), and she stated that the night before (RCP D) threw a blanket at her head and told her to shut the hell up. I asked he if she was okay, and she said yes. She did not have any notable injuries. I asked her why (RCP D) would have done that, and she said she did not know. I informed her that I would tell the administrative team, and someone would come speak to her. I then went to the social worker's office and reported what the resident had told me. The statement indicated it was obtained by the DCO and the ADCO. The statement was signed by the DCO and the ADCO. <BR/>Record review of an undated and untimed statement by the Social Worker indicated, Resident (Resident #1) state that she wanted to tell me about (RCP D) last night. (RCP D) got mad at her because she told her to pick up the bowls and stuff. (RCP D) threw a blanket at her, and it hit the top of her, and she didn't say she was sorry. The statement was signed by the Social Worker. <BR/>Record review of a Disciplinary Action Record dated 04/01/25 indicated RCP D was suspended pending investigation of physical abuse allegation made by a resident. The record indicated RCP D was notified of the suspension by phone on 04/01/25 at 2:41 p.m. The record was signed by the ADCO and the DCO. <BR/>Record review of a police Incident Report dated 04/01/25 at 3:19 p.m. indicated .On April 1, 2025, (police officer) was dispatched to (the facility). Upon arrival, I was met by the Administrator (EDO) .(the EDO) stated that there was an incident where a resident (Resident #1) accused a worker of hitting her in the face with a blanket .(Resident #1) state that a nurse, (RCP D) got mad at her because she asked her to clean her room and take her food tray. (Resident #1) stated that at this point, (RCP D) who was standing in the hallway, threw a blanket and hit her in the face with it .(RCP 1) said in her statement that she was doing rounds and that she would come back to pick up trays after she was finished .(RCP D) said in her statement .she overheard (Resident #1) calling to someone to bring her a blanket and that is when (RCP D) got the blanket and went into the room. (RCP D) said that when she unfolded the blanket, she fanned it up and the edge of it brushed against (Resident #1's) face. (RCP D) said that she was sorry for that immediately and said it was an accident. (Resident #1) was not in any pain or discomfort when (RCP D) left the room according to her statement. Based on my interviews and observations, I believe that this was an unintentional accident and that (RCP D) did fan the blanket, but there was no intention to harm (Resident #1).<BR/>Record review of an undated Investigation Summary indicated, .Based upon the outcome of the investigation, it was determined that several facility employees failed to follow policy and procedure of notifying the Abuse Coordinator immediately when a suspected/actual resident abuse allegation occurs. The employees received individualized education from the EDO. The social services director was sent home once this was discovered and allowed to return after the investigation was complete. The EDO provided 1:1 education to this employee upon return.<BR/>Record review of an In-service & Education Record dated 04/02/25 at 9:45 a.m. indicated the EDO educated the Social Worker on .All allegations of abuse, neglect or misappropriation must be reported timely to the Abuse Coordinator EDO is the Abuse Coordinator. The DCO will serve in this capacity in the absence of the EDO .Failure to comply with this requirement will result in disciplinary action to include possible immediate termination .<BR/>Record review of an In-service & Education record dated 04/01/25 indicated the DCO educated LVN B on Any allegations of abuse/neglect/misappropriation must be reported to Abuse Prevention Coordinator .<BR/>During an observation and interview on 04/09/25 at 10:20 a.m., Resident #1 was resting in bed. There was no bruising or signs of abuse. She said on 3/31/25 she asked RCP D if she would pick up her meal tray. She said when RCP D came in the room she then asked for a blanket. She said RCP D threw the blanket on her and did not spread it out. She said RCP D did not say anything to her. She said she was not injured in any way. She said she reported the incident the next morning to RCP A and RCP A reported it to LVN B. She said RCP D no longer provided care to her and she was ok with it. She said she was not afraid to live in the facility. She said she had no other issues with any staff members.<BR/>During an interview on 04/09/25 at 10:59 a.m., LVN B said she did not know the specific date of the incident concerning Resident #1. She said RCP A came to her and told her what Resident #1 had reported to her. LVN B said RCP A told her that Resident #1 said RCP D threw a blanket over her head and told her to shut the hell up. She said Resident #1 did not like RCP D. She said she went in to talk to Resident #1. She said Resident #1 told her that RCP D threw a blanket at her head and told her to shut the hell up. She said Resident #1 told her she did not like RCP D, and she was going to try to get another aide in trouble because she did not like her either. She said the EDO (the Abuse Coordinator) was not in the facility at the time, so she did not report the allegation to her. She said she reported the incident immediately to the social worker. She said she was told later that she should have reported the incident to the EDO.<BR/>During an interview on 04/09/25 at 11:33 a.m., the Social Worker said she interviewed Resident #1 on the morning of 4/1/25 after the incident was reported to her by LVN B. She said LVN B told her Resident #1 was upset with RCP D. The Social Worker said Resident #1 told RCP D threw a blanket on her head. She said the only other thing she told her was that RCP D did not apologize. She said Resident #1 never told her that RCP D said to shut the hell up. The Social Worker said Resident #1 always upset with someone. She said the resident made false accusations against staff. She said she knew the allegation was reported to her before the morning meeting. She said she was disciplined for not reporting the allegation to the EDO. She said she never reported the allegation to the Administrator and did not know how she found out. She just brought me into the office. <BR/>During an interview on 04/09/2025 at 12:40 p.m., the Social Worker said she said she just did not pay enough attention to what LVN B was telling her. She said she thought LVN B was reporting the behavior of Resident #1 and not that RCP D may have done something abusive. She said she did not realize that it was an abuse allegation until after she was called into the EDO's office. She said she interviewed the resident after leaving the EDO's office and that was when Resident #1 told her that RCP D had thrown the blanket.<BR/>During an attempted interview on 04/09/2025 at 1:55 p.m., a call was made to interview RCP A. There was no answer. Left a detailed message requesting a return call. A return call was not received. <BR/>During an interview on 04/09/2025 at 2:27 p.m., RCP D said she did not know anything about the allegation made by Resident #1 until she was questioned about it. She said she never threw a blanket. She said she never told the resident to shut up. She Resident #1 was upset with her because she did not pick up the evening meal tray as fast as she wanted her too. She said she did bring Resident #1 a blanket and when she spread the blanket out it did cover her face. She said she immediately removed the blanket and told her she did not mean for that to happen. She said she apologized to the resident. She said she had been reassigned and would not be providing care to Resident #1.<BR/>During an interview on 04/09/2025 at 2:41 p.m., LVN B said RCP A reported the allegation made by Resident #1 at approximately 10:00 a.m. She said she reported the incident immediately to the Social Worker. She said she did not report it to the EDO because she was not at the facility at the time. She said she was told later that she still should have notified the EDO. She said she really was not thinking about abuse. She said she was thinking more about the resident's behaviors and had been told to report any behaviors to the social worker. She said she then told the DCO at approximately 12:45 p.m.<BR/>During an interview on 04/09/25 at 2:51 p.m., the DCO said the allegation of abuse made by Resident #1 was reported to the state on 04/01/25 but happened on 03/31/25. She said Resident #1 had asked to speak to her. She said Resident #1 told her RCP D got a blanket and threw it on her from the hallway. She said there were no witnesses to the incident. She said RCP D told her she fanned the blanket out and it went in the resident's face accidently. She said she pulled the blanket down immediately. She said when she first started interviewing RCP D, she did not know what she was talking about. The DCO said she found out about the allegation at approximately 1:00 p.m. on 04/01/25. She said she talked to LVN B. She said LVN B told her she was following instructions from a previous DCO to report any behaviors of Resident #1 to the Social Worker. She said Resident 1's version differed depending on who she told the allegation to. She said she was the one who reported the incident to the EDO. She said she would have expected for the Social Worker to have reported the incident to the EDO immediately after it was reported to her by LVN B. She said allegations of abuse not being reported timely could lead to abuse possibly continuing if it was actually occurring.<BR/>During an interview on 04/09/25 at 3:28 p.m., the EDO said Resident #1 alleged that evening (03/31/25) RCP D threw a blanket from the hallway that landed on her head and told her to shut the hell up. She said RCP D said she got the resident a blanket. Unfolded the blanket, fluffed it out and touched the resident on the face. RCP D said she removed the blanket and said she was sorry. She said Resident #1 then reported the allegation of abuse to RCP A. The EDO said she was not in the building at the moment. She said RCP A told LVN B about the allegation made by Resident #1. She said LVN B ended up reporting the allegation to the Social Worker. She said once she found out about the allegation, she sent the Social Worker home and did a one on one with her after she returned to worked. She said LVN B and RCP A was given one on one education also. She said it was about three hours from the time the allegation was made to RCP A and LVN B and the time she found out about the allegation. She said the DCO was who reported it to her around 1:00 p.m. She said she would have expected RCP A, LVN B, and the Social Worker to have reported the allegation to her sooner. She said she was out of the facility, but her number was at the desk, and they could have called her. She said she expected all allegations of abuse to be reported to her immediately. She said allegations not being reported timely limited her options to intervene and take action. <BR/>Record review of an Abuse facility policy last revised on 01/01/23 indicated, .The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure .All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation .

**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 supervision to prevent accidents for 2 of 16 residents (Resident #12, Resident #35) reviewed for adequate supervision.<BR/>The facility failed to prevent Resident #35 from having rubbing alcohol in his room.<BR/>The facility failed to ensure that electrical wires were encased in their protective covering and not exposed for Resident #12 <BR/>These failures could place residents at risk for injury, harm, and impairment or death.<BR/>Findings included: <BR/>1. Record review of Resident #35's admission Record indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Acute and Chronic Respiratory Failure with Hypoxia (a medical condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period, leading to persistently low levels of oxygen in the blood), Peripheral Vascular Disease (a condition that affects the blood vessels outside the heart and brain), Depression (a common mental health condition characterized by persistent low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily functioning).<BR/>Record review of Resident #35's quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 15 which indicated Resident #35 was cognitively intact. The MDS also revealed, Resident #35, was understood and understands others. Shows that Resident #35 requires partial assistance with activities of daily living. <BR/>Record review of Resident #35's Care Plan revealed a problem initiation on 3/13/2023 Resident #35 has a self-care performance deficit related to cellulitis. Shows that Resident #35 required partial assistance with his activities of daily living.<BR/>During an observation an interview on 2/10/25 at 9:50 a.m., Resident #35 had a bottle of isopropyl 91% rubbing alcohol in his room. He said that it was his alcohol. He said he did not know where he got it from. He said he used it on his skin to clean himself. <BR/>During an interview on 2/12/25 at 1:32 p.m., DCO P said residents are not allowed to keep rubbing alcohol in their rooms. She said there was a risk to residents because they could accidently drink the alcohol, it could poison them. <BR/>2. Record review of Resident #12's admission Record indicated he was an [AGE] year-old male admitted to the facility on [DATE]f4. His diagnoses included Bipolar Disorder (a chronic mental health condition characterized by extreme shifts in mood, energy, and activity levels), Depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities), Chronic Inflammatory Demeyelinating Polyneuritis (a rare autoimmune disorder that affects the peripheral nervous system, causing inflammation and damage to the myelin sheath, the protective layer that insulates nerve fibers).<BR/>Record review of Resident #12's significant change in status MDS dated [DATE] revealed that the resident had a BIMS score of 03 which indicates Resident #12 was severely cognitively impaired. The MDS also revealed, Resident #12, was understood and understands others. Shows that Resident #12 was dependent with activities of daily living. <BR/>Record review of Resident #12's care plan revealed a problem initiation on 11/13/2024 shows he has an ADL self-care performance deficit related to disease processes. Shows that Resident #12 has an activity intolerance, confusion, impaired balance, limited mobility.<BR/>During an interview on 2/12/25 at 1:32 p.m., DCO P said staff Report to the maintenance book if exposed wiring was found on an electronic item in room.<BR/>During an interview on 2/12/25 at 1:44 p.m., the Director of Nurses said that residents should not have rubbing alcohol in their rooms as it was against facility policy and it could place the resident at risk of harm if they drank it. She said that if a resident's bed controls had exposed wiring, then it should be replaced or repaired. She said that anyone who spotted both issues would be responsible to remove the alcohol or report the bed control wiring. <BR/>During an interview on 2/12/25 at 5:01 p.m., the Administrator said all staff and focused care partners who observe resident's rooms should keep them free of any potential hazards such as rubbing alcohol or exposed wiring. She said that residents could be placed at risk if they drank rubbing alcohol of harm. She said that electronics that have wiring should be properly maintained, and the inner wires should not be exposed for resident safety. <BR/>Record review of the facility policy titled, Incident and Accident, dated 03/1/17 indicated, Accidents or incidents involving residents shall be investigated and reported to the Executive Director of Operations Licensed nurse will complete an incident and accident report when staff is aware that an incident occurred. Review each incident report at daily clinical meeting Incident reports are located in the electronic health record and are completed electronically.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 15 residents (Resident #19) reviewed for reasonable accommodations.<BR/>The facility failed to ensure Resident #19's call light was placed on her dominant side and hand without a contracture (is a fixed tightening of muscle, tendons, ligaments, or skin). <BR/>This failure could place residents at risk for unmet needs.<BR/>Findings included:<BR/>Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including contracture, left hand and ankle, abnormal posture, hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side, and muscle weakness. <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 had limited range of motion to both sides of her lower extremities. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 was frequently incontinent of urine and always incontinent of bowel. <BR/>Record review of Resident #19's care plan dated 03/21/23, revised on 04/10/23 indicated Resident #19 had history of falls and at risk for increased falls and fracture evidence by history of falls and physical impairment/immobility. Intervention included ensure call light is in reach and answer promptly. <BR/>During an observation and interview on 01/08/24 at 1:04 p.m., Resident #19 said she could not reach the call light sometimes and could not use her left hand. Resident #19 was lying in bed and her left arm appeared flaccid with no voluntary movement of her hand. Resident #19's call light was on her left side near her hand. <BR/>During an observation on 01/09/24 at 1:15 p.m., revealed Resident #19 was lying in her bed, asleep, with her call light placed in the middle of the bed, not near her right hand. <BR/>During an interview on 01/10/24 at 12:22 p.m., RCP O said the RCP, LVN or anyone who walked in the room should make sure the resident's call light was within reach or placed on the resident's non affected side. She said Resident #19's call light should be placed on her right side, which was not affect by her stroke. She said she liked to place her left hand on a pillow because she could not control it. She said if Resident #19's call light was placed on the wrong side of her body or not within reach, she could not get help. She said call lights not being within reach could cause residents to fall or not get their needs met. <BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said the RCP and LVN were responsible for making sure resident's call light were within reach. She said it would not be appropriate to place Resident #19's call light on her left side. She said when call lights were not within reach or on the resident's stroke affected side, they could fall, not get help, or staff attention.<BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said everyone was responsible for ensuring resident's call light were within reach. She said Resident #19's call light should be placed on her unaffected side. She said call lights being placed within reach was important to get the help they needed. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said she expected call lights to be within reach. She said call lights should be placed on the resident's dominant side. She said all staff should ensure it happened. She said staff should check call light placement every 2 hours and as needed during rounds. She said when call lights were not within reach, residents were not able to call for assistance. A call light policy was requested at this time, a policy was not received before or after exit. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure, at the time each resident was admitted , there were physician orders for the resident's immediate care for 1 of 7 residents reviewed for admission physician orders. (Resident #93)<BR/>The facility failed to initiate wound care treatment after Resident #93 admitted on [DATE], with multiple areas of shearing.<BR/>The facility failed to initiate Resident #93's wound care orders noted in the wound care doctor's progress notes on 02/08/25 until 02/10/25. <BR/>An IJ was identified on 02/11/25. The IJ template was provided to the facility on [DATE] at 5:00 p.m. While the IJ was removed on 02/12/25, the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on the process of carrying out orders for residents admitted with wounds or obtaining orders if no orders accompanied the resident, completion of weekly skin assessments, wound care orders, skin management policy, and pressure ulcer prevention and interventions for residents with pressure ulcers. <BR/>These failures could place residents at risk of not receiving appropriate care and treatment services.<BR/>Findings included:<BR/>1. Record review of Resident #93's face sheet dated 02/11/25 indicated Resident #93 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #93 had diagnoses including acute kidney failure (when the kidneys suddenly can't filter waste products from the blood), urinary tract infection (is an infection in any part of your urinary system: kidneys, bladder, ureters, and urethra), morbid obesity (is a medical condition characterized by excessive body weight that significantly impacts health and well-being), and pressure ulcer of right hip, left hip, and other sites, stage 3 (a full-thickness tissue loss where the subcutaneous fat layer is visible within the wound, but the bone, tendon, or muscle is not exposed). <BR/>Record review of the MDS, on 02/10/25, indicated Resident #93 was admitted to the facility less than 21 days ago. No MDS for Resident #93 was completed prior to exit.<BR/>Record review of Resident #93's care plan dated 02/03/25 indicated: <BR/>*Resident #93 was admitted with stage 3 pressure ulcer to right thigh. Interventions included assess and document skin condition every week, pressure relieving appliances as ordered, reposition residents as indicated to relieve pressure and for comfort, and wound care per MD orders. <BR/>*Resident #93 was admitted with Stage 3 pressure ulcer to right hip. Interventions included assess and document skin condition every week, monitor nutritional intake, weight, lab values and report significant changes to MD, pressure relieving appliances as ordered, reposition residents as indicated to relieve pressure and for comfort, and wound care per MD orders.<BR/>*Resident #93 was admitted with stage 3 pressure ulcer to left thigh. Intervention included administer treatments as ordered and monitor for effectiveness, monitor nutritional status, and obtain and monitor lab/diagnostic work as ordered. <BR/>Record review of Resident #93's consolidated physician orders dated active as of 02/11/25 indicated the following:<BR/>*Left thigh- cleanse with house wound cleanser. Apply Medi honey and collagen sheet. Cover with foam and border gauze dressing everyday shift. Start 02/11/25.<BR/>*Nursing to perform weekly skin assessment. Ordered 02/09/25.<BR/>*Right hip- cleanse with house wound cleanser and pat dry. Apply Medi honey and cover with collagen sheet and foam then secure with border dressing everyday shift. Start 02/11/25. <BR/>*Right thigh- cleanse with house wound cleanser and pat dry. Apply Medi honey and collagen sheet. Cover with foam and secure with border dressing everyday shift. Start 02/11/25.<BR/>The consolidated physician order did not reflect wound care orders for Resident #93's left thigh, right hip, and right thigh pressure ulcer on admission [DATE]). <BR/>Record review of Resident #93's MAR dated 02/01/25-02/28/25 indicated the following:<BR/>*Left thigh- cleanse with house wound cleanser. Apply Medi honey and collagen sheet. Cover with foam and border gauze dressing everyday shift. Start 02/11/25.<BR/>*Nursing to perform weekly skin assessment. Ordered 02/02/25. Discontinued 02/09/25. No documentation was noted on 02/02/25 and 02/09/25. <BR/>*Right hip- cleanse with house wound cleanser and pat dry. Apply Medi honey and cover with collagen sheet and foam then secure with border dressing everyday shift. Start 02/11/25. <BR/>*Right thigh- cleanse with house wound cleanser and pat dry. Apply Medi honey and collagen sheet. Cover with foam and secure with border dressing everyday shift. Start 02/11/25.<BR/>Record review of Resident #93's progress note dated 01/12/25-02/12/25 indicated:<BR/>*02/01/25 at 7:47 p.m. by the ADCO, .new admission skin assessment .the following areas were all noted upon admission to the facility . Right Lateral thigh shearing 2cm x 5cm x0.1cm open area without exudate with surrounding scaring . Right gluteal area shearing 0.4cm x 0.4cm x 0.1 cm no exudate noted . Right lateral hip shearing with surrounding scaring 5.5cm x 1.4cm x 0.1cm no exudate noted . Right Posterior hip shearing 1.3cm x 0.9cm x 0.1cm no exudate noted . Right posterior thigh near gluteal fold 1.2cm x 0.1cm. Area is a hard area that appears to be healing . Left posterior thigh shearing 1.2cm x 1cm x 0.1cm area noted to have slight bleeding when dressing was removed . right medial posterior thigh near gluteal fold 1cm x 1cm. area is a hard area that appears to be healing .<BR/>*02/08/25 at 7:33 p.m. by DNP S, .date of service: 02/07/25 .wound initial .Resident #93 . The following wounds were evaluated during today's visit . Wound 1 Right Hip, Pressure Injury, Stage 3 . Wound 2 Right Thigh, Pressure Injury, Stage 3 . Wound 3 Left Thigh, Pressure Injury, Stage 3 . Patient is admitted with multiple wounds . Per report from DON . WOUND ASSESSMENT: .Wound: 1 . Status: Present on admission Location: Right Hip . Primary Etiology: Pressure Injury Severity: Stage 3 . Size: 6 cm x 1.5 cm x 0.1 cm. Actual area is 9 cm2. Actual volume is 0.9 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema Exudate: Light Serous .Wound Odor: None . Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Wound: 2 . Status: Present on admission Location: Right Thigh . Primary Etiology: Pressure Injury .Severity: Stage 3 . Size: 4 cm x 2 cm x 0.1 cm. Actual area is 8 cm2. Actual volume is 0.8 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema, No maceration Exudate: Light Serous . Wound Odor: None . Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Wound: 3 . Status: Present on admission Location: Left Thigh . Primary Etiology: Pressure Injury .Severity: Stage 3 . Size: 1.5 cm x 1 cm x 0.1 cm. Actual area is 1.5 cm2. Actual volume is 0.15 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema, No maceration Exudate: Light Serous . Wound Odor: None .Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Recommendations consisting of: .We will re-evaluate this patient on our next visit (anticipated 1-2 weeks), Implement pressure relieving measures, offloading, and repositioning, as tolerated . Establish turning frequency based on the characteristics of the support surface and the patient's response . Protect skin from exposure to excessive moisture (periwound) with a barrier product. Use skin emollients to hydrate dry skin . Repositioning should be undertaken using the 30-degree tilted side-lying position (alternating right side, back, left side) . Plan of care discussed with facility staff .Wound# 1 Right Hip Pressure Injury Treatment Recommendations: .clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled Wound # 2 Right Thigh Pressure Injury .Treatment Recommendations: . clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled Wound # 3 Left Thigh Pressure Injury .Treatment Recommendations: . clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled .<BR/>Record review of Resident #93's memorandum of transfer and physician certification dated 02/01/25 indicated emergency department diagnoses included pressure injury of contiguous region involving back, right buttock, and right hip, stage 2. <BR/>Record review of Resident #93's hospital Discharge summary dated [DATE] did not reflect wound care orders. <BR/>Record review of Resident #93's Braden scale for predicting pressure sore risk dated 02/01/25 indicated score of 16 which was at risk. <BR/>Record review of Resident #93's weekly skin assessment dated [DATE] indicated .does the resident have a pressure, venous, arterial, diabetic, or surgical wound .yes .stage 2 PU, multiple shearing sites to right lateral thigh, right posterior thigh multiple, left posterior thigh, right buttocks, left posterior thigh . The facility's electronic medical record did not reflect a skin assessment on 02/08/25 or 02/09/25. <BR/>Record review of Resident #93's wound assessment report dated 02/07/25 indicated .left thigh .Length: 1.50 cm .Width: 1.00 cm .Depth: 0.10 cm .left thigh .pressure injury .stage 3 .treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing .<BR/>Record review of Resident #93's wound assessment report dated 02/07/25 indicated .right thigh .length: 4 cm .width: 2 cm .depth: 0.10 cm .right thigh .pressure injury .stage 3 . treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing .<BR/>Record review of Resident #93's wound assessment report dated 02/07/25 indicated .right thigh .length: 6 cm .width: 1.5 cm .depth: 0.10cm .right hip .pressure injury .stage 3 . treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing .<BR/>Record review of the facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .specialty mattress will be implemented for residents with multiple stage 2 areas, stage 3, or stage 4 pressure injuries .<BR/>During an observation and interview on 02/10/25 at 10:51 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff did not turn her every 2 hours or prop her heels with pillows. She said she could turn herself with the assist rails but staff did not place pillows behind her back, underneath her buttocks or between her legs. <BR/>During an observation and interview on 02/10/25 at 3:05 p.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff did not turn her every 2 hours or propped her heels with pillows.<BR/>During an observation on 02/11/25 at 10:02 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. <BR/>During an observation and interview on 02/11/25 at 11:32 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff had not turn her every 2 hours or propped her heels with pillows. She said she had wounds on thighs, buttock, and hip. She said when she came from the hospital, there were dressings on two of the wounds. She said the facility did not do dressing changes every day. She said it depended on the staff as to what was done to her wounds. She said some staff did nothing and others would put cream on the wounds if they were closed. <BR/>During an observation on 02/11/25 at 1:25 p.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. <BR/>During an interview on 02/11/25 at 1:30 p.m., the ADCO said she was working the floor when Resident #93 was admitted . She said she was Resident #93's admitting nurse. She said if the admitting nurse was not a RN, then the nurse was only responsible for measuring and describing the wound. She said a RN, the DCO, or MD staged pressure wounds at the facility. She said upon admission the resident's MD should be notified and general wound care orders obtained. She said when the wound care doctor rounded on Fridays, the facility received specialized wound care orders. She said the wound care doctor came every Friday and the DCO notified him of who needed to be seen. She said after the wound care doctor rounded and made recommendations. She said the wound care doctor placed his recommendations in a progress note. She said the floor nurses or the DCO were responsible to place the recommendations in the facility's electronic medical record as an order. She said the DCO and ADCO were responsible for ensuring the wound care orders were followed through. She said the floor nurses were responsible for the resident's weekly skin assessments. She said the DON and DNP completed the weekly wound assessments when he rounded on Fridays. She said Resident #93 wounds on admission were shearing to her right hip, right buttocks, left thigh, and left buttocks. She said since she was not a RN, she did not stage Resident #93's wounds. She said Resident #93 arrived from the hospital with dressings over the wounds. She said she notified NP R by text or phone and let her know about Resident #93's shearing. She said she did not receive a response from NP R until shift change. She said she could not remember what NP R said about Resident #93's shearing. She said she knew she passed the message from NP R on to RN G when she gave report. She said she did not know what wound care treatment Resident #93 had been receiving since admission on [DATE]. She said she did not know the facility's policy or criteria on specialty mattress because she just started January 13, 2025. She said she did not know if Resident #93 met the facility's criteria for a specialty mattress but she probably did. She said other interventions for Resident #93's pressure wounds should have been frequent repositioning and incontinent care and a dietary consult. She said the dietician would be at the facility this week. She said since Resident #93 had a skin assessment on 02/01/25, then she should have had one on 02/08/25. She said even though the skin assessment was a day after the wound care doctor came, it should have been done by the floor nurse. She said skin assessments were important to ensure skin issues were not missed and proper wound care orders were in place. She said following doctors' orders were important to prevent the wound from declining and promote healing. She said the facility provided Resident #93 assist rails and trapeze bar to help with her mobility. <BR/>On 02/11/25 at 2:23 p.m., called NP R and left voicemail. <BR/>On 02/11/25 at 2:25 p.m., called RN G and left voicemail. <BR/>During an interview on 02/11/25 at 2:58 p.m., NP R said she received a text message from LVN A that Resident #93 was admitted . She said she was currently driving and could not remember if the ADCO contacted her on admission about Resident #93's wounds. She said normally the facility followed the hospital's wound care orders and did not need them to give any orders. <BR/>During an interview on 02/11/25 at 4:41 p.m., NP R called back and said LVN A and the ADCO called her on 02/01/25 about Resident #93. She said she told LVN A and the ADCO to resume all hospital orders and she would see Resident #93 on Tuesday, 02/04/25. <BR/>During an interview on 02/11/25 at 6:01 p.m., RN G said she had worked at the facility for 6 years. She said she had taken care of Resident #93. She said she was texting with NP R on 02/05/05 about another resident lab work and NP R asked about Resident #93. She said NP R mentioned the hospital had not sent Resident #93 with wound care orders when she discharged . She said she told NP R that there were no wound care orders in Resident #93's hospital discharge paperwork. She said she told NP R, she did not know what the facility had been doing either for Resident #93's pressure wounds. She said NP R ordered collagen and a dry dressing and for the wound care doctor to see Resident #93. She said she did the ordered wound care on Resident #93 that night shift (02/05/25). She said she thought she placed the wound care orders NP R gave for Resident #93 in the facility's electronic medical records. She said Resident #93's wound care orders from NP R would be on her MAR if she did. She said it was important to have put in the wound care orders from NP R, so the next person knew what to do for Resident #93's wounds. She said not doing wound care treatments for Resident #93's wounds could cause further break down or increased stages. She said Resident #93's wounds would have been called stage 2's on admission. She said if the admission nurse was not a RN, then the next RN on duty was responsible for staging the pressure ulcer. She said if a wound needed to be staged by a RN, that information needed to be passed down by the next nurse or put on the 24-hour report. She said staging a pressure ulcer was important so the wound could be caught early and treated so it did not decline. She said she was not aware Resident #93's wounds were not staged until DNP S came on 02/07/25. She said a resident had to have pressure breakdown to be on a low air loss mattress. She said Resident #93 was on a bariatric pressure reduction mattress. She said she did not if they made bariatric specialty mattresses. She said if they made bariatric low air loss mattresses, Resident #93 would qualify for one because she had several areas of pressure breakdown. <BR/>During an interview on 02/12/25 at 1:57 p.m., LVN D said nurses were responsible for resident's skin assessments. She said the skin assessments were due weekly and as needed. She said the weekly skin assessments should be charted in the resident medical records. She said a resident should be on a low air loss mattress if they have pressure ulcers or at the family request. She said heels should be floated for residents after hip surgery, residents who do not turn good, or residents with redness on their heels. She said residents should be repositioned every 2 hours. She said the RCP or LVN could do it but the RCP was primarily responsible. She said if a resident was able to turn themselves in the bed, the RCP should still encourage and help the resident turn every 2 hours. She said the RCP should be propping the resident with pillows to offload them when repositioning. She said the LVN should be ensuring the RCP are repositioning every 2 hours and offloading the residents by observation. She said a RN and LVN certified in wound care could stage pressure wounds. She said primarily RNs. She said if a resident needed a pressure wound staged, she would find a RN or contact the DCO. She said the facility had a telehealth option to stage wounds available now. She said the resident's doctor or the medical director was contacted for wound care orders. She said nursing management was responsible for taking the wound care doctor recommendations and making them orders. She said when the wound care doctor rounded on Fridays, he gave the DCO a copy of his recommendations on a piece of paper before he left. She said the wound care doctor left around 10 am. She said the bedside nurses were responsible for doing wound care treatments. She said the nurses documented on the MAR/TAR when wound care was completed. She said if wound care was not documented on the resident MAR/TAR, it could indicate it was not done. She said some residents did not show on the right screen to be done on the facility's computer system. She said skin assessments, wound care treatments, and repositioning/offloading were important to prevent skin breakdown and worsening of wound and not miss anything. <BR/>During an interview on 02/12/25 at 5:25 p.m., RCP H said she had worked at the facility for 2 years. She said she found out a resident had wounds when she changed them. She said she was not really made aware by nursing staff or during report which resident had wounds. She said it depended on the severity of the wound what type of treatment the resident required. She said some resident needed cream and other had dressing changes by the nursing staff. She said RCPs were responsible for repositioning the residents every 2 hours with rounds. She said the residents should be alternated side to side and propped with pillows. She said residents stuck in the bed should have their heels offloaded. She said Resident #93 was stuck in the bed unless PT got her up. She said when she had Resident #93, she went in her room every once in a while, to remind her to turn but not every 2 hours. She said turning and offloading were important to prevent skin breakdown. She said constant pressure caused skin breakdown. <BR/>During an interview on 02/12/25 at 5:49 p.m., the ADCO said wound care was documented on the resident's TAR in the facility's charting system. She said if wound care was not documented in the facility's charting system, it could indicate it was not done. She said the charge nurses were responsible for the resident's wound care. She said the DCO and ADCO should ensure the charge nurses were doing the ordered wound care treatments and documenting wound care on the resident's MAR/TARs. She said doing the resident's ordered wound care treatment was important to prevent decline of the wound, infection, prevent pain and more wounds. She said it was also important to do wound care to monitor the wound and follow doctor's orders. She said completion of the resident's skin assessment was documented on the TAR/MAR and a skin assessment form was also done. She said when she first started, she did not know that a skin assessment form had to be done even if the resident had no skin changes. She said she documented she completed Resident #15's skin assessment on the MAR/TAR but she did not do a new skin assessment form. She said she and the DCO Q were in the process, of putting a process in place to do chart audits to monitor skin assessments and wound care orders. <BR/>During an interview on 02/12/25 at 6:57 p.m., DCO P, who was covering for DCO Q, said she expected nursing staff to follow physician orders. She said she expected nursing staff to document wound care on the MAR/TAR and/or progress note in the facility's charting system. She said if the wound care was not documented on the MAR/TAR and/or progress note, it could indicate it was not done. She said she expected nursing staff to order skin assessment on admission. She said she expected nursing staff to complete skin assessment weekly and with skin changes. She said the DCO ordered the resident's specialty mattresses and the charge nurse should ensure it was on the correct settings. She said all resident benefited from having their heels floated. She said but immobile residents especially needed their heels floated. She said she expected residents to be repositioned and offloaded at least every 2 hours by the RCPs. She said she preferred staging pressure wounds be done by the telehealth system. She said a RN or DCO should stage the resident pressure wounds. She said the ADCO and DCO should be ensuring nursing staff were doing wound care and skin assessments. She said all of these were important for wound prevention and management. <BR/>During an interview on 02/12/25 at 7:34 p.m., the EDO said skin assessment were to be completed every 7 days in the facility's charting system. She said Resident #93 met the criteria for a low air loss mattress. She said the facility had a few specialty mattresses in house and she also could order one if needed. She said the DCO or the nursing staff who rounded with the wound care doctor was responsible for inputting his orders. She said it was important to document wound care and skin assessments to have an adequate clinical record. She said it was important to do wound care and skin assessments to promote wound healing. She said nursing management was responsible for ensuring nursing staff completed skin assessment and wound care. She said nursing management should be doing chart audits to ensure it was happening. <BR/>Record review of a facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .the purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds Skin assessments will be documented at a minimum of every 7 days on a Weekly Skin Assessment . Staging of wounds will be performed by a registered nurse or licensed nurse certified in wound care . Dependent residents will have heels floated while in bed and be turned and repositioned at a minimum of every 2 hours . A licensed nurse will obtain orders from physician for new skin wounds and transcribe onto resident's treatment record for follow up . Specialty mattresses will be implemented for residents with multiple stage II areas, stage Ill, or stage IV pressure injuries . Weekly skin assessments will be documented on the Weekly Skin Assessment every 7 days or less . Licensed nurse will initiate the schedule for the wound form in Point Click Care which automatically triggers every 7 days from day of completion .<BR/>The EDO and DCE were notified of an IJ on 02/11/25 on 5:00 p.m., were given a copy of the IJ template, and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 02/12/25 at 9:40 a.m. and included the following:<BR/>[F635]<BR/>Plan of Action: <BR/>Resident #93 had wound care orders written on 02/11/25. A weekly wound assessment was completed on 02/11/25. A specialty mattress was placed on Resident #93's bed on 02/11/25. Resident #93's heels were floated effective 02/11/25. <BR/>Skin sweep competed on 02/11/25 to ensure all skin issues were identified and had current orders and interventions in place. Completed 02/11/25 by Director of Clinical Education and designees. <BR/>Director of Clinical Education will educate Director of Clinical Services and Assistant Director of Clinical Services on the process of reviewing new resident admissions electronic health records for completion of order transcription as it relates to wound orders as well as carrying out those orders. Completed 2/11/25 If a RN or wound care certified LVN is not on duty at the time a resident admits, the admitting nurse on duty will utilize Advanced Wound Care Telehealth for a consult. Completed 02/12/25. <BR/>All licensed nurses will be educated by the ADCO or designee on the process of carrying out orders for residents admitted with wounds or obtaining orders if no order accompanies the resident when admitted . Education will also include the completion of weekly skin assessments per schedule. Completion 02/12/25 10:00 a.m. Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift. <BR/>All licensed nurses will receive in-service regarding wound care orders and weekly skin assessments prior to the beginning of their next shift to begin 02/11/25. <BR/>Any newly hired nurses will receive the above education upon hire during orientation prior to taking a shift on the floor. <BR/>Ad hoc QAPI meeting will be held with the Medical Director on 02/12/25 reviewing the policies and procedures for wound care. <BR/>All licensed nurses will be educated on the Skin Management policy regarding general guidelines, prevention, notification, treatment, and documentation the Director of Clinical Education or designee. Completed 2/12/2025 2:00 p.m. Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift.<BR/>All C.N.A.'s will be educated by the Director of Clinical Education or designee regarding pressure ulcer prevention and interventions for residents with pressure ulcers. Completed 2/12/2025 3:00 p.m. Anyone who is not on duty or cannot come in or be reached by phone will be required to complete the in-service prior to working their next shift.? <BR/>Validation/Monitoring Tools? <BR/>Director of Clinical Operations or Assistant Director of Clinical Operations will review all orders for new admissions every day in the morning clinical meeting to ensure orders have been written and carried out for residents admitted with wounds. ?Beginning 02/12/25. <BR/>Director of Clinical Operations or designee will review weekly skin assessments daily to ensure timely completion. Beginning 02/12/25. <BR/>Director of Clinical Operations or designee will review wound physician documentation weekly to ensure any orders are carried out timely. Beginning 02/12/25. <BR/>Director of Clinical Operations and/or designee will review all wound care patients orders, interventions, and skin assessments during Standards of Care Meeting weekly, Beginning 02/12/25.<BR/>The Administrator, Director of Clinical Operations and/or designee will review the action plan developed related to obtaining wound care orders, implementing wound care interventions, and weekly skin assessments in QAPI meeting monthly during the next six months. Beginning 02-12-25.? <BR/>This surveyor and team verification of the Plan of Removal from 02/12/25 was as follows:<BR/>Record review of Resident #93's MAR dated 02/01/25-02/28/25 indicated wound care written on 02/11/25.<BR/>Record review of Resident #93's skin assessment dated [DATE] completed by DCO P, indicated, .stage 3 pressure injuries x3 (right lateral hip, right thigh and left inner thigh) seen by AWC MD .<BR/>Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .right thigh .2.2cmx3cmx0.2cm .<BR/>Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .left inner thigh .1cmx0.1cmx0.2cm .<BR/>Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .right lateral hip .4.5cmx1.3cmx0.2cm .<BR/>Record review of the facility's Residents with Pressure Injuries provided by the EDO on 02/11/25 indicated seven residents with pressure injuries. Five residents were included in finalized sample. Resident #11 and Resident #15 had missing documentation of wound care and skin assessments. <BR/>Record review of the facility's weekly skin assessment dat[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 5 resident's (Resident #34) reviewed for PASRR.<BR/>The facility failed to submit NFSS forms timely for Resident #34.<BR/>This failure could place residents identified at a level II for PASRR evaluation at risk for their specialized services not being provided in a timely manner.<BR/>Findings included:<BR/>Record review of face sheet dated 01/08/24 indicated Resident #34 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses of myotonic muscular dystrophy (a genetic condition that causes progressive muscle weakness and wasting), dysphagia (difficulty swallowing), and lack of coordination. <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #34 was usually understood and understood others. The MDS indicated a BIMS of 08 which indicated moderate cognitive impairment. The MDS indicated Resident #34 required partial/moderate assistance with rolling left to right, sit to lying, and lying to sitting on side of bed. Resident #34 required partial/moderate assistance with upper body dressing and substantial/maximal assistance with bathing. Distinct Calendar Days of Therapy, was marked 5, meaning Resident #34 did receive occupational, speech, or physical therapy during the 7 days of the assessment. In section G0400, the MDS indicated Resident #34 received 0 individual minutes, concurrent minutes, and group minutes for Speech-Language Pathology and Audiology Services and 0 individual minutes, concurrent minutes, and group minutes for occupational therapy. Both had a therapy start date of 11/09/23. <BR/>Record review of physician's orders dated 01/08/24 for Resident #34 indicated an order with a start date of 07/10/23 indicated:<BR/>An order dated 07/10/23, OT (occupational therapy) to eval and treat as indicated.<BR/>An order dated 07/10/23, OT clarification: Patient to receive skilled OT services 3x week x 30 days (3 times a week for 30 days) for treatment .to include therapeutic activity, therapeutic exercise, neuro re-ed (neurological re-education), group activity and self-care training.<BR/>An order dated 08/09/23, OT clarification: Recertification completed; PT (patient) to continue to receive OT services 3x/week (3 times a week) to include ther ex (therapeutic exercise), group therapy, neuro re-ed, self-care training, and ther act (therapeutic activity).<BR/>An order dated 04/05/23, ST (speech therapy) order clarification: Skilled speech therapy to address speech production and clarity with diet evaluation and changes as needed. <BR/>An order dated 11/16/23, ST eval and treat effective 11/09/23.<BR/>Record review of a care plan last revised on 12/28/23 indicated Resident #34 had an ADL self-care performance deficit related to disease processes. There was an intervention for PT/OT to evaluate and treat as per physician's orders. The care plan did not address PASRR. <BR/>Record review of a PASRR Comprehensive Service Plan form dated 07/06/23 indicated a quarterly meeting was held. The meeting was attended by Resident #34, a PASSR Health Coordinator, the Social Worker, the DON, and the Director of the Rehabilitation department. The Nursing Facility Specialized Services section indicated specialized occupational therapy and specialized speech therapy were recommended. <BR/>Record review of Simple LTC portal (portal used to submit PASRR service requests) for Resident #34 indicated notes dated 07/24/23:<BR/>* .NFSS Form for Occupational Therapy was not submitted within 30 calendar days of the IDT meeting. <BR/>* .NFSS Form for Physical Therapy was not submitted within 30 calendar days of the IDT meeting.<BR/>* .NFSS Form for Speech Therapy was not submitted within 30 calendar days of the IDT meeting.<BR/>* Form submitted. There was no indication if this form was for physical therapy, occupation therapy, or speech therapy. <BR/>Record review of the Simple LTC portal for Resident #34 dated 7/25/23 indicated a note from the PASSR Unit, Each request must have its own, unique and original signatures and signature pages. You may not use typed or digitally written signatures, stamps, or copied signatures. Please complete the following steps. Q. Upload a valid completed signature page that is original,, ensure signatures are legible and the signature dates match the portal, and resubmit. 2. Set all appropriate tabs that are in Pending Denial status to Pending State Review before 07/31/23 to avoid a system -generated denial. <BR/>Record review of a letter dated 07/27/23 from the PASRR Unit to Resident #34 indicated, .We have received a request for PASRR nursing facility specialized services The following service or items have been denied .Occupational Therapy. Reason for Denial: We needed more information to review your request. We didn't receive the information by the deadline .Speech Therapy .Denied .We needed more information to review your request. We didn't receive the information by the deadline .<BR/>Record review of a letter dated 07/28/23 from the PASRR Unit to Resident #34 indicated, .The following services or items have been approved .Physical Therapy .<BR/>Record review of an email correspondence from the PASSR Unit to the MDS coordinator dated 06/26/23 indicated, .Provides must complete a Nursing Facility Specialized Services (NFSS) for to request PASRR nursing facility specialized services . A training link was included in the email. <BR/>During an interview on 01/09/24 at 1:12 p.m., the Director of Rehabilitation department/Certified Occupational Therapist said Resident #34 had always received physical therapy, occupation therapy, and speech therapy. She said the services were covered by his Medicare. She said Medicare would not approve further services. She said they started the process to have the services approved through PASSR specialized services. <BR/>During an interview on 01/09/24 at 2:15 p.m., the MDS Coordinator said the process to obtain PASSR services for a PASSR positive resident would be to hold a meeting with local health authority to determine if services were needed. She said then a care plan meeting would be held. She said therapy then picked them up and filled out the NFSS form to get it approved. She said Resident #34 had been in the hospital and when he came back to the facility, they used his Part B services until those services were up and there was a new meeting to determine the services needed. She said she had not received any correspondence or letter concerning denial. <BR/>During an interview 01/10/24 at 8:15 a.m., the Director of Rehabilitation department/Certified Occupational Therapist said Resident #34 received therapy from April - June 27, 2023 She said it was funded through his Part B . She said Resident #34 received occupational therapy 7/10/23 - 8/10/23 and speech therapy 7/11/23 - 8/10/23. She said on 8/10/23 Resident #34 was admitted to the hospital. When he was readmitted to the facility, he received all therapies through Part B until the benefits were exhausted. She said at this time they were working on getting him recertified through PASSR services. She said she was unaware that she had to fill at a NFSS for each service.<BR/>During an interview on 01/10/24 at 10:58 a.m., the MDS Coordinator said the Director of Rehabilitation department/Certified Occupational Therapist was responsible for submitting the NFSS forms for residents. She said she was only in the facility 2 days a week and she was not sure why the occupational therapy NFSS or the speech therapy NFSS forms were not submitted. She said the appropriate forms not being submitted could cause a resident to not receive needed services.<BR/>During an interview on 01/10/24 at 11:57 a.m., the DON said the MDS Coordinator, and the Social Worker were responsible for submitting the NFSS forms to the PASSR Unit. She said she would have expected the requested forms to have been submitted. She said the forms not being submitted could cause a resident to receive specialized services.<BR/>During an interview on 01/10/24 at 12:38 p.m., the Administrator said Director of Rehabilitation department/Certified Occupational Therapist was responsible for submitting NFSS forms. She said she would have expected for the forms to have been summited if they were requested from the PASSR unit. She said the NFSS form not being summitted could cause a resident to not receive therapy services. <BR/>Review of a facility PASSR facility policy dated 11/2023 indicated, .Follow Texas PASSR Policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASSR status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 5 residents, (Resident #16) reviewed for PASRR Level 1 screenings.<BR/>The facility failed to complete a PASRR Level 1 screening for Resident #16 following a discharge from a mental health hospital with a new diagnosis of mental illness.<BR/>This failure could place residents at risk of not being evaluated for PASRR services and receiving needed services.<BR/>The findings were:<BR/>Record review of face sheet dated 01/09/24 revealed Resident #16 was [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Bipolar type (episodes of mania and sometimes depression) with an onset of 08/19/22, Major Depressive Disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and anxiety disorder. <BR/>Record review of a quarterly MDS dated [DATE] revealed Resident #16 had a BIMS of 15, which indicated the resident was cognitively intact. Resident #16 required supervision to set up assistance with most ADLs. <BR/>Record review of a care plan last revised on 09/18/23 indicated Resident #16 was at risk for adverse consequences related to receiving psychotropic medications due to diagnoses of anxiety, depression, paranoia, and psychotic/psychosis. <BR/>Record review of PASRR Level One Screening forms dated 03/02/17 did not indicate Resident #16 had a mental illness. Resident #16's electronic medical record did not indicate any further PASRR Level One Screening forms or a PASRR Evaluation. <BR/>Record review of a Discharge Summary from a behavioral hospital with an admission date of 08/04/22 and a discharge date [DATE] indicated Resident #16 had a diagnosis of bipolar disorder type 1 (Bipolar I disorder is defined by manic episodes that last for at least 7 days (nearly every day for most of the day) or by manic symptoms that are so severe that the person needs immediate medical care), recurrent, severe, with psychotic features.<BR/>During an interview on 01/09/24 at 2:15 p.m., the MDS Coordinator said the previous DON had entered the diagnosis into the electronic medical record for Resident #16. The MDS Coordinator said she was unaware of the diagnosis of schizoaffective disorder, bipolar type for the resident and there had not been a PASSR Level One Screening resubmission. She said there was not a PASSR evaluation for Resident #16. <BR/>During an interview on 01/10/24 at 11:57 a.m., the DON said after Resident #16's medical record was updated to reflect the resident had a diagnosis of schizoaffective disorder, bipolar type 1 and after the resident returned from the behavioral hospital with a diagnosis of bipolar disorder, she would have expected the resident to have been received a new PASRR Level One Screening and a PASSR Evaluation. She said a resident with a new diagnosis of mental illness not being re-evaluated appropriately could cause them to not receive needed PASSR services.<BR/>During an interview on 01/10/24 at 12:38 p.m., the Administrator said after a resident received a new mental illness diagnosis, she would have expected a new PASRR Level One Screening and a PASSR Evaluation to have been done for the resident. She said a resident with a mental illness not having a PASSR Evaluation could cause them to not get support and services they need.<BR/>Review of a PASSR facility policy dated 11/2023 indicated, .The purpose of this policy is to ensure PASRRs are being obtained and completed timely and accurately .Follow Texas PASRR Policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 15 residents reviewed for care plans. (Resident# 19, Resident #29)<BR/>The facility failed to implement Resident #19's care plan intervention to off-load (is described as lifting or pushing an area of high pressure away from the cause of the pressure) her heels when in bed.<BR/>The facility failed to care plan Resident # 19's diagnosis of Type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and use of insulin (therapy often is an important part of diabetes treatment), diuretic (are medicines that help reduce fluid buildup in the body), opioid (sometimes called narcotics, are a type of drug), and antiplatelet (are medications that prevent blood clots from forming) coded of her MDS. <BR/>The facility failed to care plan Resident #19's use of an anticonvulsant (are prescription medications that help treat and prevent seizures). <BR/>The facility failed to care plan Resident #29's use of an antiplatelet. <BR/>These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services.<BR/>Findings included:<BR/>1. Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Type 2 diabetes, edema (is swelling caused by too much fluid trapped in the body's tissues), cerebrovascular disease (is a term for conditions that affect blood flow to your brain), bipolar (causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), and conversion disorder (is a condition where a mental health issue causes physical symptoms) with seizures (is a sudden, uncontrolled burst of electrical activity in the brain) or convulsion (are rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 had diagnoses including diabetes mellitus and seizure disorder or epilepsy (is a brain condition that causes recurring seizures). The MDS indicated Resident #19 received scheduled pain medication regimen and experienced presence of pain in the last 5 days. The MDS indicated Resident #19 received diuretic, opioid, and antiplatelet medications during the last 7 days of the assessment period. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Clopidogrel (It is an antiplatelet drug. It helps keep blood flowing smoothly in your body) 75 mg, give 1 tablet by mouth one time a day for anticoagulation, start date 03/18/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine (is in a class of medications called anticonvulsants. It works by reducing abnormal electrical activity in the brain) 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Lasix (is a strong diuretic (water pill') and may cause dehydration and electrolyte imbalance) 20 mg, give 2 tablets by mouth one time a day for cerebrovascular disease, start date 03/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Gabapentin (is an anticonvulsant medication primarily used to treat partial seizures and neuropathic pain) 600 mg, give 1 tablet by mouth one time a day for neuropathy (happens when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged), start date 03/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Novolin (is a type of insulin used to control blood sugar) 100 units/ML (Insulin Regular (Human)), inject as per sliding scale, subcutaneously two times a day for diabetes type 2, start date 04/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Tramadol (is in a class of medications called opiate (narcotic) analgesics and used to treat moderate to severe pain that is not being relieved by other types of pain medicines) 50 mg, give 1 tablet by mouth three times a day for pain, start date 08/14/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Lantus (is a long-acting form of insulin), inject 30 unit subcutaneously at bedtime for diabetes type 2, start date 11/08/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Lantus, inject 40 unit subcutaneously in the morning for diabetes type 2, start date 11/08/23. <BR/>Record review of Resident #19's care plan dated 07/19/23 indicated Resident #19 had a DTI (is a form of pressure ulcer or pressure sore) to left heel. Intervention off-load heels while in bed. The care plan did not address Resident #19's diagnosis of Type 2 diabetes and use of an anticonvulsant and use of insulin, diuretic, opioid, and antiplatelet coded of her MDS. <BR/>During an observation and interview on 01/08/24 at 1:04 p.m., Resident #19 was lying in the bed on her back. Resident #19's feet were not off-loaded. She said the staff did not put anything underneath her heels but sometimes put heel protectors on after therapy. The heel protectors were on the bed next to Resident #19. Resident #19 said she had not had them on in a while. <BR/>During an observation and interview on 01/09/24 at 1:15 p.m., Resident #19 was lying in the bed on her back. Resident #19's feet were not off-loaded.<BR/>During an interview on 01/10/24 at 12:22 p.m., RCP O said the RCPs and LVNs were responsible for ensuring Resident #19's heels were floated. She said Resident #19 also had heel protectors she would wear. She said Resident #19 had sores on her feet and they were floating them to heal. She said floating a resident's heels kept the pressure off the area damaged. <BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said the nurse was responsible for floating Resident #19's heels or placing her heel protectors on. She said Resident #19 would sometimes refuse the heel protectors or would not float her heels for long periods of time. She said Resident #19 had a DTI and was paralyzed on her left side so floating her heels was important for prevention of skin breakdown. She said she did not know if nurses had access or could see care plans interventions. She said nursing staff knew resident care from morning meeting updates. She said implementing Resident #19 care plan intervention was important to prevent wounds or injuries. <BR/>2. Record review of Resident #29's face sheet printed 01/09/24 indicated Resident #29 was an [AGE] year-old male and was admitted on [DATE] and 05/31/22 with diagnosis including atherosclerotic heart disease of native coronary artery (is caused by plaque buildup in the wall of the arteries that supply blood to the heart (called coronary arteries)). <BR/>Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated Resident #29 was understood and sometimes had the ability to understand others. The MDS indicated Resident #29 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #29 required partial/moderate assistance for toilet hygiene and shower/bath self, supervision for personal hygiene, and independent for oral hygiene and eating. The MDS indicated Resident #29 received an antiplatelet during the last 7 days of the assessment period. <BR/>Record review of Resident #29's order summary dated 01/09/24 indicated Aspirin (is used to treat pain and reduce fever or inflammation. It is sometimes used to treat or prevent heart attacks, strokes, and chest pain) 81 mg, give 1 tablet by mouth one time a day for preventative, start date 12/18/20. <BR/>Record review of Resident #29's care plan printed 01/09/24 did not indicate use of an antiplatelet. <BR/>During an interview on 01/10/24 at 1:20 p.m., the CRS said she was responsible for MDSs and care plans. She said she only worked part time at the facility. She said she developed the comprehensive care plan from the CAAs on the MDS, medical diagnoses, physician's orders, activities, reviewed progress and social notes, and anything special in the resident's history. She said Resident #19's diagnoses and medications should be included on her care plan. She said comprehensive care plans were important to make sure residents received services and any special needs the staff needed to be aware of. She said Resident #29's use of an antiplatelet should have been added to his care plan. She said new nurses could look at a care plan and may not know the appropriate care for the resident if problem areas were not added to the care plan.<BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said the MDS Coordinator (CRS) and the DCO were responsible for comprehensive care plans. She said Resident #19's diagnoses and medications and Resident #29 use of an antiplatelet should be care planned. She said comprehensive care plans were important, so nurses were aware of the resident's issues. She said the nurses were responsible for care plan interventions to be implemented. She said sometimes Resident #19 refused to off-load her heels. She said staff were supposed to chart if Resident #19 refused. The DCO said LVNs were able to view residents' care plans on the facility's charting system but not RCPs. She said LVNs should inform RCPs of care plan interventions such as off-loading heels, so they knew to monitor. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said if an intervention was on a care plan, she expected it to be followed or done. She said if the information was on the MDS and was triggered (coded), she expected it to be on the care plan. She said nurses and nurse management was responsible for ensuring comprehensive care were complete and interventions are followed or done. She said diagnoses and medications had risked that had to be monitored and intervention developed. <BR/>Record review of a facility's Comprehensive Care Plan revised on 04/21 indicated .the interdisciplinary team will continue to develop the plan in conjunction with RAI (MDS 3.0) and CAAS .the IDT will review the healthcare practitioner's notes and orders and implement a comprehensive care plan to meet the residents' immediate needs including but not limited to .physician orders .pain management .specific care plan on the main reason for admission .<BR/>Record review of a facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .is for prevention and treatment of skin breakdown such as pressure injuries .prevention .dependent residents will have heels floated while in bed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 15 resident reviewed for ADLs. (Resident #19)<BR/>The facility failed remove Resident #19's unwanted facial hair.<BR/>The facility failed to provide Resident #19 her schedule bath/showers.<BR/>These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.<BR/>Findings included:<BR/>Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side and muscle weakness.<BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene.<BR/>Record review of Resident #19's care plan dated 04/10/23 indicated Resident #19 had limited physical mobility related to stroke and weakness. Intervention included Resident #19 was non-weight bearing. The care plan did not address ADL care and intervention. <BR/>Record review of Resident #19's ADL bathing report dated 12/11/23-01/08/24 indicated no documentation for Resident #19 for 6 out of 13 scheduled bath/showers. The ADL bathing report indicated Resident #19's shower days were Mondays, Wednesdays, and Fridays. <BR/>Record review of Resident #19's shower sheets from 12/11/23-01/08/24 indicated 12/11/23 (bed bath), 12/13/23 (refused shower, received bed bath, shaved), 12/18/23, 12/22/23 (bed bath), 12/28/23 (bed bath), 01/03/24 (showered, shampoo), 01/05/24, 01/08/24 (bed bath). <BR/>During an interview and observation on 01/08/24 at 1:04 p.m., Resident #19 was lying in her bed in a hospital gown with food on her hand and the bed. Resident #19 said she did not get enough baths. She said her baths were on Mondays, Wednesdays, and Fridays but she only got them once or twice a week. Resident #19 had small amount of black, curly hair on both side of her mouth. Resident #19 said she wanted it (facial hair) off. <BR/>During an observation on 01/09/24 at 11:30 a.m., Resident #19 was lying in her bed in a hospital gown with a small amount of black, curly hair on both side of her mouth. <BR/>During an observation on 01/09/24 at 1:15 p.m., Resident #19 was lying in her bed in a hospital gown with a small amount of black, curly hair on both side of her mouth. <BR/>During an interview on 01/10/24 at 12:22 p.m., RCP O said RCPs were responsible for giving residents bath or showers and removing facial hair. She said Resident #19 refused showers at least once a shift when she worked. She said Resident #19 let the RCPs remove her facial hair. She said ADL care was charted on the facility's charting system. She said the ADCO and DCO decided the shower scheduled. She said the shower schedule was posted at the nurse's station with the resident's day and which shift. She said the facility just started using shower sheets also to document resident's showers. She said ADL care was important for hygiene. She said sometimes if the facility only had 2 RCPs on the floor, things did not get done like resident's shower and baths. <BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said RCPs were responsible for ADL care of residents. She said if the resident refused, the RCP was supposed to notify the nurse and the nurse was supposed to also ask then document if the resident still refused. She said Resident #19 refused to get up for showers but would get a bed bath instead. She said Resident #19 rarely refused to have her facial hair removed. She said refusals were documented on shower sheets. She said ADL care was important for the resident's dignity and to smell good. <BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said the RCP was responsible for ADL care. She said residents should get bed bath daily and showers three times a week. She said she was not sure when women were shaved. She said ADL care was documented in the facility's charting system. She said she was not sure if Resident #19 refused to have her facial hair removed but she refused showers but would do bed baths. She said bed baths and showers were supposed to be charted in the facility's charting system. She said shower sheets were supposed to be done for all bath and showers. She said shower/baths were important to promote cleanliness. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said RCP was responsible for ADL care. She said she expected the staff to follow the shower schedule unless the resident refused. She said facial hair should be removed as needed. She said nurses and nursing management should make rounds to ensure resident were be provided ADL care. A policy regarding ADL for shower/bath and facial hair was requested at this time, the policy was not received before or after exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure treatment and services was provided, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 3 of 7 residents reviewed for quality of care. (Resident #93, Resident #11, and Resident #15)<BR/>The facility failed to initiate wound care treatment after Resident #93 admitted on [DATE], with multiple areas of shearing.<BR/>The facility failed to perform a weekly skin assessment on Resident #93 that was due on 02/08/25. <BR/>The facility failed to initiate Resident #93's wound care orders noted in the wound care doctor's progress notes on 02/08/25 until 02/10/25. <BR/>The facility failed to implement a specialty mattress (use in the treatment and prevention of pressure ulcers) for Resident #93, per their policy, due to multiple stage 3 pressure injuries on 02/01/25. <BR/>The facility failed to float Resident #93's heels on 02/10/25 and 02/11/25.<BR/>The facility failed to offload and/or reposition Resident #93 every 2 hours on 02/10/25 and 02/11/25. <BR/>An IJ was identified on 02/11/25. The IJ template was provided to the facility on [DATE] at 5:00 p.m. While the IJ was removed on 02/12/25, the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on the process of carrying out orders for residents admitted with wounds or obtaining orders if no orders accompanied the resident, completion of weekly skin assessments, wound care orders, skin management policy, and pressure ulcer prevention and interventions for residents with pressure ulcers. <BR/>2.The facility failed to document wound care was performed on Resident #11, on 02/01/25, 02/02/25, 02/03/25, 02/05/25, and 02/10/25. <BR/>The facility failed to document Resident #11's weekly skin assessments on 01/02/25, 01/15/25, 01/22/25, 01/29/25, and 02/04/25. <BR/>3.The facility failed to document wound care was performed on Resident #15's right upper thigh wound on 01/17/25, 01/20/25, and 01/29/25. <BR/>The facility failed to document Resident #15's weekly skin assessments on 01/19/25, 01/26/25, 02/02/25, and 02/09/25.<BR/>Theses failures could place residents at risk for wound deteriorations and more wound development. <BR/>Findings included:<BR/>1. Record review of Resident #93's face sheet dated 02/11/25 indicated Resident #93 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #93 had diagnoses including acute kidney failure (when the kidneys suddenly can't filter waste products from the blood), urinary tract infection (is an infection in any part of your urinary system: kidneys, bladder, ureters, and urethra), morbid obesity (is a medical condition characterized by excessive body weight that significantly impacts health and well-being), and pressure ulcer of right hip, left hip, and other sites, stage 3 (a full-thickness tissue loss where the subcutaneous fat layer is visible within the wound, but the bone, tendon, or muscle is not exposed). <BR/>Record review of the MDS, on 02/10/25, indicated Resident #93 was admitted to the facility less than 21 days ago. No MDS for Resident #93 was completed prior to exit.<BR/>Record review of Resident #93's care plan dated 02/03/25 indicated: <BR/>*Resident #93 was admitted with stage 3 pressure ulcer to right thigh. Interventions included assess and document skin condition every week, pressure relieving appliances as ordered, reposition residents as indicated to relieve pressure and for comfort, and wound care per MD orders. <BR/>*Resident #93 was admitted with Stage 3 pressure ulcer to right hip. Interventions included assess and document skin condition every week, monitor nutritional intake, weight, lab values and report significant changes to MD, pressure relieving appliances as ordered, reposition residents as indicated to relieve pressure and for comfort, and wound care per MD orders.<BR/>*Resident #93 was admitted with stage 3 pressure ulcer to left thigh. Intervention included administer treatments as ordered and monitor for effectiveness, monitor nutritional status, and obtain and monitor lab/diagnostic work as ordered. <BR/>Record review of Resident #93's consolidated physician orders dated active as of 02/11/25 indicated the following:<BR/>*Left thigh- cleanse with house wound cleanser. Apply Medi honey and collagen sheet. Cover with foam and border gauze dressing everyday shift. Start 02/11/25.<BR/>*Nursing to perform weekly skin assessment. Ordered 02/09/25.<BR/>*Right hip- cleanse with house wound cleanser and pat dry. Apply Medi honey and cover with collagen sheet and foam then secure with border dressing everyday shift. Start 02/11/25. <BR/>*Right thigh- cleanse with house wound cleanser and pat dry. Apply Medi honey and collagen sheet. Cover with foam and secure with border dressing everyday shift. Start 02/11/25.<BR/>The consolidated physician order did not reflect wound care orders for Resident #93's left thigh, right hip, and right thigh pressure ulcer on admission [DATE]). <BR/>Record review of Resident #93's MAR dated 02/01/25-02/28/25 indicated the following:<BR/>*Left thigh- cleanse with house wound cleanser. Apply Medi honey and collagen sheet. Cover with foam and border gauze dressing everyday shift. Start 02/11/25.<BR/>*Nursing to perform weekly skin assessment. Ordered 02/02/25. Discontinued 02/09/25. No documentation was noted on 02/02/25 and 02/09/25. <BR/>*Right hip- cleanse with house wound cleanser and pat dry. Apply Medi honey and cover with collagen sheet and foam then secure with border dressing everyday shift. Start 02/11/25. <BR/>*Right thigh- cleanse with house wound cleanser and pat dry. Apply Medi honey and collagen sheet. Cover with foam and secure with border dressing everyday shift. Start 02/11/25.<BR/>Record review of Resident #93's progress note dated 01/12/25-02/12/25 indicated:<BR/>*02/01/25 at 7:47 p.m. by the ADCO, .new admission skin assessment .the following areas were all noted upon admission to the facility . Right Lateral thigh shearing 2cm x 5cm x0.1cm open area without exudate with surrounding scaring . Right gluteal area shearing 0.4cm x 0.4cm x 0.1 cm no exudate noted . Right lateral hip shearing with surrounding scaring 5.5cm x 1.4cm x 0.1cm no exudate noted . Right Posterior hip shearing 1.3cm x 0.9cm x 0.1cm no exudate noted . Right posterior thigh near gluteal fold 1.2cm x 0.1cm. Area is a hard area that appears to be healing . Left posterior thigh shearing 1.2cm x 1cm x 0.1cm area noted to have slight bleeding when dressing was removed . right medial posterior thigh near gluteal fold 1cm x 1cm. area is a hard area that appears to be healing .<BR/>*02/08/25 at 7:33 p.m. by DNP S, .date of service: 02/07/25 .wound initial .Resident #93 . The following wounds were evaluated during today's visit . Wound 1 Right Hip, Pressure Injury, Stage 3 . Wound 2 Right Thigh, Pressure Injury, Stage 3 . Wound 3 Left Thigh, Pressure Injury, Stage 3 . Patient is admitted with multiple wounds . Per report from DON . WOUND ASSESSMENT: .Wound: 1 . Status: Present on admission Location: Right Hip . Primary Etiology: Pressure Injury Severity: Stage 3 . Size: 6 cm x 1.5 cm x 0.1 cm. Actual area is 9 cm2. Actual volume is 0.9 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema Exudate: Light Serous .Wound Odor: None . Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Wound: 2 . Status: Present on admission Location: Right Thigh . Primary Etiology: Pressure Injury .Severity: Stage 3 . Size: 4 cm x 2 cm x 0.1 cm. Actual area is 8 cm2. Actual volume is 0.8 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema, No maceration Exudate: Light Serous . Wound Odor: None . Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Wound: 3 . Status: Present on admission Location: Left Thigh . Primary Etiology: Pressure Injury .Severity: Stage 3 . Size: 1.5 cm x 1 cm x 0.1 cm. Actual area is 1.5 cm2. Actual volume is 0.15 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema, No maceration Exudate: Light Serous . Wound Odor: None .Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Recommendations consisting of: .We will re-evaluate this patient on our next visit (anticipated 1-2 weeks), Implement pressure relieving measures, offloading, and repositioning, as tolerated . Establish turning frequency based on the characteristics of the support surface and the patient's response . Protect skin from exposure to excessive moisture (periwound) with a barrier product. Use skin emollients to hydrate dry skin . Repositioning should be undertaken using the 30-degree tilted side-lying position (alternating right side, back, left side) . Plan of care discussed with facility staff .Wound# 1 Right Hip Pressure Injury Treatment Recommendations: .clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled Wound # 2 Right Thigh Pressure Injury .Treatment Recommendations: . clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled Wound # 3 Left Thigh Pressure Injury .Treatment Recommendations: . clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled .<BR/>Record review of Resident #93's memorandum of transfer and physician certification dated 02/01/25 indicated emergency department diagnoses included pressure injury of contiguous region involving back, right buttock, and right hip, stage 2. <BR/>Record review of Resident #93's hospital Discharge summary dated [DATE] did not reflect wound care orders. <BR/>Record review of Resident #93's Braden scale for predicting pressure sore risk dated 02/01/25 indicated score of 16 which was at risk. <BR/>Record review of Resident #93's weekly skin assessment dated [DATE] indicated .does the resident have a pressure, venous, arterial, diabetic, or surgical wound .yes .stage 2 PU, multiple shearing sites to right lateral thigh, right posterior thigh multiple, left posterior thigh, right buttocks, left posterior thigh . The facility's electronic medical record did not reflect a skin assessment on 02/08/25 or 02/09/25. <BR/>Record review of Resident #93's wound assessment report dated 02/07/25 indicated .left thigh .Length: 1.50 cm .Width: 1.00 cm .Depth: 0.10 cm .left thigh .pressure injury .stage 3 .treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing .<BR/>Record review of Resident #93's wound assessment report dated 02/07/25 indicated .right thigh .length: 4 cm .width: 2 cm .depth: 0.10 cm .right thigh .pressure injury .stage 3 . treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing .<BR/>Record review of Resident #93's wound assessment report dated 02/07/25 indicated .right thigh .length: 6 cm .width: 1.5 cm .depth: 0.10cm .right hip .pressure injury .stage 3 . treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing .<BR/>Record review of the facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .specialty mattress will be implemented for residents with multiple stage 2 areas, stage 3, or stage 4 pressure injuries .<BR/>During an observation and interview on 02/10/25 at 10:51 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff did not turn her every 2 hours or prop her heels with pillows. She said she could turn herself with the assist rails but staff did not place pillows behind her back, underneath her buttocks or between her legs. <BR/>During an observation and interview on 02/10/25 at 3:05 p.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff did not turn her every 2 hours or propped her heels with pillows.<BR/>During an observation on 02/11/25 at 10:02 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. <BR/>During an observation and interview on 02/11/25 at 11:32 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff had not turn her every 2 hours or propped her heels with pillows. She said she had wounds on thighs, buttock, and hip. She said when she came from the hospital, there were dressings on two of the wounds. She said the facility did not do dressing changes every day. She said it depended on the staff as to what was done to her wounds. She said some staff did nothing and others would put cream on the wounds if they were closed. <BR/>During an observation on 02/11/25 at 1:25 p.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. <BR/>During an interview on 02/11/25 at 1:30 p.m., the ADCO said she was working the floor when Resident #93 was admitted . She said she was Resident #93's admitting nurse. She said if the admitting nurse was not a RN, then the nurse was only responsible for measuring and describing the wound. She said a RN, the DCO, or MD staged pressure wounds at the facility. She said upon admission the resident's MD should be notified and general wound care orders obtained. She said when the wound care doctor rounded on Fridays, the facility received specialized wound care orders. She said the wound care doctor came every Friday and the DCO notified him of who needed to be seen. She said after the wound care doctor rounded and made recommendations. She said the wound care doctor placed his recommendations in a progress note. She said the floor nurses or the DCO were responsible to place the recommendations in the facility's electronic medical record as an order. She said the DCO and ADCO were responsible for ensuring the wound care orders were followed through. She said the floor nurses were responsible for the resident's weekly skin assessments. She said the DON and DNP completed the weekly wound assessments when he rounded on Fridays. She said Resident #93 wounds on admission were shearing to her right hip, right buttocks, left thigh, and left buttocks. She said since she was not a RN, she did not stage Resident #93's wounds. She said Resident #93 arrived from the hospital with dressings over the wounds. She said she notified NP R by text or phone and let her know about Resident #93's shearing. She said she did not receive a response from NP R until shift change. She said she could not remember what NP R said about Resident #93's shearing. She said she knew she passed the message from NP R on to RN G when she gave report. She said she did not know what wound care treatment Resident #93 had been receiving since admission on [DATE]. She said she did not know the facility's policy or criteria on specialty mattress because she just started January 13, 2025. She said she did not know if Resident #93 met the facility's criteria for a specialty mattress but she probably did. She said other interventions for Resident #93's pressure wounds should have been frequent repositioning and incontinent care and a dietary consult. She said the dietician would be at the facility this week. She said since Resident #93 had a skin assessment on 02/01/25, then she should have had one on 02/08/25. She said even though the skin assessment was a day after the wound care doctor came, it should have been done by the floor nurse. She said skin assessments were important to ensure skin issues were not missed and proper wound care orders were in place. She said following doctors' orders were important to prevent the wound from declining and promote healing. She said the facility provided Resident #93 assist rails and trapeze bar to help with her mobility. <BR/>On 02/11/25 at 2:23 p.m., called NP R and left voicemail. <BR/>On 02/11/25 at 2:25 p.m., called RN G and left voicemail. <BR/>During an interview on 02/11/25 at 2:58 p.m., NP R said she received a text message from LVN A that Resident #93 was admitted . She said she was currently driving and could not remember if the ADCO contacted her on admission about Resident #93's wounds. She said normally the facility followed the hospital's wound care orders and did not need them to give any orders. <BR/>During an interview on 02/11/25 at 4:41 p.m., NP R called back and said LVN A and the ADCO called her on 02/01/25 about Resident #93. She said she told LVN A and the ADCO to resume all hospital orders and she would see Resident #93 on Tuesday, 02/04/25. <BR/>During an interview on 02/11/25 at 6:01 p.m., RN G said she had worked at the facility for 6 years. She said she had taken care of Resident #93. She said she was texting with NP R on 02/05/05 about another resident lab work and NP R asked about Resident #93. She said NP R mentioned the hospital had not sent Resident #93 with wound care orders when she discharged . She said she told NP R that there were no wound care orders in Resident #93's hospital discharge paperwork. She said she told NP R, she did not know what the facility had been doing either for Resident #93's pressure wounds. She said NP R ordered collagen and a dry dressing and for the wound care doctor to see Resident #93. She said she did the ordered wound care on Resident #93 that night shift (02/05/25). She said she thought she placed the wound care orders NP R gave for Resident #93 in the facility's electronic medical records. She said Resident #93's wound care orders from NP R would be on her MAR if she did. She said it was important to have put in the wound care orders from NP R, so the next person knew what to do for Resident #93's wounds. She said not doing wound care treatments for Resident #93's wounds could cause further break down or increased stages. She said Resident #93's wounds would have been called stage 2's on admission. She said if the admission nurse was not a RN, then the next RN on duty was responsible for staging the pressure ulcer. She said if a wound needed to be staged by a RN, that information needed to be passed down by the next nurse or put on the 24-hour report. She said staging a pressure ulcer was important so the wound could be caught early and treated so it did not decline. She said she was not aware Resident #93's wounds were not staged until DNP S came on 02/07/25. She said a resident had to have pressure breakdown to be on a low air loss mattress. She said Resident #93 was on a bariatric pressure reduction mattress. She said she did not if they made bariatric specialty mattresses. She said if they made bariatric low air loss mattresses, Resident #93 would qualify for one because she had several areas of pressure breakdown. <BR/>During an interview on 02/12/25 at 1:57 p.m., LVN D said nurses were responsible for resident's skin assessments. She said the skin assessments were due weekly and as needed. She said the weekly skin assessments should be charted in the resident medical records. She said a resident should be on a low air loss mattress if they have pressure ulcers or at the family request. She said heels should be floated for residents after hip surgery, residents who do not turn good, or residents with redness on their heels. She said residents should be repositioned every 2 hours. She said the RCP or LVN could do it but the RCP was primarily responsible. She said if a resident was able to turn themselves in the bed, the RCP should still encourage and help the resident turn every 2 hours. She said the RCP should be propping the resident with pillows to offload them when repositioning. She said the LVN should be ensuring the RCP are repositioning every 2 hours and offloading the residents by observation. She said a RN and LVN certified in wound care could stage pressure wounds. She said primarily RNs. She said if a resident needed a pressure wound staged, she would find a RN or contact the DCO. She said the facility had a telehealth option to stage wounds available now. She said the resident's doctor or the medical director was contacted for wound care orders. She said nursing management was responsible for taking the wound care doctor recommendations and making them orders. She said when the wound care doctor rounded on Fridays, he gave the DCO a copy of his recommendations on a piece of paper before he left. She said the wound care doctor left around 10 am. She said the bedside nurses were responsible for doing wound care treatments. She said the nurses documented on the MAR/TAR when wound care was completed. She said if wound care was not documented on the resident MAR/TAR, it could indicate it was not done. She said some residents did not show on the right screen to be done on the facility's computer system. She said skin assessments, wound care treatments, and repositioning/offloading were important to prevent skin breakdown and worsening of wound and not miss anything. <BR/>During an interview on 02/12/25 at 5:25 p.m., RCP H said she had worked at the facility for 2 years. She said she found out a resident had wounds when she changed them. She said she was not really made aware by nursing staff or during report which resident had wounds. She said it depended on the severity of the wound what type of treatment the resident required. She said some resident needed cream and other had dressing changes by the nursing staff. She said RCPs were responsible for repositioning the residents every 2 hours with rounds. She said the residents should be alternated side to side and propped with pillows. She said residents stuck in the bed should have their heels offloaded. She said Resident #93 was stuck in the bed unless PT got her up. She said when she had Resident #93, she went in her room every once in a while, to remind her to turn but not every 2 hours. She said turning and offloading were important to prevent skin breakdown. She said constant pressure caused skin breakdown. <BR/>During an interview on 02/12/25 at 5:49 p.m., the ADCO said wound care was documented on the resident's TAR in the facility's charting system. She said if wound care was not documented in the facility's charting system, it could indicate it was not done. She said the charge nurses were responsible for the resident's wound care. She said the DCO and ADCO should ensure the charge nurses were doing the ordered wound care treatments and documenting wound care on the resident's MAR/TARs. She said doing the resident's ordered wound care treatment was important to prevent decline of the wound, infection, prevent pain and more wounds. She said it was also important to do wound care to monitor the wound and follow doctor's orders. She said completion of the resident's skin assessment was documented on the TAR/MAR and a skin assessment form was also done. She said when she first started, she did not know that a skin assessment form had to be done even if the resident had no skin changes. She said she documented she completed Resident #15's skin assessment on the MAR/TAR but she did not do a new skin assessment form. She said she and the DCO Q were in the process, of putting a process in place to do chart audits to monitor skin assessments and wound care orders. <BR/>During an interview on 02/12/25 at 6:57 p.m., DCO P, who was covering for DCO Q, said she expected nursing staff to follow physician orders. She said she expected nursing staff to document wound care on the MAR/TAR and/or progress note in the facility's charting system. She said if the wound care was not documented on the MAR/TAR and/or progress note, it could indicate it was not done. She said she expected nursing staff to order skin assessment on admission. She said she expected nursing staff to complete skin assessment weekly and with skin changes. She said the DCO ordered the resident's specialty mattresses and the charge nurse should ensure it was on the correct settings. She said all resident benefited from having their heels floated. She said but immobile residents especially needed their heels floated. She said she expected residents to be repositioned and offloaded at least every 2 hours by the RCPs. She said she preferred staging pressure wounds be done by the telehealth system. She said a RN or DCO should stage the resident pressure wounds. She said the ADCO and DCO should be ensuring nursing staff were doing wound care and skin assessments. She said all of these were important for wound prevention and management. <BR/>During an interview on 02/12/25 at 7:34 p.m., the EDO said skin assessment were to be completed every 7 days in the facility's charting system. She said Resident #93 met the criteria for a low air loss mattress. She said the facility had a few specialty mattresses in house and she also could order one if needed. She said the DCO or the nursing staff who rounded with the wound care doctor was responsible for inputting his orders. She said it was important to document wound care and skin assessments to have an adequate clinical record. She said it was important to do wound care and skin assessments to promote wound healing. She said nursing management was responsible for ensuring nursing staff completed skin assessment and wound care. She said nursing management should be doing chart audits to ensure it was happening. <BR/>Record review of a facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .the purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds Skin assessments will be documented at a minimum of every 7 days on a Weekly Skin Assessment . Staging of wounds will be performed by a registered nurse or licensed nurse certified in wound care . Dependent residents will have heels floated while in bed and be turned and repositioned at a minimum of every 2 hours . A licensed nurse will obtain orders from physician for new skin wounds and transcribe onto resident's treatment record for follow up . Specialty mattresses will be implemented for residents with multiple stage II areas, stage Ill, or stage IV pressure injuries . Weekly skin assessments will be documented on the Weekly Skin Assessment every 7 days or less . Licensed nurse will initiate the schedule for the wound form in Point Click Care which automatically triggers every 7 days from day of completion .<BR/>The EDO and DCE were notified of an IJ on 02/11/25 on 5:00 p.m., were given a copy of the IJ template, and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 02/12/25 at 9:40 a.m. and included the following:<BR/>F686- Skin Integrity/Pressure Ulcer<BR/>Plan of Action: <BR/>Resident #93 had wound care orders written on 02/11/25. A weekly wound assessment was completed on 02/11/25. A specialty mattress was placed on Resident #93's bed on 02/11/25. Resident #93's heels were floated effective 02/11/25. <BR/>Skin sweep competed on 02/11/25 to ensure all skin issues were identified and had current orders and interventions in place. Completed 02/11/25 by Director of Clinical Education and designees. <BR/>Director of Clinical Education will educate Director of Clinical Services and Assistant Director of Clinical Services on the process of reviewing new resident admissions electronic health records for completion of order transcription as it relates to wound orders as well as carrying out those orders. Completed 2/11/25 If a RN or wound care certified LVN is not on duty at the time a resident admits, the admitting nurse on duty will utilize Advanced Wound Care Telehealth for a consult. Completed 02/12/25. <BR/>All licensed nurses will be educated by the ADCO or designee on the process of carrying out orders for residents admitted with wounds or obtaining orders if no order accompanies the resident when admitted . Education will also include the completion of weekly skin assessments per schedule. Completion 02/12/25 10:00 a.m. Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift. <BR/>All licensed nurses will receive in-service regarding wound care orders and weekly skin assessments prior to the beginning of their next shift to begin 02/11/25. <BR/>Any newly hired nurses will receive the above education upon hire during orientation prior to taking a shift on the floor. <BR/>Ad hoc QAPI meeting will be held with the Medical Director on 02/12/25 reviewing the policies and procedures for wound care. <BR/>All licensed nurses will be educated on the Skin Management policy regarding general guidelines, prevention, notification, treatment, and documentation the Director of Clinical Education or designee. Completed 2/12/2025 2:00 p.m. Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift.<BR/>All C.N.A.'s will be educated by the Director of Clinical Education or designee regarding pressure ulcer prevention and interventions for residents with pressure ulcers. Completed 2/12/2025 3:00 p.m. Anyone who is not on duty or cannot come in or be reached by phone will be required to complete the in-service prior to working their next shift.? <BR/>Validation/Monitoring Tools? <BR/>Director of Clinical Operations or Assistant Director of Clinical Operations will review all orders for new admissions every day in the morning clinical meeting to ensure orders have been written and carried out for residents admitted with wounds. ?Beginning 02/12/25. <BR/>Director of Clinical Operations or designee will review weekly skin assessments daily to ensure timely completion. Beginning 02/12/25. <BR/>Director of Clinical Operations or designee will review wound physician documentation weekly to ensure any orders are carried out timely. Beginning 02/12/25. <BR/>Director of Clinical Operations and/or designee will review all wound care patients orders, interventions, and skin assessments during Standards of Care Meeting weekly, Beginning 02/12/25.?? <BR/>The Administrator, Director of Clinical Operations and/or designee will review the action plan developed related to obtaining wound care orders, implementing wound care interventions, and weekly skin assessments in QAPI meeting monthly during the next six months. Beginning 02-12-25.? <BR/>This surveyor and team verification of the Plan of Removal from 02/12/25 was as follows:<BR/>Rec[TRUNCATED]

**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 supervision to prevent accidents for 2 of 16 residents (Resident #12, Resident #35) reviewed for adequate supervision.<BR/>The facility failed to prevent Resident #35 from having rubbing alcohol in his room.<BR/>The facility failed to ensure that electrical wires were encased in their protective covering and not exposed for Resident #12 <BR/>These failures could place residents at risk for injury, harm, and impairment or death.<BR/>Findings included: <BR/>1. Record review of Resident #35's admission Record indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Acute and Chronic Respiratory Failure with Hypoxia (a medical condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period, leading to persistently low levels of oxygen in the blood), Peripheral Vascular Disease (a condition that affects the blood vessels outside the heart and brain), Depression (a common mental health condition characterized by persistent low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily functioning).<BR/>Record review of Resident #35's quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 15 which indicated Resident #35 was cognitively intact. The MDS also revealed, Resident #35, was understood and understands others. Shows that Resident #35 requires partial assistance with activities of daily living. <BR/>Record review of Resident #35's Care Plan revealed a problem initiation on 3/13/2023 Resident #35 has a self-care performance deficit related to cellulitis. Shows that Resident #35 required partial assistance with his activities of daily living.<BR/>During an observation an interview on 2/10/25 at 9:50 a.m., Resident #35 had a bottle of isopropyl 91% rubbing alcohol in his room. He said that it was his alcohol. He said he did not know where he got it from. He said he used it on his skin to clean himself. <BR/>During an interview on 2/12/25 at 1:32 p.m., DCO P said residents are not allowed to keep rubbing alcohol in their rooms. She said there was a risk to residents because they could accidently drink the alcohol, it could poison them. <BR/>2. Record review of Resident #12's admission Record indicated he was an [AGE] year-old male admitted to the facility on [DATE]f4. His diagnoses included Bipolar Disorder (a chronic mental health condition characterized by extreme shifts in mood, energy, and activity levels), Depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities), Chronic Inflammatory Demeyelinating Polyneuritis (a rare autoimmune disorder that affects the peripheral nervous system, causing inflammation and damage to the myelin sheath, the protective layer that insulates nerve fibers).<BR/>Record review of Resident #12's significant change in status MDS dated [DATE] revealed that the resident had a BIMS score of 03 which indicates Resident #12 was severely cognitively impaired. The MDS also revealed, Resident #12, was understood and understands others. Shows that Resident #12 was dependent with activities of daily living. <BR/>Record review of Resident #12's care plan revealed a problem initiation on 11/13/2024 shows he has an ADL self-care performance deficit related to disease processes. Shows that Resident #12 has an activity intolerance, confusion, impaired balance, limited mobility.<BR/>During an interview on 2/12/25 at 1:32 p.m., DCO P said staff Report to the maintenance book if exposed wiring was found on an electronic item in room.<BR/>During an interview on 2/12/25 at 1:44 p.m., the Director of Nurses said that residents should not have rubbing alcohol in their rooms as it was against facility policy and it could place the resident at risk of harm if they drank it. She said that if a resident's bed controls had exposed wiring, then it should be replaced or repaired. She said that anyone who spotted both issues would be responsible to remove the alcohol or report the bed control wiring. <BR/>During an interview on 2/12/25 at 5:01 p.m., the Administrator said all staff and focused care partners who observe resident's rooms should keep them free of any potential hazards such as rubbing alcohol or exposed wiring. She said that residents could be placed at risk if they drank rubbing alcohol of harm. She said that electronics that have wiring should be properly maintained, and the inner wires should not be exposed for resident safety. <BR/>Record review of the facility policy titled, Incident and Accident, dated 03/1/17 indicated, Accidents or incidents involving residents shall be investigated and reported to the Executive Director of Operations Licensed nurse will complete an incident and accident report when staff is aware that an incident occurred. Review each incident report at daily clinical meeting Incident reports are located in the electronic health record and are completed electronically.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 2 residents (Resident #23) who were reviewed for indwelling urinary catheter care.<BR/>The facility failed to ensure CNA F followed appropriate procedures and infection control during foley catheter care for Resident #23. <BR/>This failure could place residents at risk for urinary tract infections.<BR/>Findings included:<BR/>Record review of Resident #23's face sheet dated 1/09/23 indicated Resident #23 was a [AGE] year-old female and admitted on [DATE] with diagnoses including paralytic syndrome (unable to move) following a cerebrovascular disease (problem with blood flow to the brain causing damage to the brain), paraplegia (complete or partial loss of muscle function to all or part of the trunk, legs, or pelvic organs), reduced mobility, and hypertension (high blood pressure).<BR/>Record review of Resident #23's quarterly MDS assessment dated [DATE] indicated Resident #23 was usually understood and usually understood others. The MDS indicated Resident #23 had a BIMS score of 13 which indicated she was cognitively intact. The MDS indicated Resident #23 required maximal assistance with toileting and bathing. The MDS indicated Resident #23 required total assistance dressing her lower body. The MDS indicated Resident #23 had an indwelling catheter, was always incontinent of urine, and was frequently incontinent of bowel.<BR/>Record review of Resident #23's care plan revised 11/17/23 indicated Resident #23 was incontinent and at risk for skin breakdown with intervention to monitor for signs and symptoms of infection and notify physician promptly. The care plan revealed Resident #23 was on an antibiotic for a urinary tract infection. Resident #23's care plan revealed there were no focused area or interventions for her foley catheter.<BR/>Record review of Resident #23's order summary report dated 1/09/24 did not reveal an order for a foley catheter.<BR/>Record review of Resident #23's progress notes dated 11/14/23 revealed the nurse had received an order from Resident #23's urologist to place a foley catheter and change it monthly and to start on Macrobid (antibiotic) 100 mg twice a day for seven days for a urinary tract infection.<BR/>During an observation and interview on 1/08/24 at 10:39 AM, Resident #23 was sitting up in her bed and a foley catheter drainage bag was hanging from the side of her bed with a privacy bag. Resident #23 said she had the foley catheter because she was unable to control her bladder or move her lower body. <BR/>During an observation on 01/09/24 at 10:30 AM, CNA F performed foley catheter care on Resident #23 with ADCO C in the room also. CNA F washed her hands, applied gloves, and placed opened trash bags on the BST. CNA F then with her same gloved hands grabbed and moved the BST closer, then pulled back Resident #23's covers, grabbed a package of incontinent wipes off of Resident #23's nightstand and pulled out 4 wipes and then laid the wipes on the resident's incontinent pad. CNA F using the same gloves, then held the bedsheet over the resident's pelvic area with her left hand and used her right hand to pick up a wipe off the incontinent pad and wiped the foley catheter starting at the point closest to Resident and slid the wipe down the foley catheter away from the resident and then placed it in the trash bag on the BST and repeated this process three times. CNA F using the same gloves, then pulled Resident #23's adult brief up between her legs and fastened the sticky tabs and then pulled up the bedsheet over the resident. CNA F then removed her gloves and pulled the rest of the covers up over the resident.<BR/>During an interview on 1/09/24 at 10:48 AM, CNA F said she usually changed her gloves at least twice when performing foley catheter care, but only changed gloves once because she was nervous. CNA F said she laid the incontinent wipes on Resident #23's incontinent pad because she had changed the resident's incontinent pad after Resident #23 had a bowel movement not long prior to going to provide foley catheter care, so she knew it was clean. CNA F said by not changing her gloves prior to starting foley care she could have transferred bacteria to the foley catheter, and the resident could get sick. CNA F said the purpose of cleaning the foley catheter was to prevent infections. <BR/>During an interview on 1/10/24 at 10:55 AM, LVN B said staff should change gloves after touching other surfaces in a resident's room, such as a BST or bedding, prior to performing foley catheter care. LVN B said it would not be appropriate to place incontinent wipes to be used to perform foley catheter care on the resident's incontinent pad. LVN B said it would be cross-contamination and could give the resident a UTI. <BR/>During an interview on 1/10/24 at 1:02 PM, the DCO said CNA F did not perform appropriate foley catheter care and should have changed her gloves prior to starting the foley catheter care after touching multiple surfaces. The DCO said CNA F should not have laid the incontinent wipes on the incontinent pad or handled Resident #23's sheet without removing or changing her gloves. The DCO said improper foley catheter care could cause infections, such as a UTI. <BR/>During an interview on 1/10/24 at 1:28 PM, the ADM said CNA F should have changed her gloves after touching multiple surfaces in Resident #23's room prior to and after performing foley catheter care. The ADM said once you touch multiple things, the gloves were no longer clean. The ADM said by not performing proper foley catheter care, it could pose an increased risk of infection to the resident.<BR/>During an interview on 1/10/24 at 3:45 PM, ADCO C said she had saw enough during the foley catheter care provided by CNA F for Resident #23 to know she needed to do an in-service with her staff on foley catheter care. ADCO C said CNA F did not change her gloves after touching multiple other surfaces prior to performing foley catheter care. ADCO C said CNA F should not have placed the incontinent wipes on the resident's incontinent pad or used the wipes off the incontinent pad. ADCO C said CNA F should not have touched Resident #23's sheet with the same gloves used to clean the foley catheter. ADCO C said the trash bags should have not been placed on the resident's BST either. ADCO C said the foley catheter care that was provided by CNA F for Resident #23 was an infection control issue and could increase the resident's risk of developing a UTI.<BR/>Requested competency or skills check list for CNA F for foley catheter care from the DCO on 1/10/24 at 1:02 PM.<BR/>Requested competency or skills check list for CNA F for foley catheter care from the ADM on 1/10/24 at 3:28 PM and at 4:00 PM the ADM said they did not have competency or skills check list for CNA F for foley catheter care.<BR/>Record review of the facility's policy titled Catheters-Insertion and Care: Indwelling, Straight, Supra-Pubic, and External dated 4/2021 revealed . it was the policy of the community that the resident with a urinary catheter be provided services in a safe and appropriate manner to minimize the risks of urinary tract complications . physician order was required for all catheters . order should include type of catheter, size of catheter and size of bulb, frequency to change catheter and drainage bag .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 3 residents (Resident #1) reviewed for nutrition.<BR/>The facility failed to obtain Resident #1's weekly weights times 4 on admission.<BR/>The facility failed to obtain Resident #1's readmission weight after her hospital stay (12/26/24-12/31/24). Resident #1 was readmitted on [DATE]. <BR/>The facility failed to follow Resident #1's January 2025 dietary recommendation for the health shakes to be changed to house shakes (nutritional supplement for weight concerns) and given for 90 days. <BR/>These failures could place residents at risk for malnourishment, weight loss, skin breakdown, and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 01/10/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses including Asperger's syndrome (is a term sometimes used to describe a developmental disorder that's part of the autism spectrum disorder (ASD)), epilepsy (is a chronic brain disorder characterized by recurrent seizures, which are brief episodes of involuntary movements, loss of consciousness, or altered awareness), displaced bimalleolar fracture of left lower leg (is a severe injury to the ankle joint and bones of the lower leg), and osteoarthritis (is a chronic condition that causes joint pain, stiffness, and inflammation). <BR/>Record review of Resident #1's admission MDS assessment dated [DATE] indicated Resident #1 was understood and had the ability to understand others. Resident #1 had a BIMS score of 09 which indicated moderate cognitive impairment. Resident #1 was 187 lbs. Resident #1 did not have a loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Resident #1 was on a therapeutic diet.<BR/>Record review of Resident #1's care plan dated 12/15/24 indicated Resident #1 was on a no added salt diet/therapeutic diet. Intervention included monitor and document intake. Resident #1 care plan did not reflect unplanned weight loss. <BR/>Record review of Resident #1's consolidated physician order dated active as of 02/10/25 indicated:<BR/>*Health Shake (has protein, vitamins, and minerals to improve nutritional parameters) two times a day due to weight loss for 60 days. Take one by mouth between meals for 60 days. Start 02/04/25. <BR/>Resident #1's current consolidated physician order did not reflect an order for weights. Resident #1's consolidated physician order did not reflect an order for house shake. <BR/>Record review of Resident #1's MAR dated 12/01/24-12/31/24 indicated:<BR/>*Obtain weight weekly times four weeks every shift, every Monday for four. Administrations weight resident weekly times four and follow facility guidelines on MD notification of weight loss or gain.<BR/> The TAR indicated on 12/09/24 (187 lbs.). No documentation noted on 12/16/24, 12/23/24, and 12/30/24. <BR/>*Health Shake one time a day for 60 days. Start 12/17/24. Discontinued 02/04/25.<BR/>*Health Shake one time a day. Start 12/05/24. Discontinued 12/16/24. Received 12 of 12 doses.<BR/>Record review of Resident #1's MAR dated 01/01/25-01/31/25 indicated:<BR/>*Health Shake one time a day for 60 days. Start 12/17/24. Discontinued 02/04/25.<BR/>* Obtain weight weekly times four weeks every shift, every Monday for four. Administrations weight resident weekly times four and follow facility guidelines on MD notification of weight loss or gain. <BR/>No start date indicated, and no weights documented. <BR/>Record review of Resident #1's MAR dated 02/01/25-02/28/25 indicated:<BR/>*Health Shake one time a day for 60 days. Start 12/17/24. Discontinued 02/04/25.<BR/>*Health Shake two times a day due to weight loss for 60 days. Take one by mouth between meals for 60 days. Start 02/04/25.<BR/>Record review of Resident #1's hospital paperwork dated 12/30/24 indicated:<BR/>*Recorded weight: 185lbs 3 oz (4 days ago (12/26/24))<BR/>*Adjusted weight: 149lbs 7.6oz (12/28/24)<BR/>Record review of Resident #1's weight summary accessed on 02/11/25 indicated:<BR/>*02/07/25 161.8 lbs.<BR/>*01/07/25 162.2 lbs.<BR/>*12/09/24 187 lbs.<BR/>*12/03/24 187.4 lbs. <BR/>Resident #1's weight summary did not reflect weekly weights times four after admission on [DATE], a weight on 12/31/24 when she was readmitted , weekly weights times for after readmission. <BR/>Record review of Resident #1's weight variance report by completed by the Consultant Dietitian, dated January 2025 indicated .Resident #1 had -13.4% loss in 30 days . Comments .weight: 162.2 # .chg [change] health shake to house shake BID between meals x 90d [days] .<BR/>During an observation on 02/10/25 at 10:51 a.m., Resident #1 was lying in her bed watching television. Resident #1 did not respond to greetings. <BR/>During an observation on 02/11/25 at 10:06 a.m., Resident #1 was sitting up in her bed. Resident #1 still did not respond to greetings. <BR/>During an interview on 02/12/25 at 1:57 p.m., LVN D said the nurses got the residents weights. She said the resident's weights were done weekly, monthly, or as ordered. She said the resident was supposed to be weighed on admission and readmission. She said obtaining resident's weights on admission times four and readmission established a baseline weight or started a new baseline for readmissions. She said the DCO and ADCO coordinated with the Dietitian regarding recommendations. She said only the nursing management received the dietary recommendation. She said nursing management was responsible for ensuring the dietary recommendations were adequately transcribed and followed. She said it was important to follow the dietary recommendations because it was a new intervention to help with weight loss. <BR/>During an interview on 02/12/25 at 5:49 p.m., the ADCO said weights for new admissions and readmissions were supposed to be weekly times four then monthly. She said the resident's weight should be documented in the resident's electronic medical record. She said the nurses, the ADCO, or the DCO could weigh the residents. She said the admitting nurse should order weekly weight times four on new admissions and readmissions. She said she was not employed at the facility for Resident #1's admission or readmission. She said she did not know why it was not done. She said Resident #1 had been admitted to the hospital for a few days and returned with weight loss. She said it would have benefited the facility if a readmission weight had been obtained to get a new baseline. She said the DCO Q, and she had started at the facility together on January 13, 2025. She said they had not had a chance to really sit down and establish who was responsible for what. She said DCO Q was out sick, and she had to work the floor. She said for now, she was responsible for dietary recommendations. She said she just put in some of the dietary recommendation. She said she thought she had correctly entered Resident #1's recommendations. She said it was important to enter the resident's recommendations correctly because it was an intervention to maintain or increase the resident's weight. <BR/>During an interview on 02/12/25 at 6:57 p.m., the DCO P, from a sister facility, said the facility's weight policy should be followed for admission and readmission. She said the charge nurse should be weighing the residents as ordered. She said admission and readmission weights were important to establish a baseline. She said the resident's dietary recommendation should be entered accurately and followed. She said the DCO or ADCO should be monitoring this process. She said she did not know who was responsible at the facility. She said the resident could experience continual weight loss if the recommendation was not followed.<BR/>During an interview on 02/12/25 at 7:34 p.m., the EDO said, nursing management was responsible for resident's weights. She said it was important to track the resident's weights and hopefully the resident's weight stabilized. She said she expected the weight loss or gain to be addressed accordingly. She said she remembered in an IDT meeting discussing Resident #1's weight loss. She said she knew the facility addressed Resident #1's weight loss. She said the dietary recommendations were submitted to the ADCO and the DCO. She said nursing management should correctly transcribe the recommendations. She said the recommendations were important to ensure necessary weight loss or gain. <BR/>Record review of a facility's Weight Surveillance Program policy revised 11/01/24 indicated .the purpose of this policy is to establish facility guidelines on how and when the facility obtains and documents residents weights .obtaining resident weights .the same staff members should weigh residents when possible .frequency of obtaining resident weights .new admission .the resident is then weighed at least weekly for at least 4 weeks .re-admission from hospital or other facility .the resident's weight should be obtained upon re-admission .the resident is then weighed at least weekly for at least 4 weeks .all residents will have a monthly weight obtained .any resident who experiences a significant weight loss or gain must be placed on the 'Weight Surveillance' program .dietitian recommendation should be implemented .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 15 residents reviewed for respiratory care. (Resident #13 and Resident #19)<BR/>1.The facility failed to ensure Resident #13's yankauer suction catheter (hard-plastic tip with handle used to suction secretions from the mouth) was properly stored.<BR/>2. The facility failed to ensure Resident #19 had a filter (the air passes through a series of filters that remove impurities, ensuring that the oxygen delivered to the patient is of high quality) in the oxygen concentrator (take air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe). <BR/>3. The facility failed to ensure Resident #19's compartment that held the oxygen concentrator filter did not have white, fuzzy material. <BR/>These failures could place residents at risk of respiratory complications or respiratory infection. <BR/>Findings included:<BR/>1. Record review of Resident #13's face sheet dated 1/08/24 revealed he was an [AGE] year-old male, who admitted to the facility on [DATE]. Resident #13 had diagnoses of COPD (chronic obstructive pulmonary disease -constriction of the airways and difficulty or discomfort in breathing), hypertension (high blood pressure), history of cerebral infarction (disruption or lack of blood supply to the brain causing parts of the brain to die, also called a stroke), right sided hemiplegia (unable to move right side of body), and weakness.<BR/>Record review of Resident #13's quarterly MDS dated [DATE] revealed he was understood and understood others. Resident #13 had a BIMS of 11 which indicated he had moderate cognitive impairment. Resident #13 was dependent on someone to perform most ADLs. Resident #13 was receiving hospice care (end of life care). <BR/>Record review of Resident #13's undated care plan revealed he had shortness of breath with an intervention to maintain a clear airway and to suction as needed to clear secretions.<BR/>Record review of Resident #13's Order Summary Report dated 1/09/24 revealed an order to admit to hospice dated 8/22/22. <BR/>During an observation on 1/09/24 at 8:48 AM revealed Resident #13's lying in bed, unable to communicate. There was a yankauer suction catheter laid directly on top of his BST (not bagged) with tubing attached to a suction machine with approximately 3 inches of yellow tinged fluid in the collection canister.<BR/>During an observation on 1/09/24 at 9:25 AM revealed Resident #13 lying in bed, unable to communicate, and his yankauer suction catheter continued to be laid directly on top of his BST (not bagged) with tubing attached to a suction machine with approximately 3 inches of yellow tinged fluid in the collection canister.<BR/>During an observation on 1/09/24 at 10:54 AM revealed Resident #13 sitting up in bed, unable to communicate and his yankauer suction catheter continued to be laid directly on top of his BST (not bagged) with tubing attached to a suction machine with approximately 3 inches of yellow tinged fluid in the collection canister.<BR/>During an interview on 1/10/24 at 10:55 AM, LVN B said she had worked at the facility for three months and normally worked the 6 AM-2 PM. LVN B said Resident #13 was on hospice services and she was performing frequent checks on him because he was nearing end of life. LVN B said Resident #13 already had the suction machine in his room prior to her 6 AM-2 PM shift on 1/09/24 and the yankauer suction catheter was already lying directly on the BST. LVN B said she had not used the yankauer suction catheter to suction his mouth during her shift. She said the yankauer suction catheter should be stored in a plastic bag with the resident's name on it to prevent the growth and/or spread of infection. LVN B said it would not be appropriate for a yankauer suction catheter to be laid directly on the BST because it was equipment used in the resident's mouth. LVN B said the yankauer suction catheter should have been thrown in the trash when she saw it lying directly on the BST to ensure it was not used on Resident #13 by other staff.<BR/>During an interview on 1/10/24 at 11:22 AM, RN E said she had worked at the facility about a year and normally worked the 6 AM-2 PM shift. RN E said the yankauer suction catheter should be stored in packaging or a plastic bag to prevent the growth of bacteria. RN E said it would not be proper procedure to lay a used uncovered yankauer suction catheter on a BST. RN E said you would be contaminating the BST and the yankauer suction catheter. RN E said the yankauer suction catheter should be properly stored to keep it clean due to it was used to suction the resident's mouth. RN E said using a contaminated yankauer suction catheter in a resident's mouth would increase the risk of infection to the resident. <BR/>During an interview on 1/10/24 at 1:02 PM, the DCO said Resident #13's yankauer suction catheter should have been replaced after being found lying directly on the BST and not properly stored due to it was then contaminated. The DON said the yankauer suction catheter should be stored in a plastic bag or something, not directly on top of the BST due to possible infection control issues and increased risk of infection to the resident. <BR/>During an interview on 1/10/24 at 1:28 PM, the ADM said she would expect Resident #13's yankauer suction catheter to have been stored properly in something and not laid directly on the BST. The ADM said not storing the yankauer suction catheter properly posed an increased risk of infection to the resident. <BR/>During an interview on 1/10/24 at 3:04 PM, LVN D said she had worked at the facility for 5-6 years PRN and normally worked the 10 PM-6 AM shift. LVN D said she had worked the 10 PM-6 AM on 1/8/24 and provided care to Resident #13. LVN D said the suction machine with the yankauer suction catheter was already in his room when she came in on her shift and the suction canister had about two inches of yellow secretions in it. LVN D said she used the yankauer suction catheter a little on him, kept his head of bed elevated, and kept him comfortable on her shift. LVN D said the yankauer suction catheter was already lying on the BST when she went into Resident #13's room, but she used the yankauer suction catheter in his mouth but was not able to suction any secretions back from his mouth. LVN D asked surveyor was I not supposed to use it after it sat on his BST? LVN D said she was not sure what the policy said but she probably should have thrown it in the trash and obtained a new one before putting it in his mouth. LVN D said by placing the yankauer suction catheter in his mouth after it had laid directly on the BST, it placed the resident at an increased risk of infection from cross-contamination.<BR/>2.Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses cerebrovascular disease (is a term for conditions that affect blood flow to your brain), morbid (severe) obesity due to excess calories, hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side. <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 experienced shortness of breath or troubled breathing with exertion. The MDS indicated Resident #19 had oxygen therapy within the last 14 days while a resident in the facility. <BR/>Record review of Resident #19's care plan dated 04/10/23 indicated Resident #19 had oxygen therapy related to cerebral vascular accident (stroke) and obesity. Intervention included give medications as ordered by physician. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated clean/change oxygen concentrator filters every night shift every Sunday, start date 03/19/23. <BR/>Record review of Resident #19's TAR dated 01/01/24-01/31/24 indicated clean/change oxygen concentrator filters every night every Sun (01/07/24 LVN Q). <BR/>During an observation on 01/08/24 at 1:04 p.m., Resident #19 was lying in her bed with a nasal cannula on which was connected to an oxygen concentrator. The oxygen concentrator did not have a filter and the compartment that held the filter, had a small amount of white, fuzzy material. <BR/>During an observation on 01/09/24 at 11:30 a.m., Resident #19 was lying in her bed with a nasal cannula on which was connected to an oxygen concentrator. The oxygen concentrator did not have a filter and the compartment that held the filter, had a small amount of white, fuzzy material. <BR/>During an observation on 01/09/24 at 1:15 p.m., Resident #19 was lying in her bed with a nasal cannula on which was connected to an oxygen concentrator. The oxygen concentrator did not<BR/>have a filter and the compartment that held the filter, had a small amount of white, fuzzy material. <BR/>On 01/10/24 at 12:05 p.m., attempted to contact LVN Q by phone, left message with no return call before or after exit.<BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said she mostly worked the 2pm-10pm shift but had worked all the shifts. She said the filters on concentrators were supposed to be cleaned by the Sunday night shift nurse. She said the nurse who cleaned the filter should make sure the resident had a filter also. She said a resident while no filter or filter area with fuzzy, white material placed them at risk for upper respiratory infection like pneumonia. <BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said the oxygen concentrator filters were cleaned on Sunday nights by the nursing staff and as needed. She said the nurses should ensure the resident had a filter in their oxygen concentrator. She said the RCPs could also notify the charge nurse if they noticed the filter missing or dirty. She said the filter was important to filter the good and bad things in the air. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said staff members who changed the oxygen tubing should also check the filter. She said there was no potential harm to the resident if the oxygen concentrator did not have a filter, but it could eventually affect how the machine worked.<BR/>Review of the facility's Respiratory policy titled Suctioning dated 04/2021 indicated . policy of this community that oral suctioning of a resident's mouth . would be provided to remove mucus, drainage or saliva away from the resident's airway . connect tubing to suction machine . put on glove and attach catheter to connecting tubing, taking care not to contaminate suction catheter . <BR/>Record review of a facility's Oxygen Therapy policy dated 04/21 indicated .wash filters from oxygen concentrators every 7 days in warm soapy water .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to attempt to use alternatives prior to installing a side or bed rail, obtain informed consent prior to installation, ensure correct installation, use and maintenance of bedrails for 1 of 10 residents (Resident #1) reviewed for bedrails.<BR/>The facility failed to ensure informed consent for the use of Resident #1's bed rails were obtained prior to installation.<BR/>The facility failed to obtain a bed rail assessment to assess the risk of entrapment for Resident #1's bed rails. <BR/>These failures could place residents at risk of entrapment or injury. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 01/10/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including Asperger's syndrome (is a term sometimes used to describe a developmental disorder that's part of the autism spectrum disorder (ASD)), epilepsy (is a chronic brain disorder characterized by recurrent seizures, which are brief episodes of involuntary movements, loss of consciousness, or altered awareness), displaced bimalleolar fracture of left lower leg (is a severe injury to the ankle joint and bones of the lower leg), and osteoarthritis (is a chronic condition that causes joint pain, stiffness, and inflammation). <BR/>Record review of Resident #1's admission MDS assessment dated [DATE] indicated Resident #1 was understood and had the ability to understand others. Resident #1 had a BIMS score of 09 which indicated moderate cognitive impairment. Resident #1 had lower extremity functional limitation in range of motion on one side. Resident #1 used a wheelchair for mobility. Resident #1 required supervision for sit to lying, roll left and right, and lying to sitting on side of the bed. Resident #1 required substantial/maximal assistance for sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Resident #1 had a fall in the last month prior to admission/entry or reentry. Resident #1 had a fracture related to a fall in the 6 months prior to admission/entry or reentry.<BR/>Record review of Resident #1's care plan dated 12/15/24 indicated Resident #1 had a history of seizures and was at risk for injury related to weakness, balancing difficulties, cognitive limitations or altered consciousness, and loss of large or small muscle coordination. Resident #1 had a risk for ineffective airway clearance and was at risk for the inability to clear secretions or obstructions for the respiratory tract to maintain a clear airway. Interventions included padded side rails on bed if required. Resident #1 care plan did not reflect use of assist rails for bed mobility or repositioning. <BR/>Record review of Resident #1's consolidated physician orders, dated 02/10/25 did not reflect an order for assist rails. <BR/>Record review of Resident #1's electronic medical records accessed on 02/11/25 did not reflect a side rail or entrapment assessment or informed consent documentation. <BR/>During an observation on 02/10/25 at 10:51 a.m., Resident #1 was lying in her bed watching television. Resident #1 did not respond to greetings. Resident #1 had an assist bar on both sides of the bed. <BR/>During an observation on 02/10/25 at 12:37 p.m., Resident #1 was asleep in her bed. Resident #1 was lying more toward the left side of the bed with her head resting on the assist bar. <BR/>During an observation on 02/11/25 at 10:06 a.m., Resident #1 was sitting up in her bed. Resident #1 still did not respond to greetings. Resident #1 had an assist bar on both sides of the bed. <BR/>During an interview on 02/12/25 at 1:15 p.m., the DOR, with the PTA present, said Resident #1 was no longer on therapy services. The PTA said Resident #1 refused to get out of bed to do therapy so she was discharged . The PTA said when Resident #1 was admitted she needed and used the assist rails. The PTA said Resident #1 currently did not need the assist rails because she refused to get out of the bed. The DOR said Resident #1 used the assist rails sometimes but not enough to keep them on her bed. The DOR said Resident #1 was currently a 1 person assist for bed mobility. The PTA said Resident #1 did not have good safety awareness. They said the nurses were responsible for putting in the orders for the assist rails. They said the DPO installed the assist rails on the resident's beds. They said when Resident #1 was on therapy services, they recommended assist rails. They said they normally assessed the residents on therapy services for assist rails. They said the staff could ask therapy to assess a resident for placement and removal of assist rails who was not on therapy services. They said they were not responsible for the facility's bed rail or entrapment assessment. They said Resident #1 could potentially hit her head or get an extremity stuck in the rails. The DOR said she would get Resident #1's assist rails removed today. <BR/>During an interview on 02/12/25 at 1:57 a.m., LVN D said assist rails were supposed to help with repositioning. She said the bed rail assessments were done quarterly by the nurses. She said the nurses were responsible for getting an order for the assist rails. She said side rails required a consent from the resident or their family. She said when the assist rails became a safety risk to the resident, the nurse should notify the DPO to remove them. She said sometimes therapy coordinated with the DPO on the installation and removal of the assist rails. She said assist rails were removed after a bedrail assessment was completed or a therapy evaluation said the resident was no longer safe. She said the nurses should ensure the assist rails order and bed rail assessment were done. She said if a resident was no longer using the assist rails for bed mobility or repositioning, they could be considered a restraint. She said Resident #1 did not need the assist rails but because of her lack of motivation, she could benefit from them. <BR/>On 2/12/25 at 5:45 PM, called Resident #1's responsible party and was unable to leave a message because the mailbox was full. No return call was received before or after exit.<BR/>During an interview on 02/12/25 at 5:25 p.m., RCP H said Resident #1 was a one person assist with cues for bed mobility and transfers. She said Resident #1 liked to stay in the bed but would sometimes sit on the side of the bed to eat. She said Resident #1's assist rails used to help her with turning, getting out of the bed, and a feeling of securement. She said she felt Resident #1 had a pretty good safety awareness. <BR/>During an interview on 02/12/25 at 5:49 p.m., the ADCO said the nurses were responsible for the resident's the assist/side rail order and assessment. She said the bed rail assessments were done on admission, quarterly, or with a condition change. She said for a resident to benefit from an assist/side rail, they must have the cognition to know how to use them. She said the residents should be using the rails for stabilization and turning. She said Resident #1 will use the assist rails when instructed to for repositioning. She said assist rails needed to be discontinued when the resident no longer used them. She said the DCO Q, and she should be monitoring this process by doing chart audits and rounds. <BR/>During an interview on 02/12/25 at 6:57 p.m., the DCO P, from a sister facility, said the assist rails required an assessment prior to installation. She said the assessments were done by the nurses quarterly. She said the resident had to be able to reposition themselves to qualify for assist rails. She said she did not know if the facility required an order or consent for assist rails. She said a resident having assist rails without an assessment was a safety risk. She said if Resident #1 could harm herself then the assist rails needed to be removed. <BR/>During an interview on 02/12/25 at 7:34 p.m., the EDO said, the therapy department and LVNs were responsible for bed rail assessments. She said bed rail assessment were supposed to be done quarterly and with a significant change in status. She said a resident needed an order for assist rails. She said the resident had to be able to utilize or reposition themselves to have assist rails. She said some days Resident #1 would not get out of the bed but other days she would. She said it depended on the staff how Resident #1 responded. She said the nursing staff and therapy department should be determining if a resident no longer needed assist rails. She said bed rail assessments and a physician's orders were important to make sure the assist rails were appropriate for the resident. <BR/>Record review of a facility's Bed Safety policy dated 04/2021 indicated .The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment . To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails .) . Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment . If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative . The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use . Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified . Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 2 of 13 residents (Resident #1 and Resident #15) reviewed for pharmacy services.<BR/>The facility failed to ensure Resident #1's Atorvastatin (is medication used to lower cholesterol and triglycerides (fats) levels to help prevent heart disease, angina (chest pain), strokes, and heart attacks) was available for administration on 01/28/25.<BR/>The facility failed to ensure Resident #1's Cannabidiol (is an active cannabinoid used as an adjunctive treatment for the management of seizures) was available for administration on 01/10/25, 01/13/25, 01/14/25, 01/15/25, and 01/16/25.<BR/>The facility failed to ensure Resident #1's Lamotrigine (is a medication used to treat epilepsy and stabilize mood in bipolar disorder) was available for administration on 01/15/25, 01/16/25, 01/17/25, 01/18/25, and 01/19/25. <BR/>The facility failed to ensure Resident #1's Sertraline (is used to treat depression) was available for administration on 01/12/25, 01/15/25, 01/17/25, 01/20/25, 01/22/25, 01/23/25, 01/28/25, and 01/30/25. <BR/>The facility failed to ensure Resident #1's Minocycline (is an antibiotic that treats bacterial infections) was available for administration on 01/06/25, 01/07/25, 01/08/25, 01/14/25, and 01/30/25. <BR/>The facility failed to ensure Resident #1's Topiramate (is a medication that treats epilepsy, and it can also prevent migraine headaches) was available for administration on 01/16/25. <BR/>The facility failed to ensure Resident #15's Amiodarone (is a medication that prevents and treats an irregular heartbeat (arrhythmia)) was available for administration on 01/07/25, 01/11/25, 01/12/25, 01/15/25, and 01/21/25. <BR/>The facility failed to ensure Resident #15's Aricept (is commonly used to treat mild, moderate, and severe dementia related to Alzheimer's disease) was available for administration on 01/07/25, 01/10/25, 01/11/25, 01/12/25, 01/15/25, 01/17/25, and 01/18/25. <BR/>The facility failed to ensure Resident #15's Aspirin (can be effective at preventing heart attack or stroke) was available for administration on 01/06/25 and 01/07/25.<BR/>The facility failed to ensure Resident #15's Calcitriol (is a medication that treats low calcium levels caused by kidney disease) was available for administration on 01/05/25, 01/06/25, 01/07/25, 01/10/25, 01/11/25, 01/15/25, 01/17/25, 01/18/25, and 01/21/25.<BR/>The facility failed to ensure Resident #15's Cozaar (is used alone or together with other medicines to treat high blood pressure (hypertension)) was available for administration on 01/06/25, 01/07/25, 01/10/25, 01/11/25, 01/12/25, 01/15/25, and 01/21/25.<BR/>The facility failed to ensure Resident #15's Lokelma (is indicated for the treatment of hyperkalemia in adults) was available for administration on 01/08/25 and 01/12/25.<BR/>The facility failed to ensure Resident #15's Carvedilol was available for administration on 01/06/25, 01/07/25, 01/11/25, 01/12/25, and 01/15/25. <BR/>The facility failed to ensure Resident #15's Macrobid (is an antibiotic that fights bacteria in the body) was available for administration on 01/05/25, 01/06/25, and 01/07/25.<BR/>The facility failed to ensure Resident #15's Miconazole (is an antifungal skin cream that treats fungal or yeast infections) was available for administration on 01/04/25, 01/05/25, 01/06/25, 01/07/25, 01/08/25, 01/14/25, 01/17/25, 01/18/25, and 01/20/25. <BR/>These failures could place residents at risk for inaccurate drug administration.<BR/>1. Record review of Resident #1's face sheet dated 01/10/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including Asperger's syndrome (is a term sometimes used to describe a developmental disorder that's part of the autism spectrum disorder (ASD)), epilepsy (is a chronic brain disorder characterized by recurrent seizures, which are brief episodes of involuntary movements, loss of consciousness, or altered awareness), major depressive disorder (is a common mental health condition characterized by persistent low mood, loss of interest, and other symptoms that significantly interfere with daily life), anxiety disorder (are a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), and hyperlipidemia (is an excess of lipids or fats in your blood). <BR/>Record review of Resident #1's admission MDS assessment dated [DATE] indicated Resident #1 was understood and had the ability to understand others. Resident #1 had a BIMS score of 09 which indicated moderate cognitive impairment. Resident #1 received an antidepressant, antibiotic, opioid, antiplatelet, and anticonvulsant during the last 7 days of the assessment period.<BR/>Record review of Resident #1's care plan dated 12/15/24 indicated:<BR/>*Resident #1 was at risk for adverse consequences related to receiving psychotropic medication. Intervention included administer psychotropic medication as ordered.<BR/>*Resident #1 had potential for complications, signs and symptoms related to diagnosis of hyperlipidemia. Intervention included document any side effects in my clinical record and notify the MD. <BR/>*Resident #1 had a history of seizures and was at risk for injury related to weakness, balancing difficulties, cognitive limitations or altered consciousness, and loss of large or small muscle coordination. Resident #1 had a risk for ineffective airway clearance and at risk for the inability to clear secretions or obstructions for the respiratory tract to maintain a clear airway. Interventions included administer medications as prescribed. <BR/>Record review of Resident #1's consolidated physician order dated 02/10/25 indicated: <BR/>*Atorvastatin Calcium 20mg, give 1 tablet by mouth at bedtime for supplement. Start 12/02/24.<BR/>*Cannabidiol Oral Solution 100mg/1ml, give 4 ml by mouth in the afternoon for epilepsy. Start 12/03/24.<BR/>*Cannabidiol Oral Solution 100mg/1ml, give 5ml by mouth two times a day for seizures. Start 12/02/24.<BR/>*Lamotrigine 100mg, give 1 tablet by mouth two times a day. Start 12/02/24. <BR/>*Lamotrigine 100mg, give 1.5 tablet by mouth one time a day. Start 12/03/24.<BR/>*Minocycline 100mg, give 1 capsule by mouth two times a day. Start 12/02/24.<BR/>*Sertraline Oral Tablet 100mg, give 1 tablet by mouth one time a day. Start 12/03/24. <BR/>*Topiramate Oral Tablet 100mg, give 1 tablet by mouth two times a day. Start 12/03/24. <BR/>*Topiramate Oral tablet 100mg, give 2 tablets by mouth one time a day. Start 12/02/24. <BR/>Record review of Resident #1's MAR dated 01/01/25-01/31/25 indicated:<BR/>*Atorvastatin Calcium 20mg, give 1 tablet by mouth at bedtime for supplement. Start 12/02/24. The MAR indicated code 9 other/see progress notes on 01/28/25. <BR/>*Cannabidiol Oral Solution 100mg/1ml, give 4 ml by mouth in the afternoon for epilepsy. Start 12/03/24. The MAR indicated code 9 other/see progress notes on 01/10/25, 01/13/25, 01/14/25, 01/15/25, and 01/16/25. <BR/>*Cannabidiol Oral Solution 100mg/1ml, give 5ml by mouth two times a day for seizures. Start 12/02/24. The MAR indicated code 9 other/see progress notes on 01/10/25 (8am), 01/13/25 (8pm), 01/14/25 (8am and 8pm), and 01/15/25 (8am and 8pm). <BR/>*Lamotrigine 100mg, give 1 tablet by mouth two times a day. Start 12/02/24. The MAR indicated code 9 other/see progress notes on 01/16/25 (2pm), 01/17/25 (2pm and 8pm), 01/18/25 (2pm and 8pm), and 01/19/25 (2pm).<BR/>*Lamotrigine 100mg, give 1.5 tablet by mouth one time a day. Start 12/03/24. The MAR indicated code 9 other/see progress notes on 01/15/25, 01/17/25, and 01/18/25.<BR/>*Minocycline 100mg, give 1 capsule by mouth two times a day. Start 12/02/24. The MAR indicated code 9 other/see progress notes on 01/06/25 (8pm), 01/07/25 (8pm), 01/08/25 (8pm), 01/14/25 (8pm), and 1/30/25 (8am).<BR/>*Sertraline Oral Tablet 100mg, give 1 tablet by mouth one time a day. Start 12/03/24. The MAR indicated code 9 other/see progress notes on 01/12/25, 01/15/25, 01/17/25, 01/20/25, 01/22/25, 01/23/25, 01/28/25, and 01/30/25.<BR/>*Topiramate Oral Tablet 100mg, give 1 tablet by mouth two times a day. Start 12/03/24. The MAR indicated code 9 other/see progress notes on 01/16/25 (2pm).<BR/>Record review of Resident #1's progress note dated 01/11/25-02/11/25 indicated:<BR/>*01/12/25 at 8:50 a.m., Sertraline 1 tablet on order.<BR/>*01/13/25 at 2:02 p.m., Cannabidiol 4ml awaiting pharmacy.<BR/>*01/13/25 at 7:04 p.m., Cannabidiol 5ml awaiting pharmacy delivery.<BR/>*01/14/25 at 10:35 a.m., Cannabidiol 5ml none available. <BR/>*01/14/25 at 2:12 p.m., Cannabidiol 4ml awaiting pharmacy. <BR/>*01/14/25 at 7:34 p.m., Cannabidiol 5ml awaiting delivery. <BR/>*01/14/25 at 7:35 p.m., Minocycline 1 capsule awaiting delivery.<BR/>*01/15/24 at 8:53 a.m., Cannabidiol 5ml on order.<BR/>*01/15/25 at 8:56 a.m., Sertraline 1 tablet on order. <BR/>*01/15/24 at 8:56 a.m., Lamotrigine 1.5 tablet on order.<BR/>*01/15/25 at 3:14 p.m., Cannabidiol 4ml on order, waiting for delivery from family.<BR/>*01/15/25 at 7:06 p.m., Cannabidiol 5ml not available.<BR/>*01/16/25 at 5:21 p.m., Resident had times two seizures, nasal spray administered and effective. <BR/>*01/17/25 at 10:49 a.m., Lamotrigine 1.5 tablet not available.<BR/>*01/17/25 at 10:50 a.m., Sertraline 1 tablet not available.<BR/>*01/17/25 at 2:06 p.m., Lamotrigine 1 tablet none available-on order. <BR/>*01/17/25 at 8:58 p.m., Lamotrigine 1 tablet medication unavailable. <BR/>*01/18/25 at 12:48 p.m., Lamotrigine 1.5 tablet medication on order waiting on pharmacy. <BR/>*01/18/25 at 1:26 p.m., Lamotrigine 1 tablet medication on order.<BR/>*01/18/25 at 8:30 p.m., Lamotrigine 1 tablet awaiting delivery of medication.<BR/>*01/19/25 at 1:46 p.m., Lamotrigine 1 tablet awaiting pharmacy arrival.<BR/>*01/20/25 at 8:27 p.m., Sertraline 1 tablet on order.<BR/>*01/22/25 at 7:07 a.m., Sertraline 1 tablet awaiting pharmacy delivery.<BR/>*01/23/25 at 7:07 a.m., Sertraline 1 tablet awaiting on pharmacy. <BR/>*01/28/25 at 7:17 a.m., Sertraline 1 tablet.<BR/>*01/28/25 at 7:36 p.m., Atorvastatin 1 tablet awaiting delivery from pharmacy.<BR/>*01/30/25 at 9:12 a.m., Minocycline 1 capsule awaiting pharmacy delivery. <BR/>*01/30/25 at 9:12 a.m., Sertraline 1 tablet awaiting pharmacy delivery. <BR/>On 2/12/25 at 5:45 PM, called Resident #1's responsible party and unable to leave message because the mailbox was full. No return call was received before or after exit.<BR/>2. Record review of Resident #15's face sheet dated 02/10/25 indicated Resident #15 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #15 had diagnoses including type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), neuromuscular dysfunction of bladder (a condition where the nerves controlling bladder function are damaged, leading to impaired bladder control due to disrupted communication between the brain and the bladder muscles, causing issues like incontinence, difficulty urinating, or incomplete bladder emptying), dementia (is a term used to describe a group of symptoms affecting memory, thinking and social abilities), urinary tract infection (is an infection of the urinary system, which includes the kidneys, bladder, ureters, and urethra), hypocalcemia (is a condition where the level of calcium in the blood is below normal), and hypertension (high blood pressure). <BR/>Record review of Resident #15's admission MDS assessment dated [DATE] indicated Resident #15 was understood and had the ability to understand others. Resident #15 had a BIMS score of 13 which indicated intact cognition. Resident #15 had an indwelling catheter and occasional bowel incontinence. Resident #15 received an antibiotic, diuretic, and antiplatelet during the last 7 days of the assessment period. <BR/>Record review of Resident #15's care plan dated 01/21/25 indicated:<BR/>*Resident #15 had potential complications, injury related to antiplatelet medication and hypertension. Intervention included administer medications as ordered. <BR/>*Resident #15 had potential for complications, signs/symptoms related to diagnosis of hypertension. Resident #15 received anti-hypertensive and was at risk for side effects. Intervention included administer anti-hypertensive medications as ordered. <BR/>*Resident #15 had an indwelling catheter related to neurogenic bladder and was at risk for increased urinary tract infection. Intervention included monitor/record/report to MD for signs/symptoms of UTI. <BR/>*Resident #15 had potential for complications, signs/symptoms related to diagnosis of hyperlipidemia. Intervention included document any side effects in my clinical record and notify the MD. <BR/>Record review of Resident #15's consolidated physician order dated 02/10/25 indicated:<BR/>*Amiodarone 200mg, give 1 tablet by mouth one time a day for abnormal heart rhythm. Start 01/05/25.<BR/>*Aricept 10mg, give 1 tablet by mouth one time a day for dementia. Start 01/05/25.<BR/>*Aspirin 81 mg, give 1 tablet by mouth one time a day for hypertension. Start 01/05/25.<BR/>*Atorvastatin 20mg, give 1 tablet by mouth at bedtime for hyperlipidemia. Start 01/04/25.<BR/>*Calcitriol 6.25mcg, give 1 capsule by mouth one time a day for hypocalcemia. Start 01/05/25. <BR/>*Carvedilol 6.25mg, give 1 tablet by mouth two times a day for hypertension. Hold for SBP less than 100 or DBP less than 60 or HR less than 55. Start 01/04/25. <BR/>*Cozaar 25mg, give 1 tablet by mouth one time a day for hypertension, Hold SBP less than 100 or DBP less than 60.<BR/>*Miconazole-Zinc Oxide-Petrolate External Ointment 0.25-15-81.35%, apply to arms and feet topically every shift for moisture barrier. Start 01/04/25.<BR/>Record review of Resident #15's MAR dated 01/01/25-01/31/25 indicated:<BR/>*Amiodarone 200mg, give 1 tablet by mouth one time a day for abnormal heart rhythm. Start 01/05/25. The MAR indicated code 5 hold/see progress notes on 01/06/25. The MAR indicated code 9 other/see progress notes on 01/07/25, 01/11/25, 01/12/25, 01/15/25, and 01/21/25.<BR/>*Aricept 10mg, give 1 tablet by mouth one time a day for dementia. Start 01/05/25. The MAR indicated code 5 hold/see progress notes on 01/06/25. The MAR indicated code 9 other/see progress notes on 01/07/25, 01/10/25, 01/11/25, 01/12/25, 01/15/25, 01/17/25, and 01/18/25.<BR/>*Aspirin 81 mg, give 1 tablet by mouth one time a day for hypertension. Start 01/05/25. The MAR indicated code 5 hold/see progress notes on 01/06/25. The MAR indicated code 9 other/see progress notes on 01/07/25.<BR/>*Atorvastatin 20mg, give 1 tablet by mouth at bedtime for hyperlipidemia. Start 01/04/25. The MAR indicated code 9 other/see progress notes on 01/05/25.<BR/>*Calcitriol 6.25mcg, give 1 capsule by mouth one time a day for hypocalcemia. Start 01/05/25. The MAR indicated code 5 hold/see progress notes on 01/05/25 and 01/06/25. The MAR indicated code 9 other/see progress notes on 01/07/25, 01/10/25, 01/11/25, 01/15/25, 01/17/25, 01/18/25, 01/21/25.<BR/>*Carvedilol 6.25mg, give 1 tablet by mouth two times a day for hypertension. Hold for SBP less than 100 or DBP less than 60 or HR less than 55. Start 01/04/25. The MAR indicated code 5 hold/see progress notes on 01/06/25. The MAR indicated code 9 other/see progress notes on 01/07/25, 01/11/25, and 01/15/25.<BR/>*Cozaar 25mg, give 1 tablet by mouth one time a day for hypertension, Hold SBP less than 100 or DBP less than 60. The MAR indicated code 5 hold/see progress notes on 01/06/25. The MAR indicated code 9 other/see progress notes on 01/07/25, 01/10/25, 01/11/25, 01/12/25, 01/15/25, and 01/21/25. <BR/>*Macrobid 100mg, give 1 capsule by mouth two times a day for UTI for 7 days. Start 01/06/25. The MAR indicated code 9 other/see progress notes on 01/06/25 (8pm) and 01/07/25 (8am and 8pm).<BR/>*Macrobid 100mg, give 1 capsule by mouth two times a day for UTI. Start 01/04/25. Discontinued 01/06/25. The MAR indicated code 5 hold/see progress notes on 01/05/25 (9pm) and 01/06/25 (9pm). The MAR indicated code 9 other/see progress notes on 01/05/25 (9pm).<BR/>*Miconazole-Zinc Oxide-Petrolate External Ointment 0.25-15-81.35%, apply to arms and feet topically every shift for moisture barrier. Start 01/04/25. The MAR indicated code 9 other/see progress notes on 01/04/25 (6p), 01/06/25 (6a), 01/07/25 (6a), 01/08/25 (6a), 01/14/25 (6a), and 01/18/25 (6a). No documentation of administration on 01/05/25 (6a), 01/17/25 (6a), and 01/20/25 (6a). <BR/>*Lokelma 5GM, give 1 packet by mouth one time a day for hyperkalemia. Start 01/08/25. The MAR indicated code 9 other/see progress notes on 01/08/25 and 01/12/25.<BR/>Record review of Resident #15's progress note date 01/11/25-02/11/25 indicated:<BR/>*01/11/25 at 9:38 a.m. by LVN Y, Carvedilol 6.25mg, give 1 tablet by mouth two times a day for hypertension. Hold for SBP less than 100 or DBP less than 60 or HR less than 55. No documented indication of why code 9 was selected. <BR/>*01/11/25 at 9:39 a.m. by LVN Y, Amiodarone 200mg, give 1 tablet by mouth one time a day for abnormal heart rhythm. No documented indication of why code 9 was selected.<BR/>*01/11/25 at 9:39 a.m. by LVN Y, Aricept 10mg, give 1 tablet by mouth one time a day for dementia. No documented indication of why code 9 was selected.<BR/>*01/11/25 at 9:39 a.m. by LVN Y, Calcitriol 6.25mcg, give 1 capsule by mouth one time a day for hypocalcemia. No documented indication of why code 9 was selected.<BR/>*01/11/25 at 9:40 a.m. by LVN Y, Cozaar 25mg, give 1 tablet by mouth one time a day for hypertension, Hold SBP less than 100 or DBP less than 60. No documented indication of why code 9 was selected.<BR/>*01/12/25 at 9:33 a.m. by LVN Y, Aricept 10mg, give 1 tablet by mouth one time a day for dementia. On order. <BR/>*01/12/25 at 9:35 a.m. by LVN T, Lokelma 5GM, give 1 packet by mouth one time a day for hyperkalemia. On order. <BR/>*01/14/25 at 5:44 p.m. by RN Z, Miconazole-Zinc Oxide-Petrolate External Ointment 0.25-15-81.35%, apply to arms and feet topically every shift for moisture barrier. On order- not available. <BR/>*01/15/25 at 10:01 a.m. by LVN Y, Aricept 10mg, give 1 tablet by mouth one time a day for dementia. On order, will call pharmacy.<BR/>*01/15/25 at 10:02 a.m. by LVN Y, Calcitriol 6.25mcg, give 1 capsule by mouth one time a day for hypocalcemia. On order, will call pharmacy. <BR/>*01/21/25 at 9:33 a.m. by LVN Y, Amiodarone 200mg, give 1 tablet by mouth one time a day for abnormal heart rhythm. Called pharmacy and medication cannot be filled until [DATE]th. Pharmacy will call insurance company for possible override due to resident never receiving medication while here. <BR/>*01/21/25 at 9:35 a.m. by LVN Y, Calcitriol 6.25mcg, give 1 capsule by mouth one time a day for hypocalcemia. Called pharmacy and medication cannot be filled until [DATE]th. Pharmacy will call insurance company for possible override due to resident never receiving medication while here. <BR/>*01/21/25 at 9:35 a.m. by LVN Y, Cozaar 25mg, give 1 tablet by mouth one time a day for hypertension, Hold SBP less than 100 or DBP less than 60. Called pharmacy and medication cannot be filled until [DATE]th. Pharmacy will call insurance company for possible override due to resident never receiving medication while here. <BR/>During an interview on 02/12/25 at 1:57 p.m., LVN D said new admission medication orders were done through the facility's electronic chart system. She said if new admission orders were done before 7pm, the medications were normally filled the same day. She said the cutoff time for same day delivery was 2 pm on the weekends. She said refills needed to be ordered when the only pills left, on the blister packet, were in the blue section. She said refills normally took about a day to be delivered. She said Resident #1's family was providing Resident #1's Cannabidiol prescription. She said Resident #1's prescription was through a neurologist not in town and a local chain pharmacy filled it. She said Resident #1's family was filling and picking up the Cannabidiol. She said she finally calculated the amount Resident #1 needed for the week. She said she tried to notify Resident #1's family in enough time so Resident #1 did not run out of the Cannabidiol. She said the facility had a backup Pyxis machine that had medications in it. She said most of the resident's prescribed medications were in the backup Pyxis machine. She said the pharmacy could also be contacted to refill the backup Pyxis, so the residents did not miss a dose. She said code 9 on the resident's MAR/TAR typically meant see the progress note for why the medication was not given or held. She said the nurses were responsible for ensuring the residents did not miss doses of medications. She said if a resident did not receive their anticonvulsant medication, they could have seizures. She said if a resident did not receive their antidepressant medication for an extended period, they could experience depression and anxiety. She said Resident #11 and Resident #15 had a lot of missed medication doses. She said Resident #15 used a different pharmacy. She said Resident #15's medications could not be filled electronically. She said Resident #15's prescriptions had to be faxed or called in to the pharmacy. She said it was recently discovered Resident #15's pharmacy turned the fax machine off at night. She said a lot of staff probably thought the resident's orders were going through but they were not. She said she did not know if all the staff knew about Resident #15's pharmacy company turning off the fax machine at night. She said it depended on why the resident was prescribed the medication, how the missed doses would affect them.<BR/>During an interview on 02/12/25 at 5:49 p.m., the ADCO said the floor nurses were responsible for ordering the residents medications. She said the medications should be ordered 7 to 8 days before the medication was going to run out. She said some resident's medications could be ordered through the facility's charting system. She said other residents, the physician order, or refill paperwork had to be faxed or called in. She said the facility should be notifying Resident #1's family in enough time so she did not run out. She said the family needed to be notified before, a quarter or half of the bottle was empty. She said Resident #1's Cannabidiol bottle normally came with 98 ml in it. She said Resident #1's family needed to be called when there was about 35-40 ml was left. She said the emergency Pyxis could be utilized so the resident did not miss doses. She said she had found several of Resident #1 and Resident #15's medications in the medication room when staff had been documenting it was unavailable. She said LVN Y no longer worked at the facility. She said she was not aware the other pharmacy company Resident #15 used, turned off the fax machine a night. She said it depended on the type of medication, for how it would affect the resident. She said a resident seizure medication was important. She said the DCO and ADCO should ensure the resident's medication were ordered timely by the nursing staff. <BR/>During an interview on 02/12/25 at 6:57 p.m., the DCO P, from a sister facility, said the nurses were responsible for ordering resident's medications. She said the resident's medications should be ordered at least a week before they ran out. She said the medications were ordered in the facility's chart system. She said it was important for the resident's medication to be given because it was a doctor's order. She said the doctor prescribed the medication for a reason to manage a diagnosis. She said missed doses caused the illness to not be managed. She said the DCO and ADCO should be overseeing this process. <BR/>During an interview on 02/12/25 at 7:34 p.m., the EDO said she expected the nurses to order the resident's medication timely. She said the resident's medication should be ordered through the facility's chart system. She said it was an electronically process. She said the resident's medication needed to be ordered as need or within 7 days of the medications running out. She said it depended on what diagnosis the medication was treating, how the missed does affected them. She said the nursing management should be monitoring this process. <BR/>Record review of a facility's Ordering and Receiving Non-Controlled Medications dated 06/2024 indicated .medications and related products are received from the pharmacy on a timely basis .ordering medications from the pharmacy . Medications orders are written on a physician order form, telephone order sheet, or reorder form provided by the pharmacy, written in the chart by the physician, or entered into the facility's EHR system and transmitted to the pharmacy . Repeat medications (refills) are written on a medication reorder form or by peeling the reorder tab from the prescription label and placing it in the appropriate area on the medication reorder form provided by the pharmacy for that purpose, or requested via the facility's EHR system .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: in excessive doses (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 2 of 5 residents (Resident #1 and Resident #11) reviewed for unnecessary medications.<BR/>The facility failed to ensure Resident #1, and Resident #11 had monitoring for being on an antiplatelet.<BR/>The facility failed to ensure Resident #1 had side effect monitoring for her anticonvulsant use. <BR/>The facility failed to ensure Resident #1 had documented diagnoses entered for use of Lamotrigine (is a medication used to treat epilepsy and stabilize mood in bipolar disorder), Levothyroxine (is used to treat hypothyroidism), Minocycline (is an antibiotic that treats bacterial infections, Ondansetron (is used to prevent nausea and vomiting), Sertraline (is used to treat depression), and Topiramate (is a medication that treats epilepsy and it can also prevent migraine headaches).<BR/>The facility failed to ensure Resident #11 had correct diagnoses on entered orders for Aricept (is commonly used to treat mild, moderate, and severe dementia related to Alzheimer's disease) and Aspirin (can be effective at preventing heart attack or stroke). <BR/>These failures could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the use of medicines) and receiving unnecessary medications.<BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet dated 01/10/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including Asperger's syndrome (is a term sometimes used to describe a developmental disorder that's part of the autism spectrum disorder (ASD)), epilepsy (is a chronic brain disorder characterized by recurrent seizures, which are brief episodes of involuntary movements, loss of consciousness, or altered awareness), major depressive disorder (is a common mental health condition characterized by persistent low mood, loss of interest, and other symptoms that significantly interfere with daily life), anxiety disorder (are a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), and hypothyroidism (is a condition that happens when your thyroid gland doesn't make or release enough hormone into your bloodstream). <BR/>Record review of Resident #1's admission MDS assessment dated [DATE] indicated Resident #1 was understood and had the ability to understand others. Resident #1 had a BIMS score of 09 which indicated moderate cognitive impairment. Resident #1 received an antidepressant, antibiotic, opioid, antiplatelet, and anticonvulsant during the last 7 days of the assessment period.<BR/>Record review of Resident #1's care plan dated 12/15/24 indicated:<BR/>*Resident #1 was at risk for adverse consequences related to receiving psychotropic medication. Intervention included administer psychotropic medication as ordered.<BR/>*Resident #1 had a history of seizures and was at risk for injury related to weakness, balancing difficulties, cognitive limitations or altered consciousness, loss of large or small muscle coordination. Resident #1 had a risk for ineffective airway clearance and at risk for the inability to clear secretions or obstructions for the respiratory tract to maintain a clear airway. Interventions included administer medications as prescribed.<BR/>*Resident #1 had a potential for complications, signs/symptoms related to diagnosis of hypothyroidism. Intervention included administer medication as ordered. <BR/>Record review of Resident #1's consolidated physician order dated 02/10/25 indicated: <BR/>*Lamotrigine 100mg, give 1 tablet by mouth two times a day. Start 12/02/24. <BR/>*Lamotrigine 100mg, give 1.5 tablet by mouth one time a day. Start 12/03/24.<BR/>*Minocycline 100mg, give 1 capsule by mouth two times a day. Start 12/02/24.<BR/>*Sertraline Oral Tablet 100mg, give 1 tablet by mouth one time a day. Start 12/03/24. <BR/>*Topiramate Oral Tablet 100mg, give 1 tablet by mouth two times a day. Start 12/03/24. <BR/>*Topiramate Oral tablet 100mg, give 2 tablets by mouth one time a day. Start 12/02/24. <BR/>*Levothyroxine 150 mcg, give 1 tablet by mouth in the morning. Start 12/03/24.<BR/>*Ondansetron 8mg, give 1 tablet by mouth two times a day. Start 12/02/24. <BR/>Resident #1 consolidated physician order did not reflect diagnoses for the prescribed medications. The consolidated physician order did not reflect monitoring for use of an antiplatelet. The consolidated physician order did not reflect side effect monitoring for anticonvulsant use. <BR/>Record review of Resident #1's MAR dated 02/01/25-02/28/25 indicated:<BR/>*Lamotrigine 100mg, give 1.5 tablet by mouth one time a day. Start 12/03/24. Resident #1 received 10 of 10 doses.<BR/>*Levothyroxine 150 mcg, give 1 tablet by mouth in the morning. Start 12/03/24. Resident #1 received 10 of 10 doses. <BR/>*Sertraline Oral Tablet 100mg, give 1 tablet by mouth one time a day. Start 12/03/24. Resident #1 received 10 of 10 doses. <BR/>*Topiramate Oral Tablet 100mg, give 1 tablet by mouth two times a day. Start 12/03/24. Resident #1 received 10 of 10 doses. <BR/>*Lamotrigine 100mg, give 1 tablet by mouth two times a day. Start 12/02/24. Resident #1 received 19 of 19 doses. <BR/>*Minocycline 100mg, give 1 capsule by mouth two times a day. Start 12/02/24. Resident #1 received 19 of 19 doses.<BR/>*Ondansetron 8mg, give 1 tablet by mouth two times a day. Start 12/02/24. Resident #1 received 19 of 19 doses. <BR/>*Topiramate Oral Tablet 100mg, give 1 tablet by mouth two times a day. Start 12/03/24. Resident #1 received 19 of 19 doses. <BR/>Resident #1 MAR did not reflect diagnoses for the prescribed medications. The MAR did not reflect monitoring for use of an antiplatelet. The MAR did not reflect side effect monitoring for anticonvulsant use. <BR/>2. Record review of Resident #11's face sheet dated 02/11/25 indicated Resident #11 was an [AGE] year-old, female admitted to the facility on [DATE]. Resident #11 had diagnoses including cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced), type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and muscle weakness. The face sheet did not reflect diagnoses of dementia or Alzheimer's. <BR/>Record review of Resident #11's quarterly MDS assessment dated [DATE] indicated Resident #11 was understood and had the ability to understand others. Resident #11 had a BIMS score of 06 which indicated severe cognitive impairment. Resident #11 had received an antiplatelet during the last 7 days of the assessment period. <BR/>Record review of Resident #11's care plan dated 08/28/23 indicated Resident #1 had impaired cognitive function or impaired thought process related to recent CVA, impaired decision-making abilities, was not always understood or able to understand verbal and non-verbal expression. Intervention included administer medication as ordered. <BR/>Record review of Resident #11's care plan dated 12/13/24 did not reflect use of an antiplatelet. <BR/>Record review of Resident #11's consolidated physician order dated active as of 02/11/25 indicated:<BR/>*Aspirin 81 mg, give 1 tablet by mouth one time a day for antiplatelet. Start 04/03/24.<BR/>*Aricept 10mg, give 1 tablet by mouth at bedtime for cognitive awareness. Start 02/03/24.<BR/>Resident #11's consolidated physician orders did not reflect monitoring for use of an anticoagulant. <BR/>Record review of Resident #11's MAR dated 02/01/25-02/28/25 indicated:<BR/>*Aspirin 81 mg, give 1 tablet by mouth one time a day for antiplatelet. Start 04/03/24. Resident #11 received 11 of 11 doses. <BR/>*Aricept 10mg, give 1 tablet by mouth at bedtime for cognitive awareness. Start 02/03/24. Resident #11 received 10 of 10 doses. <BR/>Resident #11's MAR did not reflect monitoring for use of an anticoagulant. <BR/>During an interview on 02/12/25 at 1:57 p.m., LVN D said Aspirin 81 mg was considered an antiplatelet if ordered for a heart condition. She said if a resident was on an antiplatelet, bruise monitoring needed to be ordered. She said the LVNs were responsible for ordering bruise monitoring for the resident on an antiplatelet or anticoagulants. She said the monitoring should pop up in the facility's charting system when an antiplatelet was ordered. She said it was important to assess and monitor the resident on an antiplatelet for abnormal bruising. She said the residents on an anticonvulsant should have side effect monitoring. She said side effect monitoring was important, so the nursing staff knew what side effect to look for. She said the LVNs were responsible for ensuring the physician orders had an appropriate diagnosis. She said it helped the staff know why the medications were being used and what it was treating. She said Aricept was normally ordered for a resident with a dementia diagnosis. She said she would call and clarify with Resident #11's MD about Aricept being used for cognitive awareness. She said an antiplatelet was a drug classification and should not be used as a diagnosis for Aspirin 81mg use. She said Resident #11's Aspirin ordered also needed to be clarified with the MD. She said she felt like the LVNs were overall responsible for ensuring the resident had appropriate diagnoses for their medications. <BR/>During an interview on 02/12/25 at 5:49 p.m., the ADCO said when the LVNs entered the physician orders, they should be ensuring an appropriate diagnosis or indication for use was added to the order. She said the nurse should be ordering bruise monitoring for the resident on an antiplatelet. She said it was important to monitor the resident on an antiplatelet for bleeding and abnormal bruising. She said the nurses should order side effect monitoring on an anticonvulsant. She said she did not know if cognitive awareness was an appropriate diagnosis for the use of Aricept. She said Aricept was prescribed for residents with dementia. She said Aspirin 81mg was an antiplatelet but the diagnosis or indication for use should not be antiplatelet. She said the ADCO should be monitoring the LVN to ensure they were ordering monitoring and orders had appropriate diagnoses. <BR/>During an interview on 02/12/25 at 7:34 p.m., the EDO said, the LVNs were responsible for inputting correct diagnoses with the resident ordered medications. She said the LVNs should also be ordering side effect and bruise monitoring. She said the IDT should be monitoring the LVNs to ensure this process was being followed. She said the monitoring should be done by chart audits and during clinical stand-up meeting. <BR/>Record review of a facility's General Guidelines for Medication Administration revised 08/2020 indicated .Medications are administered as prescribed in accordance with good nursing principles and practices . Monitoring of side effects or medication-related problems occurs continually .<BR/>Record review of a facility's Ordering and Receiving Non-Controlled Medications dated 06/2024 indicated .Medications orders are written on a physician order form, telephone order sheet, or reorder form provided by the pharmacy, written in the chart by the physician, or entered into the facility's EHR system and transmitted to the pharmacy. The written entry includes . Indication for use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 of 5 residents (Resident #19, Resident #25, and Resident #29) reviewed for unnecessary psychotropic medications (are medications that affect the mind, emotions, and behavior).<BR/>The facility failed to ensure Resident #19 had behavior monitoring for her prescribed antianxiety (treats anxiety disorders), anticonvulsant (are prescription medications that help treat and prevent seizures), and antipsychotic (are the main class of drugs used to treat people with schizophrenia) medications. <BR/>The facility failed to ensure Resident #19 had side effect monitoring for her prescribed antianxiety, anticonvulsant, and antipsychotic medications. <BR/>The facility failed to ensure Resident #25 had an appropriate diagnosis for his prescribed Quetiapine (Seroquel; is an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and depression) 50 mg. <BR/>The facility failed to ensure Resident #25 had an anxiety diagnosis for his prescribed antianxiety medication. <BR/>The facility failed to ensure Resident #25's prn Lorazepam (is used to treat anxiety) was ordered for 14 days.<BR/>The facility failed to ensure Resident #25 had behavior monitoring for his prescribed psychotropic medications. <BR/>The facility failed to ensure Resident #25 had side effect monitoring for his prescribed psychotropic medications.<BR/>The facility failed to ensure Resident #29 had a documented diagnosis for the use of his prescribed Seroquel (Quetiapine) 25 mg.<BR/>These failures could put residents at risk of receiving unnecessary psychotropic medications.<BR/>Findings included:<BR/>1. Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including Schizoaffective Disorder (is a mental illness that can affect your thoughts, mood and behavior), Bipolar type, Bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), mild depressed, recurrent depressive disorder (a depressed mood or loss of pleasure or interest in activities for long periods of time), generalized anxiety (you are worrying constantly and can't control the worrying), insomnia (is a common sleep disorder), and conversion disorder with seizures or convulsions (is a condition in which a person experiences physical and sensory problems, such as paralysis, numbness, blindness, deafness or seizures, with no underlying neurologic pathology). The face sheet did not indicate a diagnosis of anxiety. <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 received antipsychotic, antianxiety, and antidepressant during the last 7 days of the assessment period. <BR/>Record review of Resident #19's care plan dated 03/21/23, revised 04/10/23 indicated Resident #19 was at risk for adverse consequence related to receiving psychotropic medications. Interventions included monitor side effects of anti-depressant (a type of medicine used to treat clinical depression) and antipsychotic. Monitor/document/report prn adverse reactions to antidepressant and psychotropic, monitor/record occurrence for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, verbal/aggression towards staff/others, etc.,) and document per facility protocol. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine (is used to treat certain types of seizures and bipolar disorder) 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Gabapentin (works in the brain to prevent seizures and relieve pain for certain conditions in the nervous system) 600 mg, give 1 tablet by mouth one time a day for neuropathy (happens when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged). <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Zyprexa (is an antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder), give 20 mg by mouth at bedtime for increased mood, decreased anxiety, and agitation, start date 08/11/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Buspirone (is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety) 10 mg, give 1 tablet by mouth three times a day for antianxiety, start date 08/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated monitor resident for side effect of muscle rigidity, change in appetite, sleep disturbance, tardive dyskinesia (is an uncommon side effect of certain medicines), seizures, cardiac changes every shift, start date 03/18/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated monitor resident for behaviors including but not limited to crying, withdrawn, and unrealistic fears every shift for depression, start date 03/19/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated monitor resident for behavior of unrealistic fears, yelling/screaming, hallucinations every shift: see diagnosis, start date 08/28/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 did not indicate behavioral monitoring for Buspirone (antianxiety), Carbamazepine (anticonvulsant), Gabapentin (anticonvulsant), Zyprexa (antipsychotic). <BR/>Record review of Resident #19's order summary dated 01/09/24 did not indicate side effect monitoring for Buspirone (antianxiety), Carbamazepine (anticonvulsant), Gabapentin (anticonvulsant), Zyprexa (antipsychotic). <BR/>2. Record review of Resident#25's face sheet printed on 01/09/24 indicated Resident #25 was an [AGE] year-old male and was admitted on [DATE] with diagnoses including Parkinson's disease (is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) with dyskinesia, Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), moderate, with other behavioral disturbance, and Alzheimer's disease (is a type of dementia that affects memory, thinking and behavior). <BR/>Record review of Resident #25's quarterly MDS assessment dated [DATE] indicated Resident #25 was usually understood and usually had the ability to understand others. The MDS indicated Resident #25 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #25 did not have display behaviors. The MDS indicated Resident #25 was dependent for walking and substantial/maximal assistance for toilet transfer, chair/bed to chair transfer, and sit to stand. The MDS indicated Resident #25 received an antipsychotic during the last 7 days of the assessment period. <BR/>Record review of Resident #25's care plan dated 12/27/23 indicated Resident #25 was at risk for adverse consequence related to receiving psychotropic medication. I [Resident #25] am currently taking psychotropic medication with diagnosis of anxiety and dementia with behaviors. Intervention administers psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift. <BR/>Record review of Resident #25's order summary dated 01/09/24 indicated Lorazepam 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxiety/sundowners, start date 12/13/23. <BR/>Record review of Resident #25 order summary dated 01/09/24 indicated Quetiapine 50mg, give 1 tablet by mouth at bedtime for behaviors, start date 12/27/23. <BR/>Record review of Resident #25 order summary dated 01/09/24 did not indicate behavior monitoring for psychotropic medications.<BR/>Record review of Resident #25 order summary dated 01/09/24 did not indicate side effect monitoring for psychotropic medications.<BR/>Record review of Resident #25's MAR dated 01/01/24-01/31/24 indicated Lorazepam 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxiety/sundowners. Dose given 01/01/24, 01/02/24, 01/04/24, 01/05/24, 01/06/24, 01/07/24, 01/09/24, 01/10/24. <BR/>3. Record review of Resident #29's face sheet dated printed 01/09/24 indicated Resident #29 was an [AGE] year-old male and admitted on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mild, with agitation, delusional disorder (is a type of psychotic disorder), and psychosis (is when people lose some contact with reality). The face sheet did not indicate schizoaffective disorder (is a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). The face sheet indicated MD S was Resident #29's primary physician. <BR/>Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated Resident #29 was understood and sometimes had the ability to understand others. The MDS indicated Resident #29 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS did not indicate Resident #29 had psychosis or behavioral symptoms. The MDS indicated Resident #29 required partial/moderate assistance for toilet hygiene and shower/bath self, supervision for personal hygiene, and independent for oral hygiene and eating. The MDS indicated Resident #29 received an antipsychotic during the last 7 days of the assessment period. <BR/>Record review of Resident #29's care plan dated 01/09/23 indicated Resident #29 was at risk for adverse consequence related to receiving psychotropic medication. I [Resident #29] am currently taking psychotropic medication with diagnosis of depression and psychotic/psychosis. Intervention administers psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift. <BR/>Record review of Resident #29's order summary dated 01/09/24 indicated Seroquel 25 mg, give 1 tablet by mouth at bedtime for schizoaffective, start date 09/30/23. <BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said she used diagnoses list in the chart to add to orders she received. She said sometimes MD and NP sent order with diagnoses already added. She said nurses were responsible for ordering and doing behavior and side effect monitoring. She said the behavior and side effect monitoring should be done by drug classification. She said it was important to do behavior and side effect monitoring for each drug class because each classification had different side effects monitor and behaviors it treated. She said prn psychotropic meds could be ordered for 14 days for hospice residents. She said she was not sure about other residents. She said she did not know why prn psychotropic meds needed 14 days stop dates. She said the MDS coordinator (CRS), NP, and MD made sure residents had appropriate diagnosis for antipsychotic meds and would let the staff know if it was not appropriate. She said antipsychotic meds should have appropriate diagnoses to make sure the resident gets the right medication and know if the black box warnings applied to the resident. <BR/>During an interview on 01/10/24 at 1:20 p.m., the CRS said if she found an inappropriate diagnoses while reviewing the chart, she notified staff of the issue. She said Resident #25 diagnosis of dementia with behaviors was not an appropriate diagnosis for Seroquel. She said the Resident #29 did not have Schizoaffective as a listed diagnosis on his chart.<BR/>On 01/10/24 at 2:23 p.m., attempted to contact MD S by phone, no return call before or after exit. <BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said nurse were responsible for doing behavior and side effect monitoring. She said the nurse who received the order should make sure to add behavior and side effect monitoring. She said behavioral and side effect monitoring should be for each drug classification. She said it was important to have side effect monitoring to have information to relay to the doctor. She said it was important to have behavioral monitoring to know if a medication worked or needed. She said an antianxiety prn medication should have 14 days stop date. She said the nurse who received the prn order and before administration of the antianxiety med should make sure it had a stop day. She said she monitored prn orders and 14 days stop dates. She said she must have missed Resident #25's Lorazepam order. She said 14 days stop date were important to reassess the need of the medication. She said it could risk the resident getting a medication they did not need. She said the CRS looked at orders for appropriate diagnoses. She said appropriate diagnoses and medications were important to treat the actual diagnosis. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said if the resident was care planned for side effect and behavior monitoring, it should be done. She said monitoring should be documented in notes and followed up on. She said monitoring should be done by drug class. She said it was the nurse responsibility for monitoring of psychotropic medications. She said nursing management should be ensuring nurses were doing the monitoring. She said nursing management should be doing chart audits and if issues found, do in-services with the staff. She said prn meds should be 14 days so they could be reassessed for the need of it. She said diagnosis added to the resident chart should come from the physician. <BR/>Record review of a facility's Psychotropic Medication Review policy dated 04/20 indicated .careful assessment as to whether the medication is necessary and pharmacologically appropriate .comply with state and federal regulations related to the use .to include regular review for continued need, appropriate dosage, side effects, risk and/or benefits .monitors psychotropic drug use noting and adverse effects .reviews of the use of the medication with IDT on monthly basis .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure that residents were free of significant medication errors for 2 of 13 residents (Residents #1 and Resident #93) reviewed for medication administration.<BR/>The facility failed to ensure Resident #1's Protonix (is used to treat certain conditions in which there is too much acid in the stomach) was scheduled before meals for optimal desired results. <BR/>The facility failed to ensure Resident #93's prescribed Midodrine (is used to treat low blood pressure (hypotension)) was not administered when her blood pressure was outside of the ordered parameters 2/6/25, 2/7/25, 2/8/25, 2/9/25, 2/10/25, and 2/11/25. <BR/>The facility failed to ensure Resident #93 was administered Midodrine with meals per the physician's order. <BR/>These failures could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.<BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet dated 01/10/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including Asperger's syndrome (is a term sometimes used to describe a developmental disorder that's part of the autism spectrum disorder (ASD)), muscle weakness, and constipation. <BR/>Record review of Resident #1's admission MDS assessment dated [DATE] indicated Resident #1 was understood and had the ability to understand others. Resident #1 had a BIMS score of 09 which indicated moderate cognitive impairment.<BR/>Record review of Resident #1's care plan dated 12/15/24 indicated Resident #1 had potential for complications, discomfort, related to GERD (is a common condition in which the stomach contents move up into the esophagus). Intervention included administer medications per MD orders and monitor for effectiveness. <BR/>Record review of Resident #1's consolidated physician order dated 2/10/25 indicated Protonix Tablet Delayed Release 40 MG, 1 tablet by mouth one time a day for GERD. Start 01/24/25.<BR/>Record review of Resident#1's MAR dated 01/01/25-01/31/25 indicated Protonix Tablet Delayed Release 40 MG, 1 tablet by mouth one time a day for GERD. Start 01/24/25. Resident #1 had 7 doses scheduled for 8am (1/24/25-1/30/25) and 1 dose scheduled for 9am (1/31/25). <BR/>Record review of Resident #1's MAR dated 02/01/25-02/28/25 indicated Protonix Tablet Delayed Release 40 MG, 1 tablet by mouth one time a day for GERD. Start 01/24/25. Resident #1 had 10 of 10 doses scheduled for 9am (2/1/25-2/10/25).<BR/>During an observation on 02/10/25 at 10:51 a.m., Resident #1 was lying in her bed watching television. Resident #1 did not respond to greetings. <BR/>During an observation on 02/11/25 at 10:06 a.m., Resident #1 was sitting up in her bed. Resident #1 still did not respond to greetings. <BR/>On 2/12/25 at 5:45 PM, called Resident #1's responsible party and unable to leave message because the mailbox was full. No return call was received before or after exit.<BR/>2. Record review of Resident #93's face sheet dated 02/11/25 indicated Resident #93 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #93 had diagnoses including acute kidney failure (when the kidneys suddenly can't filter waste products from the blood) and hypotension (low blood pressure). <BR/>Record review of the MDS indicated Resident #93 was admitted to the facility less than 21 days ago. No MDS for Resident #93 was completed prior to exit.<BR/>Record review of Resident #93's care plan dated 02/10/25 indicated Resident #93 had hypotension. Intervention included check blood pressure as ordered by the MD. <BR/>Record review of Resident #93's consolidated physician order dated 02/11/25 indicated Midodrine Tablet 10MG, give 1 tablet by mouth three times a day for treat hypotension. Hold for SBP (is the pressure in your arteries when your heart beats and pumps blood throughout your body) greater than 110 or DBP (is the pressure in the arteries when the heart rests between beats) greater than 80 and give with meals. Start 2/5/25. <BR/>Record review of Resident #93 MAR dated 2/1/25 and 2/28/25 indicated Midodrine Tablet 10MG, give 1 tablet by mouth three times a day to treat hypotension. Hold for SBP greater than 110 or DBP greater than 80 and give with meals. Start 2/5/25. Administration documented on 2/6/25 at 7am: 138/72 (ADCO), 2/7/25 at 7am: 130/65 (LVN A), 2/7/25 at 7pm: 116/72 (LVN E), 2/8/25 at 7am: 119/49(RN C), 2/8/25 at 1pm: 122/54 (RN C), 2/8/25 at 7pm: 119/67 (LVN E), 2/9/25 at 7pm: 120/70 (LVN E), 2/10/25 at 7am: 128/72(ADCO), 2/10/25 at 1pm: 132/78 (ADCO), and 2/11/25 at 7am: 152/86.<BR/>During an interview on 2/12/25 at 1:57 p.m., LVN D said Protonix should be scheduled to be given on an empty stomach, in the morning. She said the medications worked better on an empty stomach and before meals. She said Resident #1's Protonix should be scheduled at 6am. She said 9am was not a good time to administer Protonix. She said Resident #93's Midodrine was ordered to raise her blood pressure for hypotension. She said if Resident #93 was administered Midodrine and her blood pressure was greater than the ordered parameters, it placed her at risk for hypertension or stroke. She said the nurse should look at the physician order and follow the hold parameters and administration instructions before giving a medication. <BR/>During an interview on 2/12/25 at 5:49 p.m., the ADCO said Protonix should be given before breakfast or at least 30 minutes before a meal. She said Resident #1's Protonix should be scheduled for 6am. She said it should not be schedule for 9am. She said for the medication to work and prevent GERD it needed to administer before breakfast. She said Resident #93's Midodrine administration instruction said for it to be given with meals. She said Resident #93's current Midodrine schedule did not follow those instructions. She said she did not know why the doctor wanted it given with meals, but the facility should follow the orders. She said she already knew about the medication errors for Resident #93's Midodrine. She said she was embarrassed about not following Resident #93's Midodrine hold parameters. She said the medication administration order and parameters were supposed to be read before administration. She said she should have read the physician order more carefully. She said most blood pressure parameters are hold for less than the SBP or DBP not greater than. She said giving Resident #93 the Midodrine when her blood pressure was not low placed her at risk for a stroke. <BR/>During an interview on 2/12/25 at 6:57 p.m., the DCO P, from a sister facility, said Protonix should be given on an empty stomach, before breakfast. She said the medication was not effective or therapeutic when it was taken with food. She said she expected the nursing staff to read the physician's order and follow the hold parameters. She said Midodrine was for hypotension. She said if the resident was not experiencing hypotension and was still given the medication, it was not good. She said Resident #93 could have experienced hypertension. She said the ADCO, DCO Q, and pharmacy consult should be ensuring medications were timed correctly, and physician orders and hold parameters were followed. She said monitoring should be done with chart audits. <BR/>During an interview on 2/12/25 at 7:34 p.m., the EDO said she expected physician's orders to be followed by the nursing staff. She said the nursing management should be monitoring this process. <BR/>Record review of a facility's General Guidelines for Medication Administration policy dated 08/2020 indicated . Medications are administered as prescribed in accordance with good nursing principles and practices . Medications are administered in accordance with written orders of the prescriber . Medications are administered within 60 minutes of the scheduled administration time, except before, with, or after meal orders, which are administered based on mealtimes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure each resident receives and the facility provides food that accommodates residents' food preferences for 1 of 18 residents (Resident #17) reviewed for food preferences and the accommodation of resident's meal choices.<BR/>The facility failed to honor Resident #17's request for an alternate meal choice for lunch service on 2/12/25 without state surveyor intervention. <BR/>This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. <BR/>Findings included: <BR/>Record review of Resident #17's face sheet dated 2/12/25 revealed she was [AGE] years old and admitted to the facility initially on 3/02/17 and re-admitted [DATE]. Resident #17 had diagnoses including bipolar disorder, major depressive disorder, and anxiety disorder.<BR/>Record review of Resident #17's quarterly MDS assessment dated [DATE] indicated she had a BIMS score of 15, which indicated she was cognitively intact. The MDS indicated Resident #17 had active diagnoses of anxiety disorder, depression, and bipolar disorder. <BR/>Record review of Resident #17's undated Care Plan Report indicated she had requested to not have an evening meal brought to her room unless requested, the resident would also like to be asked if she wished to have anything else and had interventions which included to monitor if the resident wanted other foods or evening meal back and to remind the resident she could request foods as she wished, revised on 11/27/20; resident was on a regular diet, she filled out her menus and would request items off the cycle, staff would try and meet her needs, as much as possible and had interventions which included the Dietary Manager to monitor/discuss food preferences, serve diet as ordered and offer substitutes if less than 50% was eaten, revised on 8/31/23; she was at risk for malnutritional issues due to regular diet, food choices, malabsorption disease process, metabolic needs higher than intake, psychological factors hinder eating with interventions including to encourage resident to take small frequent meals, revised on 7/24/24.<BR/>Record review of Resident #17's Selective Menu dated 2/12/25 reflected she had circled winter mix vegetables, chocolate &eacute;clair, and iced tea for the noon meal. <BR/>During an observation and interview on 2/12/25 at 12:29 PM, Resident #17 had just been served lunch. Resident #17 said she was served spaghetti and she did not like spaghetti. Resident #17 said she had forgotten to circle the deli sandwich on her menu for lunch and said she had told a staff member to let dietary know she wanted the sandwich. Resident #17 did not remember what staff member she had asked to let dietary know she wanted a sandwich.<BR/>During an interview on 2/12/25 at 12:35 PM, RCP M said Resident #17 had not asked her about letting dietary know she wanted a deli sandwich because she did not like spaghetti, but she would go let dietary know.<BR/>During an interview on 2/12/25 at 12:40 PM, RCP M informed the state surveyor in the hallway that she had talked to the Dietary Manager and the Dietary Manager said Resident #17 had only circled the vegetables on the list. RCP M asked the state surveyor to accompany her to talk to talk to the Dietary Manager.<BR/>During an interview on 2/12/25 at 12:43 PM, the Dietary Manager said Resident #17 did her this way all the time and Resident #17 could have anything she circled on the menu list and Resident #17 had only circled vegetables and a dessert. The Dietary Manager said she did not ask Resident #17 if she had not circled a main meal item by accident and did she have a preference of a main meal item. The Dietary Manager said she did look to see what Resident #17 ate last week and she had spaghetti, so she gave her spaghetti so she would have more than vegetables and dessert for lunch. The Dietary Manager said residents could have something else on the menu if they did not like what they had chosen if the dietary staff had time and the food was available. The Dietary Manager said she would get Resident #17 a sandwich, but it might take a little bit . <BR/>During an interview on 2/12/25 at 1:13 PM, RCP M informed the state surveyor in the hallway that she was glad the state surveyor went with her to talk to the Dietary Manager because if the state surveyor had not gone with her, the Dietary Manager would not have given Resident #17 a sandwich. RCP M said the residents usually were only allowed to get what was marked on their menus. RCP M said the Dietary Manager acted like it was her money she was spending to feed the residents. RCP M said the residents paid to live at the facility and it was their right to choose what they wanted to eat .<BR/>During an interview on 2/12/25 at 1:10 PM, Resident #17 said staff had brought her a sandwich and it was so good that she ate all of it. Resident #17 was asked if she had asked for something different to eat before and told she could not have it. Resident #17 said one morning she was in the dining room before they started serving breakfast and thought to herself that oatmeal sure sounded good. Resident #17 said she knew she had not marked it on her menu, but she said she asked the cook if she could get some oatmeal before they started serving and the cook told her yes. Resident #17 said she was headed back to her table and the Dietary Manager came over to her and had her menu in hand and said this was what you ordered, and the Dietary Manager told her she could not have oatmeal. Resident #17 said they did bring her some oatmeal later. Resident #17 said she did not remember what date it was on, but it had been in the last week or two. Resident #17 said the Dietary Manager did not like her. <BR/>During an interview on 2/12/25 at 1:33 PM, the ADCO said the residents had the right to choose to eat something else, regardless of what they marked on their menus. The ADCO said if residents were not served what they wanted to eat, the resident could have decreased intake of food, which could lead to weight loss, malnutrition, or even depression. The ADCO said she knew if she did not get what she wanted to eat, she would be depressed, and if the Dietary Manager was argumentative or rude, it would make residents not want to ask for anything different. <BR/>During an interview on 2/12/25 at 2:18 PM, DCO P said she was covering the facility while DCO Q was out sick. DCO P said the resident had the right to choose or change their mind on what they wanted to eat. DCO P said if residents were not allowed to choose what they wanted to eat, it could cause a weight loss issue for one thing, and it affected the resident's rights to choose preferences of food. <BR/>During an interview on 2/12/25 at 5:46 PM, the EDO said the Dietary Manager cooked the meals from the menu based off the residents' menu choices circled on the forms. The EDO said she would have expected Resident #17 to have been served a sandwich after everyone had been served based on what had been circled on the menus, then be served from the always available menu of her preference. <BR/>Record review of the facility's policy titled Resident Food Preferences revised July 2017 indicated . Individual food preferences would be assessed upon admission and communicated to the interdisciplinary team . when possible, staff would interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes . if the resident refuses or was unhappy with his or her diet, the staff would create a care plan that the resident was satisfied with . the Food Services Department would offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 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 for 2 of 2 residents reviewed for transmission-based precautions. (Resident #6 and Resident #9)<BR/>The facility failed to isolate Resident #6 and Resident #9 after urine cultures (test checks urine for germs (microorganisms) that cause infections) revealed ESBL (enzymes break down and destroy some commonly used antibiotics) in their urine.<BR/>This failure could place residents at risk for being exposed to health complications and infectious diseases. <BR/>Findings included:<BR/>1. Record review of Resident #6's face sheet printed on 01/10/24 indicated Resident #6 was an [AGE] year-old female and admitted on [DATE] with diagnoses including senile degeneration of brain (a progressive decline in a person's ability to think and remember can be due to a wide range of brain conditions) and need for assistance with personal care.<BR/>Record review of Resident #6's annual MDS assessment dated [DATE] indicated Resident #6 was understood and understood others. The MDS indicated Resident #6 had a BIMS score of 06 which indicated severe cognitive impairment. The MDS indicated Resident #6 was dependent for toilet hygiene and was always incontinent of urine and bowel. <BR/>Record review of Resident #6's care plan dated 10/30/21 indicated Resident #6 was frequently incontinent and at risk for skin breakdown. Intervention labs as ordered. <BR/>Record review of Resident #6's order summary dated 12/01/23-01/10/24 indicated urinalysis (s a test that examines the visual, chemical and microscopic aspects of your urine)with culture (is a test to find germs (such as bacteria or a fungus) that can cause an infection) and sensitivity (checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection), ordered date 12/18/23. The order summary did not indicate isolation for ESBL in the urine. <BR/>Record review of Resident #6's culture and sensitivity results dated 12/19/23 indicated .high pathogens detected .Escherichia coli .antibiotic notes .ESBL (Extended Spectrum Beta-lactamase detected .are usually multi-drug resistant .<BR/>2. Record review of Resident #9's face sheet printed 01/16/24 indicated Resident #9 was a [AGE] year-old male and admitted on [DATE] with diagnoses including schizoaffective disorder (is a mental health condition with symptoms of both schizophrenia and mood disorders), acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), and overactive bladder (is a collection of symptoms that may affect how often you pee and your urgency). <BR/>Record review of Resident #9's quarterly MDS assessment dated [DATE] indicated Resident #9 was understood and understood others. The MDS indicated Resident #9 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #9 required partial/moderate assistance for toileting hygiene and was occasionally incontinent of urine and bowel. <BR/>Record review of Resident #9's care plan dated 01/17/23 indicated Resident #9 had occasional bladder incontinence and was at risk for skin breakdown. Intervention included monitor/document for signs and symptoms of urinary tract infection. <BR/>Record review of Resident #9's order summary dated 01/10/24 did not indicate isolation for ESBL in the urine.<BR/>Record review of Resident #9's culture and sensitivity results dated 11/14/23 indicated .high pathogens detected .Escherichia coli .antibiotic notes .ESBL (Extended Spectrum Beta-lactamase detected .are usually multi-drug resistant .<BR/>During an interview on 01/10/24 at 9:45 a.m., the DCO said the ADCO was the ICP, but she was unavailable due to being out sick today. She said the facility did not notice Resident #6 or Resident #9's lab results that said they had ESBL in their urine. She said the ICP was responsible for reviewing lab results. She said the ICP and LVNs were responsible for developing and implementing interventions to address the results. She said so neither Resident #6 nor Resident #9 were placed on contact isolation. She said it was the facility's policy to place residents with ESBL on contact isolation. She said she was not sure of the duration of the contact isolation period. She said Resident #6 and Resident #9 should have been placed on contact isolation to prevent the spread of ESBL. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said after reviewing the lab results of Resident #6 and Resident #9, she said she felt the lab needed a better way to relay information like ESBL. She said the ICP was responsible for reviewing lab results and coordinating the treatment. She said not placing the resident on contact isolation could have allowed ESBL to spread and other resident to spread it. <BR/>Record review of a facility's Transmission-Based Precaution for Infections policy revised on 10/24/22 indicated .contact .in addition to standard precaution, use Contact precautions (gown, gloves, mask, or face shield if splashing could occur) for resident known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact .the above included epidemiologically important organisms (Multidrug-resistant organisms) .physician order is required to begin transmission-based precaution and to end .add transmission-based precaution to care plan with all interventions based on type .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure the residents has the right to be informed of the risks and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options he or she preferred, for 2 of 15 residents (Resident #19 and Resident #242) reviewed for resident rights.<BR/>1. The facility failed to ensure Resident #19's psychoactive (substances that, when taken in or administered into one's system, affect mental processes) medication therapy consents were completed properly upon admission and prior to the administration of Zyprexa ( antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder), Venlafaxine ( used to treat major depressive disorder, anxiety, and panic disorder), Trazodone ( used to treat depression), and Carbamazepine ( used to treat certain types of seizures and bipolar disorder). <BR/>2.The facility failed to obtain informed consent based on information of the benefits, risks, and options available for Resident #242 prior to administering Risperdal (is an antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder), Depakote (used to treat seizures and stabilize mood), and Buspirone (used to treat anxiety). <BR/>These failures could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. <BR/>Findings included: <BR/>1. Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including Schizoaffective Disorder (is a mental illness that can affect your thoughts, mood and behavior), Bipolar type, Bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), mild depressed, recurrent depressive disorder, generalized anxiety (you are worrying constantly and can't control the worrying), insomnia (is a common sleep disorder), and conversion disorder with seizures or convulsions (is a condition in which a person experiences physical and sensory problems, such as paralysis, numbness, blindness, deafness or seizures, with no underlying neurologic pathology). <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 received antipsychotic, antianxiety, and antidepressant during the last 7 days of the assessment period. <BR/>Record review of Resident #19's care plan dated 03/21/23, revised 04/10/23 indicated Resident #19 was at risk for adverse consequence related to receiving psychotropic medications. Intervention included administer psychotropic medications as ordered. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated:<BR/>*Carbamazepine 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23.<BR/>*Trazodone 100 mg, give 1 tablet by mouth at bedtime for insomnia, start date 03/18/23.<BR/>*Venlafaxine, give 225 mg by mouth one time a day for depression, start date 03/19/23. <BR/>*Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23. <BR/>* Zyprexa, give 20 mg by mouth at bedtime for increased mood, decreased anxiety, and agitation, start date 08/11/23.<BR/>* Zyprexa, give 50 mg by mouth in the morning for increased mood, decreased anxiety, and agitation, start date 08/12/23.<BR/>Record review of Resident #19's MAR dated 01/01/24-01/31/24 indicated:<BR/>*Carbamazepine 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23.<BR/>*Trazodone 100 mg, give 1 tablet by mouth at bedtime for insomnia, start date 03/18/23.<BR/>*Venlafaxine, give 225 mg by mouth one time a day for depression, start date 03/19/23. <BR/>*Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23. <BR/>* Zyprexa, give 20 mg by mouth at bedtime for increased mood, decreased anxiety, and agitation, start date 08/11/23.<BR/>* Zyprexa, give 50 mg by mouth in the morning for increased mood, decreased anxiety, and agitation, start date 08/12/23.<BR/>Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Zyprexa. The consent indicated Zyprexa .Schiz-affective .improved function ability .antipsychotic .the probable clinically significant side effects or risks associated with the medication included: stiffness of neck, confusion, muscle rigidity .black box warning .<BR/>Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Trazodone. The consent indicated Trazodone .Schizo-Affective .Sleep disorder . antidepressant . the probable clinically significant side effects or risks associated with the medication included: dry mouth, blurred vision . black box warning .<BR/>Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Carbamazepine. The consent indicated Carbamazepine .bipolar disorder .improved function ability .antimanic (are medications used as mood stabilizers in psychiatric conditions such as bipolar disorder and schizophrenia) . the probable clinically significant side effects or risks associated with the medication included: confusion, drowsiness, hypotension (low blood pressure) . black box warning .<BR/>Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Venlafaxine. The consent indicated Venlafaxine .Depression .improved function ability .antidepressant . the probable clinically significant side effects or risks associated with the medication included: dry mouth, blurred vision . black box warning .<BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said the LVNs, or upper nursing management were responsible for medication consents. She said when a verbal consent was done, the nurse who received the verbal consent signed and the ADCO or DCO signed behind them. She said she believed a medication could be given with one nurse signature for verbal consent. She said if the family visited, staff were supposed to try to get a hand signature. She said consents done correctly were important so family aware of current treatment. <BR/>During an interview on 01/10/24 at 2:25 p.m., the responsible party for Resident #19 said she did not recall giving verbal consent for Resident #19's medication immediately after admission. She said she remembered when her family member was transferred to the facility and was not called. She said the facility only told her when Resident #19 started medications but did not go over the consent form. <BR/>During an interview on 01/10/24 at 2:29 a.m., the DCO said nurses were responsible to get consent for medication when they were ordered. She said consent should also be obtained upon admission. She said consent for medication was important to make sure family was aware of risks and benefits of treatment. She said she expected staff to go over the consent form and explain risks and benefits with family before consent was received. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said she expected staff to get consent before giving medications. She said staff should go over risks and benefits before consent was received. She said it was important to give informed consent, so the resident or family understood what the resident was taking. <BR/>2. Record review of Resident #242's face sheet dated 1/08/24 indicated she was a [AGE] year-old female and admitted to the facility on [DATE] with diagnoses including heart failure, Bipolar disorder (associated with episodes of mood swings ranging from depressive or sad lows to manic or excited highs), schizoaffective disorder (combination of symptoms of schizophrenia (affects ability to think, feel and behave clearly) and mood disorder, such as depression or bipolar disorder), major depressive disorder (persistent depressed mood or loss of interest in activities, causing impairment in daily life), and dementia (progressive loss of intellectual functioning, impairment of memory and thinking, often with personality changes caused by disease of the brain).<BR/>Record review of Resident #242's admission MDS assessment revealed it had not been completed.<BR/>Record review of Resident #242's Baseline Care plan dated 1/03/24 revealed she used psychotropic medications.<BR/>Record review of Resident #242's Order summary report dated 1/08/24 revealed an order for: Risperdal 2 mg 1 tablet by mouth at bedtime for bipolar disorder with a start date of 1/03/24; Buspirone 5 mg 2 tablets three times daily for anxiety with a start date of 1/03/24, and Depakote 125 mg 4 tablets three times a day for behaviors with a start date of 1/04/24. <BR/>Record review of Resident #242's MAR dated 1/01/24-1/31/24 indicated Resident #242 had received: Risperdal 2 mg at bedtime since 1/03/24, Buspirone 5 mg 2 tablets three times daily since 1/03/24, Depakote 125 mg 4 tablets two times a day on 1/03/24 to 1/04/24, and Depakote 125 mg 4 tablets three times a day since 1/04/24. <BR/>Record review of a Behavioral Management-psychoactive medication therapy consent dated 1/04/24 indicated a verbal consent for the use of Risperdal was obtained from Resident #242's RP on 1/09/24. This verbal consent was obtained 6 days after admission and after administration of Risperdal to Resident #242.<BR/>Record review of a Behavioral Management-psychoactive medication therapy consent dated 1/04/24 indicated a verbal consent for the use of Buspirone was obtained from Resident #242's RP on 1/09/24. This verbal consent was obtained 6 days after admission and after administration of Buspirone to Resident #242.<BR/>Record review of a Behavioral Management-psychoactive medication therapy consent dated 1/04/24 indicated a verbal consent for the use of Depakote was obtained from Resident #242's RP on 1/09/24. This verbal consent was obtained 6 days after admission and after administration of Depakote to Resident #242.<BR/>On 1/08/24 at 2:27 PM and 1/10/23 at 12:36 PM, attempted to interview Resident #242's RP via phone. There was no answer, and a voicemail was left. Resident #242's RP did not return call prior to the exit of the facility. <BR/>During an interview on 1/09/24 at 11:30 AM, RN N said the admitting nurses were responsible for obtaining the consents for antipsychotics and psychotropic medications. RN N said the admitting nurse obtained consent by calling the RP for verbal consent or obtaining written consent from the RP if they were in the facility. RN N said the DCO was responsible for ensuring the antipsychotic and psychotropic medication consents were completed.<BR/>During an interview on 1/10/24 at 1:02 PM, the DCO said antipsychotic and psychotropic medication consents should be obtained upon admission and the medications should not be administered without obtaining proper informed consent. The DCO said she did not know what happened or why Resident #242's consents were not obtained upon admission. The DCO said she was the initial admitting nurse for Resident #242 and started the admission, but she did not complete it and turned it over to the next nurse. The DCO said it was a group effort to ensure proper informed consent was obtained for antipsychotic and psychotropic medications from the resident or their RP prior to administering the medications.<BR/>During an interview on 1/10/24 at 1:28 PM, the ADM said she would expect proper informed consent to be obtained prior to administering antipsychotic or psychotropic medications from the resident or their RP. <BR/>Requested a policy on antipsychotic and psychotropic medication consents from the DCO on 1/10/24 at 1:02 PM. <BR/>Requested a policy on antipsychotic and psychotropic medication consents from the ADM on 1/10/24 at 3:28 PM.<BR/>On 1/10/24 at 4:00 PM, the ADM said they did not have a policy on antipsychotic or psychotropic medication consents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure treatment and services was provided, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 3 of 7 residents reviewed for quality of care. (Resident #93, Resident #11, and Resident #15)<BR/>The facility failed to initiate wound care treatment after Resident #93 admitted on [DATE], with multiple areas of shearing.<BR/>The facility failed to perform a weekly skin assessment on Resident #93 that was due on 02/08/25. <BR/>The facility failed to initiate Resident #93's wound care orders noted in the wound care doctor's progress notes on 02/08/25 until 02/10/25. <BR/>The facility failed to implement a specialty mattress (use in the treatment and prevention of pressure ulcers) for Resident #93, per their policy, due to multiple stage 3 pressure injuries on 02/01/25. <BR/>The facility failed to float Resident #93's heels on 02/10/25 and 02/11/25.<BR/>The facility failed to offload and/or reposition Resident #93 every 2 hours on 02/10/25 and 02/11/25. <BR/>An IJ was identified on 02/11/25. The IJ template was provided to the facility on [DATE] at 5:00 p.m. While the IJ was removed on 02/12/25, the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on the process of carrying out orders for residents admitted with wounds or obtaining orders if no orders accompanied the resident, completion of weekly skin assessments, wound care orders, skin management policy, and pressure ulcer prevention and interventions for residents with pressure ulcers. <BR/>2.The facility failed to document wound care was performed on Resident #11, on 02/01/25, 02/02/25, 02/03/25, 02/05/25, and 02/10/25. <BR/>The facility failed to document Resident #11's weekly skin assessments on 01/02/25, 01/15/25, 01/22/25, 01/29/25, and 02/04/25. <BR/>3.The facility failed to document wound care was performed on Resident #15's right upper thigh wound on 01/17/25, 01/20/25, and 01/29/25. <BR/>The facility failed to document Resident #15's weekly skin assessments on 01/19/25, 01/26/25, 02/02/25, and 02/09/25.<BR/>Theses failures could place residents at risk for wound deteriorations and more wound development. <BR/>Findings included:<BR/>1. Record review of Resident #93's face sheet dated 02/11/25 indicated Resident #93 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #93 had diagnoses including acute kidney failure (when the kidneys suddenly can't filter waste products from the blood), urinary tract infection (is an infection in any part of your urinary system: kidneys, bladder, ureters, and urethra), morbid obesity (is a medical condition characterized by excessive body weight that significantly impacts health and well-being), and pressure ulcer of right hip, left hip, and other sites, stage 3 (a full-thickness tissue loss where the subcutaneous fat layer is visible within the wound, but the bone, tendon, or muscle is not exposed). <BR/>Record review of the MDS, on 02/10/25, indicated Resident #93 was admitted to the facility less than 21 days ago. No MDS for Resident #93 was completed prior to exit.<BR/>Record review of Resident #93's care plan dated 02/03/25 indicated: <BR/>*Resident #93 was admitted with stage 3 pressure ulcer to right thigh. Interventions included assess and document skin condition every week, pressure relieving appliances as ordered, reposition residents as indicated to relieve pressure and for comfort, and wound care per MD orders. <BR/>*Resident #93 was admitted with Stage 3 pressure ulcer to right hip. Interventions included assess and document skin condition every week, monitor nutritional intake, weight, lab values and report significant changes to MD, pressure relieving appliances as ordered, reposition residents as indicated to relieve pressure and for comfort, and wound care per MD orders.<BR/>*Resident #93 was admitted with stage 3 pressure ulcer to left thigh. Intervention included administer treatments as ordered and monitor for effectiveness, monitor nutritional status, and obtain and monitor lab/diagnostic work as ordered. <BR/>Record review of Resident #93's consolidated physician orders dated active as of 02/11/25 indicated the following:<BR/>*Left thigh- cleanse with house wound cleanser. Apply Medi honey and collagen sheet. Cover with foam and border gauze dressing everyday shift. Start 02/11/25.<BR/>*Nursing to perform weekly skin assessment. Ordered 02/09/25.<BR/>*Right hip- cleanse with house wound cleanser and pat dry. Apply Medi honey and cover with collagen sheet and foam then secure with border dressing everyday shift. Start 02/11/25. <BR/>*Right thigh- cleanse with house wound cleanser and pat dry. Apply Medi honey and collagen sheet. Cover with foam and secure with border dressing everyday shift. Start 02/11/25.<BR/>The consolidated physician order did not reflect wound care orders for Resident #93's left thigh, right hip, and right thigh pressure ulcer on admission [DATE]). <BR/>Record review of Resident #93's MAR dated 02/01/25-02/28/25 indicated the following:<BR/>*Left thigh- cleanse with house wound cleanser. Apply Medi honey and collagen sheet. Cover with foam and border gauze dressing everyday shift. Start 02/11/25.<BR/>*Nursing to perform weekly skin assessment. Ordered 02/02/25. Discontinued 02/09/25. No documentation was noted on 02/02/25 and 02/09/25. <BR/>*Right hip- cleanse with house wound cleanser and pat dry. Apply Medi honey and cover with collagen sheet and foam then secure with border dressing everyday shift. Start 02/11/25. <BR/>*Right thigh- cleanse with house wound cleanser and pat dry. Apply Medi honey and collagen sheet. Cover with foam and secure with border dressing everyday shift. Start 02/11/25.<BR/>Record review of Resident #93's progress note dated 01/12/25-02/12/25 indicated:<BR/>*02/01/25 at 7:47 p.m. by the ADCO, .new admission skin assessment .the following areas were all noted upon admission to the facility . Right Lateral thigh shearing 2cm x 5cm x0.1cm open area without exudate with surrounding scaring . Right gluteal area shearing 0.4cm x 0.4cm x 0.1 cm no exudate noted . Right lateral hip shearing with surrounding scaring 5.5cm x 1.4cm x 0.1cm no exudate noted . Right Posterior hip shearing 1.3cm x 0.9cm x 0.1cm no exudate noted . Right posterior thigh near gluteal fold 1.2cm x 0.1cm. Area is a hard area that appears to be healing . Left posterior thigh shearing 1.2cm x 1cm x 0.1cm area noted to have slight bleeding when dressing was removed . right medial posterior thigh near gluteal fold 1cm x 1cm. area is a hard area that appears to be healing .<BR/>*02/08/25 at 7:33 p.m. by DNP S, .date of service: 02/07/25 .wound initial .Resident #93 . The following wounds were evaluated during today's visit . Wound 1 Right Hip, Pressure Injury, Stage 3 . Wound 2 Right Thigh, Pressure Injury, Stage 3 . Wound 3 Left Thigh, Pressure Injury, Stage 3 . Patient is admitted with multiple wounds . Per report from DON . WOUND ASSESSMENT: .Wound: 1 . Status: Present on admission Location: Right Hip . Primary Etiology: Pressure Injury Severity: Stage 3 . Size: 6 cm x 1.5 cm x 0.1 cm. Actual area is 9 cm2. Actual volume is 0.9 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema Exudate: Light Serous .Wound Odor: None . Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Wound: 2 . Status: Present on admission Location: Right Thigh . Primary Etiology: Pressure Injury .Severity: Stage 3 . Size: 4 cm x 2 cm x 0.1 cm. Actual area is 8 cm2. Actual volume is 0.8 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema, No maceration Exudate: Light Serous . Wound Odor: None . Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Wound: 3 . Status: Present on admission Location: Left Thigh . Primary Etiology: Pressure Injury .Severity: Stage 3 . Size: 1.5 cm x 1 cm x 0.1 cm. Actual area is 1.5 cm2. Actual volume is 0.15 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema, No maceration Exudate: Light Serous . Wound Odor: None .Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Recommendations consisting of: .We will re-evaluate this patient on our next visit (anticipated 1-2 weeks), Implement pressure relieving measures, offloading, and repositioning, as tolerated . Establish turning frequency based on the characteristics of the support surface and the patient's response . Protect skin from exposure to excessive moisture (periwound) with a barrier product. Use skin emollients to hydrate dry skin . Repositioning should be undertaken using the 30-degree tilted side-lying position (alternating right side, back, left side) . Plan of care discussed with facility staff .Wound# 1 Right Hip Pressure Injury Treatment Recommendations: .clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled Wound # 2 Right Thigh Pressure Injury .Treatment Recommendations: . clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled Wound # 3 Left Thigh Pressure Injury .Treatment Recommendations: . clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled .<BR/>Record review of Resident #93's memorandum of transfer and physician certification dated 02/01/25 indicated emergency department diagnoses included pressure injury of contiguous region involving back, right buttock, and right hip, stage 2. <BR/>Record review of Resident #93's hospital Discharge summary dated [DATE] did not reflect wound care orders. <BR/>Record review of Resident #93's Braden scale for predicting pressure sore risk dated 02/01/25 indicated score of 16 which was at risk. <BR/>Record review of Resident #93's weekly skin assessment dated [DATE] indicated .does the resident have a pressure, venous, arterial, diabetic, or surgical wound .yes .stage 2 PU, multiple shearing sites to right lateral thigh, right posterior thigh multiple, left posterior thigh, right buttocks, left posterior thigh . The facility's electronic medical record did not reflect a skin assessment on 02/08/25 or 02/09/25. <BR/>Record review of Resident #93's wound assessment report dated 02/07/25 indicated .left thigh .Length: 1.50 cm .Width: 1.00 cm .Depth: 0.10 cm .left thigh .pressure injury .stage 3 .treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing .<BR/>Record review of Resident #93's wound assessment report dated 02/07/25 indicated .right thigh .length: 4 cm .width: 2 cm .depth: 0.10 cm .right thigh .pressure injury .stage 3 . treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing .<BR/>Record review of Resident #93's wound assessment report dated 02/07/25 indicated .right thigh .length: 6 cm .width: 1.5 cm .depth: 0.10cm .right hip .pressure injury .stage 3 . treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing .<BR/>Record review of the facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .specialty mattress will be implemented for residents with multiple stage 2 areas, stage 3, or stage 4 pressure injuries .<BR/>During an observation and interview on 02/10/25 at 10:51 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff did not turn her every 2 hours or prop her heels with pillows. She said she could turn herself with the assist rails but staff did not place pillows behind her back, underneath her buttocks or between her legs. <BR/>During an observation and interview on 02/10/25 at 3:05 p.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff did not turn her every 2 hours or propped her heels with pillows.<BR/>During an observation on 02/11/25 at 10:02 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. <BR/>During an observation and interview on 02/11/25 at 11:32 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff had not turn her every 2 hours or propped her heels with pillows. She said she had wounds on thighs, buttock, and hip. She said when she came from the hospital, there were dressings on two of the wounds. She said the facility did not do dressing changes every day. She said it depended on the staff as to what was done to her wounds. She said some staff did nothing and others would put cream on the wounds if they were closed. <BR/>During an observation on 02/11/25 at 1:25 p.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. <BR/>During an interview on 02/11/25 at 1:30 p.m., the ADCO said she was working the floor when Resident #93 was admitted . She said she was Resident #93's admitting nurse. She said if the admitting nurse was not a RN, then the nurse was only responsible for measuring and describing the wound. She said a RN, the DCO, or MD staged pressure wounds at the facility. She said upon admission the resident's MD should be notified and general wound care orders obtained. She said when the wound care doctor rounded on Fridays, the facility received specialized wound care orders. She said the wound care doctor came every Friday and the DCO notified him of who needed to be seen. She said after the wound care doctor rounded and made recommendations. She said the wound care doctor placed his recommendations in a progress note. She said the floor nurses or the DCO were responsible to place the recommendations in the facility's electronic medical record as an order. She said the DCO and ADCO were responsible for ensuring the wound care orders were followed through. She said the floor nurses were responsible for the resident's weekly skin assessments. She said the DON and DNP completed the weekly wound assessments when he rounded on Fridays. She said Resident #93 wounds on admission were shearing to her right hip, right buttocks, left thigh, and left buttocks. She said since she was not a RN, she did not stage Resident #93's wounds. She said Resident #93 arrived from the hospital with dressings over the wounds. She said she notified NP R by text or phone and let her know about Resident #93's shearing. She said she did not receive a response from NP R until shift change. She said she could not remember what NP R said about Resident #93's shearing. She said she knew she passed the message from NP R on to RN G when she gave report. She said she did not know what wound care treatment Resident #93 had been receiving since admission on [DATE]. She said she did not know the facility's policy or criteria on specialty mattress because she just started January 13, 2025. She said she did not know if Resident #93 met the facility's criteria for a specialty mattress but she probably did. She said other interventions for Resident #93's pressure wounds should have been frequent repositioning and incontinent care and a dietary consult. She said the dietician would be at the facility this week. She said since Resident #93 had a skin assessment on 02/01/25, then she should have had one on 02/08/25. She said even though the skin assessment was a day after the wound care doctor came, it should have been done by the floor nurse. She said skin assessments were important to ensure skin issues were not missed and proper wound care orders were in place. She said following doctors' orders were important to prevent the wound from declining and promote healing. She said the facility provided Resident #93 assist rails and trapeze bar to help with her mobility. <BR/>On 02/11/25 at 2:23 p.m., called NP R and left voicemail. <BR/>On 02/11/25 at 2:25 p.m., called RN G and left voicemail. <BR/>During an interview on 02/11/25 at 2:58 p.m., NP R said she received a text message from LVN A that Resident #93 was admitted . She said she was currently driving and could not remember if the ADCO contacted her on admission about Resident #93's wounds. She said normally the facility followed the hospital's wound care orders and did not need them to give any orders. <BR/>During an interview on 02/11/25 at 4:41 p.m., NP R called back and said LVN A and the ADCO called her on 02/01/25 about Resident #93. She said she told LVN A and the ADCO to resume all hospital orders and she would see Resident #93 on Tuesday, 02/04/25. <BR/>During an interview on 02/11/25 at 6:01 p.m., RN G said she had worked at the facility for 6 years. She said she had taken care of Resident #93. She said she was texting with NP R on 02/05/05 about another resident lab work and NP R asked about Resident #93. She said NP R mentioned the hospital had not sent Resident #93 with wound care orders when she discharged . She said she told NP R that there were no wound care orders in Resident #93's hospital discharge paperwork. She said she told NP R, she did not know what the facility had been doing either for Resident #93's pressure wounds. She said NP R ordered collagen and a dry dressing and for the wound care doctor to see Resident #93. She said she did the ordered wound care on Resident #93 that night shift (02/05/25). She said she thought she placed the wound care orders NP R gave for Resident #93 in the facility's electronic medical records. She said Resident #93's wound care orders from NP R would be on her MAR if she did. She said it was important to have put in the wound care orders from NP R, so the next person knew what to do for Resident #93's wounds. She said not doing wound care treatments for Resident #93's wounds could cause further break down or increased stages. She said Resident #93's wounds would have been called stage 2's on admission. She said if the admission nurse was not a RN, then the next RN on duty was responsible for staging the pressure ulcer. She said if a wound needed to be staged by a RN, that information needed to be passed down by the next nurse or put on the 24-hour report. She said staging a pressure ulcer was important so the wound could be caught early and treated so it did not decline. She said she was not aware Resident #93's wounds were not staged until DNP S came on 02/07/25. She said a resident had to have pressure breakdown to be on a low air loss mattress. She said Resident #93 was on a bariatric pressure reduction mattress. She said she did not if they made bariatric specialty mattresses. She said if they made bariatric low air loss mattresses, Resident #93 would qualify for one because she had several areas of pressure breakdown. <BR/>During an interview on 02/12/25 at 1:57 p.m., LVN D said nurses were responsible for resident's skin assessments. She said the skin assessments were due weekly and as needed. She said the weekly skin assessments should be charted in the resident medical records. She said a resident should be on a low air loss mattress if they have pressure ulcers or at the family request. She said heels should be floated for residents after hip surgery, residents who do not turn good, or residents with redness on their heels. She said residents should be repositioned every 2 hours. She said the RCP or LVN could do it but the RCP was primarily responsible. She said if a resident was able to turn themselves in the bed, the RCP should still encourage and help the resident turn every 2 hours. She said the RCP should be propping the resident with pillows to offload them when repositioning. She said the LVN should be ensuring the RCP are repositioning every 2 hours and offloading the residents by observation. She said a RN and LVN certified in wound care could stage pressure wounds. She said primarily RNs. She said if a resident needed a pressure wound staged, she would find a RN or contact the DCO. She said the facility had a telehealth option to stage wounds available now. She said the resident's doctor or the medical director was contacted for wound care orders. She said nursing management was responsible for taking the wound care doctor recommendations and making them orders. She said when the wound care doctor rounded on Fridays, he gave the DCO a copy of his recommendations on a piece of paper before he left. She said the wound care doctor left around 10 am. She said the bedside nurses were responsible for doing wound care treatments. She said the nurses documented on the MAR/TAR when wound care was completed. She said if wound care was not documented on the resident MAR/TAR, it could indicate it was not done. She said some residents did not show on the right screen to be done on the facility's computer system. She said skin assessments, wound care treatments, and repositioning/offloading were important to prevent skin breakdown and worsening of wound and not miss anything. <BR/>During an interview on 02/12/25 at 5:25 p.m., RCP H said she had worked at the facility for 2 years. She said she found out a resident had wounds when she changed them. She said she was not really made aware by nursing staff or during report which resident had wounds. She said it depended on the severity of the wound what type of treatment the resident required. She said some resident needed cream and other had dressing changes by the nursing staff. She said RCPs were responsible for repositioning the residents every 2 hours with rounds. She said the residents should be alternated side to side and propped with pillows. She said residents stuck in the bed should have their heels offloaded. She said Resident #93 was stuck in the bed unless PT got her up. She said when she had Resident #93, she went in her room every once in a while, to remind her to turn but not every 2 hours. She said turning and offloading were important to prevent skin breakdown. She said constant pressure caused skin breakdown. <BR/>During an interview on 02/12/25 at 5:49 p.m., the ADCO said wound care was documented on the resident's TAR in the facility's charting system. She said if wound care was not documented in the facility's charting system, it could indicate it was not done. She said the charge nurses were responsible for the resident's wound care. She said the DCO and ADCO should ensure the charge nurses were doing the ordered wound care treatments and documenting wound care on the resident's MAR/TARs. She said doing the resident's ordered wound care treatment was important to prevent decline of the wound, infection, prevent pain and more wounds. She said it was also important to do wound care to monitor the wound and follow doctor's orders. She said completion of the resident's skin assessment was documented on the TAR/MAR and a skin assessment form was also done. She said when she first started, she did not know that a skin assessment form had to be done even if the resident had no skin changes. She said she documented she completed Resident #15's skin assessment on the MAR/TAR but she did not do a new skin assessment form. She said she and the DCO Q were in the process, of putting a process in place to do chart audits to monitor skin assessments and wound care orders. <BR/>During an interview on 02/12/25 at 6:57 p.m., DCO P, who was covering for DCO Q, said she expected nursing staff to follow physician orders. She said she expected nursing staff to document wound care on the MAR/TAR and/or progress note in the facility's charting system. She said if the wound care was not documented on the MAR/TAR and/or progress note, it could indicate it was not done. She said she expected nursing staff to order skin assessment on admission. She said she expected nursing staff to complete skin assessment weekly and with skin changes. She said the DCO ordered the resident's specialty mattresses and the charge nurse should ensure it was on the correct settings. She said all resident benefited from having their heels floated. She said but immobile residents especially needed their heels floated. She said she expected residents to be repositioned and offloaded at least every 2 hours by the RCPs. She said she preferred staging pressure wounds be done by the telehealth system. She said a RN or DCO should stage the resident pressure wounds. She said the ADCO and DCO should be ensuring nursing staff were doing wound care and skin assessments. She said all of these were important for wound prevention and management. <BR/>During an interview on 02/12/25 at 7:34 p.m., the EDO said skin assessment were to be completed every 7 days in the facility's charting system. She said Resident #93 met the criteria for a low air loss mattress. She said the facility had a few specialty mattresses in house and she also could order one if needed. She said the DCO or the nursing staff who rounded with the wound care doctor was responsible for inputting his orders. She said it was important to document wound care and skin assessments to have an adequate clinical record. She said it was important to do wound care and skin assessments to promote wound healing. She said nursing management was responsible for ensuring nursing staff completed skin assessment and wound care. She said nursing management should be doing chart audits to ensure it was happening. <BR/>Record review of a facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .the purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds Skin assessments will be documented at a minimum of every 7 days on a Weekly Skin Assessment . Staging of wounds will be performed by a registered nurse or licensed nurse certified in wound care . Dependent residents will have heels floated while in bed and be turned and repositioned at a minimum of every 2 hours . A licensed nurse will obtain orders from physician for new skin wounds and transcribe onto resident's treatment record for follow up . Specialty mattresses will be implemented for residents with multiple stage II areas, stage Ill, or stage IV pressure injuries . Weekly skin assessments will be documented on the Weekly Skin Assessment every 7 days or less . Licensed nurse will initiate the schedule for the wound form in Point Click Care which automatically triggers every 7 days from day of completion .<BR/>The EDO and DCE were notified of an IJ on 02/11/25 on 5:00 p.m., were given a copy of the IJ template, and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 02/12/25 at 9:40 a.m. and included the following:<BR/>F686- Skin Integrity/Pressure Ulcer<BR/>Plan of Action: <BR/>Resident #93 had wound care orders written on 02/11/25. A weekly wound assessment was completed on 02/11/25. A specialty mattress was placed on Resident #93's bed on 02/11/25. Resident #93's heels were floated effective 02/11/25. <BR/>Skin sweep competed on 02/11/25 to ensure all skin issues were identified and had current orders and interventions in place. Completed 02/11/25 by Director of Clinical Education and designees. <BR/>Director of Clinical Education will educate Director of Clinical Services and Assistant Director of Clinical Services on the process of reviewing new resident admissions electronic health records for completion of order transcription as it relates to wound orders as well as carrying out those orders. Completed 2/11/25 If a RN or wound care certified LVN is not on duty at the time a resident admits, the admitting nurse on duty will utilize Advanced Wound Care Telehealth for a consult. Completed 02/12/25. <BR/>All licensed nurses will be educated by the ADCO or designee on the process of carrying out orders for residents admitted with wounds or obtaining orders if no order accompanies the resident when admitted . Education will also include the completion of weekly skin assessments per schedule. Completion 02/12/25 10:00 a.m. Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift. <BR/>All licensed nurses will receive in-service regarding wound care orders and weekly skin assessments prior to the beginning of their next shift to begin 02/11/25. <BR/>Any newly hired nurses will receive the above education upon hire during orientation prior to taking a shift on the floor. <BR/>Ad hoc QAPI meeting will be held with the Medical Director on 02/12/25 reviewing the policies and procedures for wound care. <BR/>All licensed nurses will be educated on the Skin Management policy regarding general guidelines, prevention, notification, treatment, and documentation the Director of Clinical Education or designee. Completed 2/12/2025 2:00 p.m. Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift.<BR/>All C.N.A.'s will be educated by the Director of Clinical Education or designee regarding pressure ulcer prevention and interventions for residents with pressure ulcers. Completed 2/12/2025 3:00 p.m. Anyone who is not on duty or cannot come in or be reached by phone will be required to complete the in-service prior to working their next shift.? <BR/>Validation/Monitoring Tools? <BR/>Director of Clinical Operations or Assistant Director of Clinical Operations will review all orders for new admissions every day in the morning clinical meeting to ensure orders have been written and carried out for residents admitted with wounds. ?Beginning 02/12/25. <BR/>Director of Clinical Operations or designee will review weekly skin assessments daily to ensure timely completion. Beginning 02/12/25. <BR/>Director of Clinical Operations or designee will review wound physician documentation weekly to ensure any orders are carried out timely. Beginning 02/12/25. <BR/>Director of Clinical Operations and/or designee will review all wound care patients orders, interventions, and skin assessments during Standards of Care Meeting weekly, Beginning 02/12/25.?? <BR/>The Administrator, Director of Clinical Operations and/or designee will review the action plan developed related to obtaining wound care orders, implementing wound care interventions, and weekly skin assessments in QAPI meeting monthly during the next six months. Beginning 02-12-25.? <BR/>This surveyor and team verification of the Plan of Removal from 02/12/25 was as follows:<BR/>Rec[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 2 residents (Resident #23) who were reviewed for indwelling urinary catheter care.<BR/>The facility failed to ensure CNA F followed appropriate procedures and infection control during foley catheter care for Resident #23. <BR/>This failure could place residents at risk for urinary tract infections.<BR/>Findings included:<BR/>Record review of Resident #23's face sheet dated 1/09/23 indicated Resident #23 was a [AGE] year-old female and admitted on [DATE] with diagnoses including paralytic syndrome (unable to move) following a cerebrovascular disease (problem with blood flow to the brain causing damage to the brain), paraplegia (complete or partial loss of muscle function to all or part of the trunk, legs, or pelvic organs), reduced mobility, and hypertension (high blood pressure).<BR/>Record review of Resident #23's quarterly MDS assessment dated [DATE] indicated Resident #23 was usually understood and usually understood others. The MDS indicated Resident #23 had a BIMS score of 13 which indicated she was cognitively intact. The MDS indicated Resident #23 required maximal assistance with toileting and bathing. The MDS indicated Resident #23 required total assistance dressing her lower body. The MDS indicated Resident #23 had an indwelling catheter, was always incontinent of urine, and was frequently incontinent of bowel.<BR/>Record review of Resident #23's care plan revised 11/17/23 indicated Resident #23 was incontinent and at risk for skin breakdown with intervention to monitor for signs and symptoms of infection and notify physician promptly. The care plan revealed Resident #23 was on an antibiotic for a urinary tract infection. Resident #23's care plan revealed there were no focused area or interventions for her foley catheter.<BR/>Record review of Resident #23's order summary report dated 1/09/24 did not reveal an order for a foley catheter.<BR/>Record review of Resident #23's progress notes dated 11/14/23 revealed the nurse had received an order from Resident #23's urologist to place a foley catheter and change it monthly and to start on Macrobid (antibiotic) 100 mg twice a day for seven days for a urinary tract infection.<BR/>During an observation and interview on 1/08/24 at 10:39 AM, Resident #23 was sitting up in her bed and a foley catheter drainage bag was hanging from the side of her bed with a privacy bag. Resident #23 said she had the foley catheter because she was unable to control her bladder or move her lower body. <BR/>During an observation on 01/09/24 at 10:30 AM, CNA F performed foley catheter care on Resident #23 with ADCO C in the room also. CNA F washed her hands, applied gloves, and placed opened trash bags on the BST. CNA F then with her same gloved hands grabbed and moved the BST closer, then pulled back Resident #23's covers, grabbed a package of incontinent wipes off of Resident #23's nightstand and pulled out 4 wipes and then laid the wipes on the resident's incontinent pad. CNA F using the same gloves, then held the bedsheet over the resident's pelvic area with her left hand and used her right hand to pick up a wipe off the incontinent pad and wiped the foley catheter starting at the point closest to Resident and slid the wipe down the foley catheter away from the resident and then placed it in the trash bag on the BST and repeated this process three times. CNA F using the same gloves, then pulled Resident #23's adult brief up between her legs and fastened the sticky tabs and then pulled up the bedsheet over the resident. CNA F then removed her gloves and pulled the rest of the covers up over the resident.<BR/>During an interview on 1/09/24 at 10:48 AM, CNA F said she usually changed her gloves at least twice when performing foley catheter care, but only changed gloves once because she was nervous. CNA F said she laid the incontinent wipes on Resident #23's incontinent pad because she had changed the resident's incontinent pad after Resident #23 had a bowel movement not long prior to going to provide foley catheter care, so she knew it was clean. CNA F said by not changing her gloves prior to starting foley care she could have transferred bacteria to the foley catheter, and the resident could get sick. CNA F said the purpose of cleaning the foley catheter was to prevent infections. <BR/>During an interview on 1/10/24 at 10:55 AM, LVN B said staff should change gloves after touching other surfaces in a resident's room, such as a BST or bedding, prior to performing foley catheter care. LVN B said it would not be appropriate to place incontinent wipes to be used to perform foley catheter care on the resident's incontinent pad. LVN B said it would be cross-contamination and could give the resident a UTI. <BR/>During an interview on 1/10/24 at 1:02 PM, the DCO said CNA F did not perform appropriate foley catheter care and should have changed her gloves prior to starting the foley catheter care after touching multiple surfaces. The DCO said CNA F should not have laid the incontinent wipes on the incontinent pad or handled Resident #23's sheet without removing or changing her gloves. The DCO said improper foley catheter care could cause infections, such as a UTI. <BR/>During an interview on 1/10/24 at 1:28 PM, the ADM said CNA F should have changed her gloves after touching multiple surfaces in Resident #23's room prior to and after performing foley catheter care. The ADM said once you touch multiple things, the gloves were no longer clean. The ADM said by not performing proper foley catheter care, it could pose an increased risk of infection to the resident.<BR/>During an interview on 1/10/24 at 3:45 PM, ADCO C said she had saw enough during the foley catheter care provided by CNA F for Resident #23 to know she needed to do an in-service with her staff on foley catheter care. ADCO C said CNA F did not change her gloves after touching multiple other surfaces prior to performing foley catheter care. ADCO C said CNA F should not have placed the incontinent wipes on the resident's incontinent pad or used the wipes off the incontinent pad. ADCO C said CNA F should not have touched Resident #23's sheet with the same gloves used to clean the foley catheter. ADCO C said the trash bags should have not been placed on the resident's BST either. ADCO C said the foley catheter care that was provided by CNA F for Resident #23 was an infection control issue and could increase the resident's risk of developing a UTI.<BR/>Requested competency or skills check list for CNA F for foley catheter care from the DCO on 1/10/24 at 1:02 PM.<BR/>Requested competency or skills check list for CNA F for foley catheter care from the ADM on 1/10/24 at 3:28 PM and at 4:00 PM the ADM said they did not have competency or skills check list for CNA F for foley catheter care.<BR/>Record review of the facility's policy titled Catheters-Insertion and Care: Indwelling, Straight, Supra-Pubic, and External dated 4/2021 revealed . it was the policy of the community that the resident with a urinary catheter be provided services in a safe and appropriate manner to minimize the risks of urinary tract complications . physician order was required for all catheters . order should include type of catheter, size of catheter and size of bulb, frequency to change catheter and drainage bag .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 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 for 2 of 2 residents reviewed for transmission-based precautions. (Resident #6 and Resident #9)<BR/>The facility failed to isolate Resident #6 and Resident #9 after urine cultures (test checks urine for germs (microorganisms) that cause infections) revealed ESBL (enzymes break down and destroy some commonly used antibiotics) in their urine.<BR/>This failure could place residents at risk for being exposed to health complications and infectious diseases. <BR/>Findings included:<BR/>1. Record review of Resident #6's face sheet printed on 01/10/24 indicated Resident #6 was an [AGE] year-old female and admitted on [DATE] with diagnoses including senile degeneration of brain (a progressive decline in a person's ability to think and remember can be due to a wide range of brain conditions) and need for assistance with personal care.<BR/>Record review of Resident #6's annual MDS assessment dated [DATE] indicated Resident #6 was understood and understood others. The MDS indicated Resident #6 had a BIMS score of 06 which indicated severe cognitive impairment. The MDS indicated Resident #6 was dependent for toilet hygiene and was always incontinent of urine and bowel. <BR/>Record review of Resident #6's care plan dated 10/30/21 indicated Resident #6 was frequently incontinent and at risk for skin breakdown. Intervention labs as ordered. <BR/>Record review of Resident #6's order summary dated 12/01/23-01/10/24 indicated urinalysis (s a test that examines the visual, chemical and microscopic aspects of your urine)with culture (is a test to find germs (such as bacteria or a fungus) that can cause an infection) and sensitivity (checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection), ordered date 12/18/23. The order summary did not indicate isolation for ESBL in the urine. <BR/>Record review of Resident #6's culture and sensitivity results dated 12/19/23 indicated .high pathogens detected .Escherichia coli .antibiotic notes .ESBL (Extended Spectrum Beta-lactamase detected .are usually multi-drug resistant .<BR/>2. Record review of Resident #9's face sheet printed 01/16/24 indicated Resident #9 was a [AGE] year-old male and admitted on [DATE] with diagnoses including schizoaffective disorder (is a mental health condition with symptoms of both schizophrenia and mood disorders), acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), and overactive bladder (is a collection of symptoms that may affect how often you pee and your urgency). <BR/>Record review of Resident #9's quarterly MDS assessment dated [DATE] indicated Resident #9 was understood and understood others. The MDS indicated Resident #9 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #9 required partial/moderate assistance for toileting hygiene and was occasionally incontinent of urine and bowel. <BR/>Record review of Resident #9's care plan dated 01/17/23 indicated Resident #9 had occasional bladder incontinence and was at risk for skin breakdown. Intervention included monitor/document for signs and symptoms of urinary tract infection. <BR/>Record review of Resident #9's order summary dated 01/10/24 did not indicate isolation for ESBL in the urine.<BR/>Record review of Resident #9's culture and sensitivity results dated 11/14/23 indicated .high pathogens detected .Escherichia coli .antibiotic notes .ESBL (Extended Spectrum Beta-lactamase detected .are usually multi-drug resistant .<BR/>During an interview on 01/10/24 at 9:45 a.m., the DCO said the ADCO was the ICP, but she was unavailable due to being out sick today. She said the facility did not notice Resident #6 or Resident #9's lab results that said they had ESBL in their urine. She said the ICP was responsible for reviewing lab results. She said the ICP and LVNs were responsible for developing and implementing interventions to address the results. She said so neither Resident #6 nor Resident #9 were placed on contact isolation. She said it was the facility's policy to place residents with ESBL on contact isolation. She said she was not sure of the duration of the contact isolation period. She said Resident #6 and Resident #9 should have been placed on contact isolation to prevent the spread of ESBL. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said after reviewing the lab results of Resident #6 and Resident #9, she said she felt the lab needed a better way to relay information like ESBL. She said the ICP was responsible for reviewing lab results and coordinating the treatment. She said not placing the resident on contact isolation could have allowed ESBL to spread and other resident to spread it. <BR/>Record review of a facility's Transmission-Based Precaution for Infections policy revised on 10/24/22 indicated .contact .in addition to standard precaution, use Contact precautions (gown, gloves, mask, or face shield if splashing could occur) for resident known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact .the above included epidemiologically important organisms (Multidrug-resistant organisms) .physician order is required to begin transmission-based precaution and to end .add transmission-based precaution to care plan with all interventions based on type .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility did not immediately notify the physician and resident representative of a significant change in in the resident's mental or psychosocial status for 1 of 15 residents (Resident #5) reviewed for resident rights. <BR/>The facility failed to inform the attending Physician and the residents representative for Resident #5 when she barricaded herself in her room on 10/22/2023. <BR/>This failure could place residents at risk for not receiving appropriate care and interventions. <BR/>Findings included :<BR/>Record Review of Resident #5 Face Sheet dated 1/8/2024 indicated Resident #5 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #5's diagnosis included Alzheimer's disease with late onset (progressive decline in episodic memory that begins after the age of 64), Dementia in other diseases classified elsewhere (general term for loss of memory, language, and problem-solving abilities), unspecified severity, without behavioral disturbances and other abnormalities of gait and mobility. <BR/>Record review of Resident #5's Quarterly MDS assessment dated [DATE] indicated resident was understood and usually able to understand others. The MDS indicated a BIMS score of 3 indicating Resident #5 was severely cognitive impaired. Resident #5's MDS indicated physical behaviors, verbal behaviors and other behavior symptoms not directed toward others for 1-3 days during the look back period. <BR/>Record Review of Resident #5's care plan revised date 10/23/2023 indicated Resident #5's focus of care on Alzheimer's with late onset with fluctuations between stages with interventions initiated on 6/28/2023 of resident can move around room or facility with use if a walker but requires assist for long distances with occasional use of wheelchair. Resident #5's Care plan revised on 8/4/2023 indicating the resident's mobility will be improved/restored by use of adaptive equipment such as crutches, cane, walker, or wheelchair. Resident #5's care plan revised on 7/31/2023 indicated to monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, except course, declines in function. Resident #5's Care plan revised on 8/4/2023 indicating the resident's mobility will be improved/restored by use of adaptive equipment such as crutches, cane, walker, or wheelchair. Resident #5's care plan revised on 7/31/2023 indicated to monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, except course, declines in function. Resident #5's care plan indicated impaired cognitive function and thought processes but did not address behavioral issues. <BR/>Record Review of the facility investigation summary provided by the Administrator on 1/8/2024, not dated or signed by the author, indicated an incident involving Resident #5 occurred on 10/22/2023, on the night shift. The report indicated Resident #5 refused care during the entire night shift on 10/22/2023, where Resident #5 barricaded herself in her room. The night shift reported they were able to check on Resident #5 through a small opening in the door. Resident #5's representative made an allegation of neglect to the facility's DCO on 10/23/2023 at 1:30 pm. He reportedly made the statement that he did not believe that the staff adequately checked on/monitored Resident #5 during the previous night. The investigation summary indicated that a thorough review of all statements by residents and staff did not support the allegations of neglect. Actions taken post-investigation reflected: all community staff were provided with in-service education on resident abuse and neglect, education on notifying the DCO and/or ADCO immediately if a resident barricaded themselves in their room. The DCO completed 1:1 education with the charge nurse on duty during time of investigation. <BR/>Record Review of a witness statement, dated/signed by CNA M on 10/25/2023, indicated CNA M made first rounds at an unknown time. Resident #5 refused care x 2 attempts and then was reported to the charge nurse. At 12 am the resident was still sitting in her chair with the door open and continued to refuse care and was reported to charge nurse. The next round started at 2 am and the door was closed. The CNA attempted to open the door but could not and notified the charge nurse. Multiple attempts between rounds were made according to the statement. During med pass rounds starting at 4 am, CNA M still could not get in the door and reported to the charge nurse. CNA M went to the room before leaving their shift and reported to 6 a.m.-2 p.m. shift aide about not being able to gain access to room. <BR/>Record Review of Resident #5 Progress note dated 10/23/2023 at 11:52 p.m. revealed LVN G noted that Resident #5 was sitting in front of the restroom door falling asleep in her chair. LVN G offered to assist Resident #5 to bed, and the resident refused. Resident #5 told LVN G that she did not want to be bothered. LVN G gave Resident #5 a moment to calm down, then returned to her room and Resident #5 had the door open slightly with her wheel to her wheelchair blocking the door and refused care. LVN G noted he would attempt contact later. <BR/>Record Review of Resident #5 Progress Note dated 10/23/2023 12:22 am revealed LVN G noted Resident #5 refused assistance and slammed the door and parked the wheelchair behind the closed door and would not open the door. Resident #5 refused to move from behind the door. <BR/>Record review of Resident #5 Progress note dated 10/23/2023 at 2:25 am revealed LVN G documented that Resident #5 was still behind door in her wheelchair. <BR/>Record review of Resident #5 Progress note dated 10/23/2023 at 4:45 am revealed LVN G documented he received report from the RCP who attempted to speak with Resident #5 through the door but could not make out what Resident #5 was saying. LVN G attempted to push on the door while turning the doorknob and was able to get the door open enough just to see Resident #5. Resident #5 was still seated in wheelchair behind the door holding the curtain. Resident #5 yelled Don't do that, I'm putting my socks on. LVN G said ok and advised Resident #5 he would be back to give her time to calm down. At 5:15 am after passing morning medications, LVN G returned to room to see if Resident #5 had moved. Resident #5 remained seated right behind the door in her wheelchair. Resident #5 stated Leave me alone. LVN G reported during the morning shift change that the resident blocked the door and did not want to be bothered. LVN G noted that Resident #5 was still awake and alert sitting in wheelchair at the end of shift. <BR/>Record review of Resident #5 Progress note dated 10/23/2023 at 8:30 am revealed LVN H noted that LVN G reported at 6:15 am during the morning shift change that Resident #5 was sitting in wheelchair against the door throughout the night and would not let anyone in room. After the report was received at 6:15 am, LVN H went to Resident #5 room and was able to push the door open about 2 inches, enough to see her feet stretched out in front of her and could see her striped shirt. LVN H noted it appeared Resident #5 was sitting on the floor with her right shoulder against the door. LVN H asked Resident #5 to move away from the door so she could come in. Resident #5 yelled Give me a minute, don't do that. LVN H notified the DCO and ADCO at 6:19 am and explained the situation. LVN H returned to the room and where Resident #5 continued to refuse to move. LVN H notified the resident's hospice provider at 6:47 am. LVN H called the DCO again at 6:54 am and LVN H called Resident #5'srepresentative to notify him of the situation. Representative arrived at facility at approximately at 7:30 am and Plant Operation Manager J was able to the open window from the outside to get into room and open the door. LVN H documented she observed Resident #5 sitting on her bottom on the floor with her right shoulder toward door and feet stretched out in front of her. Resident #5 was observed to have multiple red markings on back of right shoulder and she c/o pain but was able to move her arm. Vital signs documented at 8:30 am reflected blood pressure 136/85 , HR 92, RR 18 Temperature 97.6 degrees Fahrenheit, and Oxygen 94% Room Air. LVN H noted that Resident #5 appeared more confused than normal. Resident #5 was assisted into her wheelchair and onto the bed. The RCP and ADCO noted to have washed Resident #5 up and changed her clothes. Resident #5 was served breakfast and given her morning medications. <BR/>Record review of In-service dated 10/23/2023 RE: Notification. Description- Nurses and RCP's: Anytime a resident is in a room barricaded please notify the DCO and ADCO immediately. <BR/>Record Review of Resident #5's Hospice Comprehensive Assessment and Plan of Care Updated report dated 6/30/2023 revealed Resident #5 had become more forgetful, delusional, and confused resulting in more combative behaviors toward staff providing ADL care. <BR/>Record Review of progress notes from 10/9/2023 to 1/10/2024 revealed resident had behaviors of refusing care, medications, and increased episodes of crying. Resident #5 did not have any previous reports of barricading herself in her room. <BR/>Observation of Resident #5 on 1/9/2024 at 8:00 am revealed the resident was observed sitting up in bed eating breakfast. Resident #5 said she had a good night and smiled during the conversation. <BR/>Observation of Resident #5's room on 1/9/2024 at 10:25 am with Plant Operations Manager J revealed the bathroom door swung open toward the hinges of entrance of Resident #5's room door which blocked the opening of the entrance door. Observed the entrance door opening approximately 2 inches when the bathroom door was fully opened. <BR/>Attempted Interview with CNA M on 1/9/2024 at 1:09 PM but was unable to leave a message and did not receive a return call by exit date 1/10/2024.<BR/>During an interview on 1/8/2024 at 1:28 PM, Resident #5 said she did not have any concerns about facility other than she has lots of falls. Resident #5 said she was not interested in talking. <BR/>During an interview on 1/8/2024 at 2: 04 PM, Resident #5's RP said the facility reported to him on 10/23/2023 Resident #5 had barricaded herself in her room the previous night. Resident #5's RP said a male nurse was taking care of her that night. Resident #5 was lying down on the other side of the door. Resident #5's RP said that the maintenance man walked by while he was there, and they decided to walk around to window and determined it was open. Resident #5's RP said that his mother was on the floor against the door and was wet of urine. Resident #5's RP said the nurse did not notify him that his mother was barricaded in her room, refused access to staff, and refused to take her medications throughout the night. Resident #5's RP said if he had been notified, earlier in the situation, he could have come to facility and intervened preventing his mother from lying in the floor for extended period of time in her own urine. <BR/>During an interview on 1/9/2024 at 11:53 AM, LVN H said it was reported by the night shift nurse that the resident had barricaded self in her room and Resident # 5 was in her wheelchair. LVN H went down to check on the situation and was only able to open the door about an inch. She stated that the night shift nurse had already left. LVN G reported to her that he was able to see the resident in her wheelchair 20 minutes prior. LVN H said she felt like Resident #5 was on the floor when she attempted to visualize Resident #5 inside her room. LVN H immediately notified the DCO, Physician or representative. LVN H said Resident #5's RP arrived at facility and the Plant Operations Manager and Resident #5's RP went to the window and was able to gain access through the outside window. LVN H reported Resident #5 was wet from incontinence. LVN H said Resident #5 was confused and said Resident #5 had been experiencing hallucinations, talking about people trying to hurt her all night. LVN H said not being able to access the resident could result in fall with injury such as hitting head or worse injury. <BR/>During an interview on 1/9/2024 at 1:09 PM, LVN G said he arrived at facility on 10/22/2023 at 9:30 p.m . and the resident was sitting in her wheelchair. LVN G said he made his rounds to first check vital signs. LVN G said that he did not observe weakness with Resident #5. LVN G said the aide came in at 10 p.m. and made rounds and filled ice. LVN G said Resident #5 was agitated and upset the whole night. LVN G said the resident's bedroom door was wide open all night. LVN G said Resident #5 has an attitude and did not want to be bothered. LVN G said he noticed between 3:30 a.m. - 4 am that her door was closed, and Resident #5 was up all night. LVN G said after Resident #5's door was observed closed, he attempted to open the door and Resident #5 told him Stop, I am back here. LVN G said he was able to open the door enough to stick his head in and visualize her sitting up in her wheelchair. LVN G said he was not able to pass morning medications to the resident due to her barricading herself in room and only reported to the oncoming nurse. <BR/>During an interview on 1/10/2024 at 1:30 PM, LVN G said he relayed information to the nurse the next morning concerning Resident #5 being barricaded behind the door and refusing care. LVN G said CNA M did report Resident #5 was refusing care and she refused care all night. LVN G said he made 3 attempts to provide care. LVN G was unable to determine how many times a resident refuses care before contacting the family, physician, or administrator per the facility policy. LVN G said he received advice from staff that was on duty at the time on what to do. LVN G said he spoke with another nurse on another unit. LVN G said that he did have access to an on-call nurse after-hours. LVN G said that he was hoping to coach Resident #5 down to a better mood and did not call the on-call nurse. LVN G said he felt it was appropriate care at the time, so he sent CNA M to check and coach Resident #5. LVN G said he does not feel Resident #5 wants a male nurse. LVN G said he was concerned Resident #5 may have some sundowners . (Increased confusion with Alzheimer's and dementia may experience from dusk through night)<BR/>During an interview on 1/9/2024 at 3:12 PM, the DCO said she expected the staff to call and report to the DCN/ADCO/Admin for help and guidance on a barricaded resident. The DCO said she was unsure of any policy on barricaded residents. The DCO said she expected staff to notify family of a barricaded resident. The DCO said she expected staff to notify the family if the resident refused care 3 times and that included monitoring the resident. The DCO said if a resident was barricaded behind a door and not monitored appropriately, she could have adverse symptoms such as shortness of breath , elimination issues, cardiovascular issues, depending on disease process, including death. DCO said she was updated on Resident #5's condition once she was able to be assessed.<BR/>During an interview on 1/9/2024 at 3:33 PM, the ADCO said the morning shift nurse reported to her that Resident #5 was barricaded behind the closed door throughout the night. The ADCO said she expected the night shift nurse to report any issues after-hours to the on-call nurse or administration. The ADCO said LVN G reported that he could see part of her such as her legs. The ADCO said after 3 attempts, LVN G should have contacted the ADCO/DCO/ADM. The ADCO said with Resident #5 barricaded behind a closed door could result in adverse events such as stop breathing, injury or death. <BR/>During an interview on 1/10/2024 at 12:20 PM, the Administrator said she expected the nurse and staff to report changes in condition to the family, MD, and administration. Administrator said Resident #5 had the right to refuse care but she expected in this situation, that after a couple of hours, the family, MD and ADM or nurse on-call to be notified. The Administrator said LVN G was able to see the resident through a crack in the door and was able to visualize her. Administrator said their ability to monitor Resident #5 was limited. <BR/>Record review of a policy titled Incident and Accidents, dated 3/1/2017 revealed Accidents or incidents involving residents shall be investigated and reported to the Executive Director of Operations .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure treatment and care was provided to meet professional standards of practice for 1 of 7 residents reviewed for quality of care. (Resident #1)<BR/>The facility failed to ensure Resident #1 was provided a timely assessment when she experienced a change of condition. <BR/>LVN A noted Resident #1 had a change in condition on 02/09/24 around 2:00 p.m. but LVN A did not assess the resident at that time. At 8:00 p.m., Resident #1's oxygen level was 87 percent and she had vomited a black substance. The resident was also lethargic/unresponsive at dinner and unable to eat with assistance. EMS was called and placed a face mask on Resident #1 at 15L of oxygen and transported the resident to the ER where she was diagnosed with sepsis secondary to pneumonia. The resident was intubated and placed in ICU.<BR/>An Immediate Jeopardy (IJ) was identified on 03/12/24. The IJ template was provided to the facility on [DATE] at 1:05 p.m. While the IJ was removed on 03/13/24, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. <BR/>These deficient practices could place residents at risk of not being assessed for a change of condition that may require treatment alterations and could lead to additional pain and suffering. <BR/>Findings included:<BR/>Record of Resident #1's face sheet dated 3/5/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were congestive heart failure, bipolar disorder, schizoaffective disorder (mental health disorder including symptoms such as hallucinations, delusions, disorganized thinking, mania, and depression), dementia, and lack of coordination.<BR/>Record review of Resident #1's admission MDS dated [DATE] indicated moderate cognitive impairment. The resident required supervision or touching assistance with eating. The resident required partial to moderate assistance with hygiene showers, upper body dressing, lower body dressing. The resident required partial to moderate assistance with transferring from chair to bed and toilet.<BR/>Record review of Resident #1's care plan dated 1/5/24 indicated a focused area of the resident was at risk for adverse consequences related to receiving antipsychotic medications with a diagnosis of schizoaffective disorder. Some of the interventions were: Monitor resident for side effects of anti-anxiety medication, including but not limited to hypotension, sedation, and increase anxiety. Monitor the resident for side effects of anti-depressant medication's, including but not limited to increased confusion, changes in appetite, and changes in sleep pattern. Monitor the resident for side effects of antipsychotic medication's, such as muscle, rigidity, changes in appetite, sleep, disturbances, tardive, dyskinesia (side effect of antipsychotic medications that cause involuntary movements of the head and body including lip smacking, grimacing, eye blinking, and repetitive movements), seizures, and cardiac changes.<BR/>Record review of Resident #1's nursing note indicated:<BR/>On 2/8/24 at 1:41 p.m. resident continued to be very sleepy, did not wake up to take meds and ate 30 percent of lunch. She was in the wheelchair in the hallway sleeping. Her vital signs were stable.<BR/>On 2/9/24 at 5:09 a.m. the resident was in bed with eyes closed easily arouse with respirations even and unlabored. No shortness of breath noted discontinued Venlafaxine HCL day three no adverse reactions. No signs and symptoms of sedations. The residence behavior within normal limits. No pain or discomfort observed. <BR/>At 8:50 a.m. the resident blood pressure medications metoprolol and lisinopril were held due to blood pressure of 93/51. <BR/>At 8:34 p.m. medications were held due to residence status.<BR/>At 8:50 p.m. the resident was sent to the hospital due to change in condition. (There were no other notes or assessments.) Signed by LVN A<BR/>Record review of Resident #1's EMS report dated 2/9/24 indicated arrived at the scene at 8:33 p.m. Upon arrival at the scene the patient was lying in bed, mumbling, and reaching aimlessly into the air. The patient could tell us her name and the staff (LVN A) stated she was a [AGE] year-old female, and she started acting strangely at approximately 2:00 p.m. The patient was placed on monitor and vitals were obtained her temperature was 100.6 Fahrenheit. blood pressure was 92/61, respirations were 18 and labored and her oxygen stat was 93 percent. The sounds in her lungs revealed bubbling and gurgling. She was given a nebulizer treatment which improved her lung sounds and was placed on 15 mL of oxygen via facemask. The patient was transported to the ER and arrived at the destination at 9:15 p.m. The chief complaint was, altered consciousness, and lethargy (unusual decreased consciousness) for at least six hours and fever. <BR/>Record review of Resident #1's emergency hospital records dated 2/9/24 with the arrival time of 9:20 p.m. indicated the patient was found in respiratory distress, low blood pressure and rapid heartbeat. On arrival the patient was in respiratory distress on a non-breather mask at 15 L oxygen. The nurses at the nursing home stated there was a possible aspiration (when food, liquid, vomit, or foreign object enters the lungs) episode today. Her blood pressure was 124/68, her pulse was 142, her temp was 103, her oxygen stat was 94%. The diagnosis was sepsis (the body's response to an infection or widespread inflammation) secondary to pneumonia. The patient will be transferred to an ICU for further management due to the complexity of the case and being a full code. Patient received from a nursing home with respiratory distress with a stat of 87 per nursing home. Staff said the condition noted at 2:00 p.m. The patient vomited around that time. She was transferred to the hospital on 2/10/24 at 2:00 a.m. <BR/>Record review of Resident #1's hospital records indicated the resident was admitted to their facility on 2/10/24 on arrival she was on 12 L nasal cannula and unresponsive with blood pressures in the 80 systolic and O2 stats in the 80s. She was emergently intubated (to establish an airway and prevent secondary brain injury).<BR/>During an interview on 3/5/24 at 3:36 p.m. the DON said she received a message from LVN A on the night of 2/9/24. She said LVN A sent Resident #1 to the ER because she was not acting herself. The DON said LVN A said she contacted NP F and she said to send Resident #1 out. The DON said LVN A said Resident #1 did not eat supper and looked like she vomited something black. The LVN said Resident# 1's O2 stat was at 87 percent. The DON said the facility Interact transfer form was not in the clinical record and there was nothing in the nursing notes about Resident #1's condition prior to hospitalization. The DON said from what she saw in Resident #1's clinical record LVN A did not make the clinical document, she had likely assessed Resident #1 because she told her the blood pressure and oxygen status, but she did not document anything. <BR/>During an interview on 3/5/24 at 5:05 p.m. RN C said Resident #1 had a steady decline. She said Resident #1 would repeat things over and over and over and sit in the hallway and yell out. She said the doctor put Resident #1 on Venlafaxine to aide with her behaviors. RN C said Resident#1 had been a lethargic for several days, the medications were reduced and discontinued. She said on 2/9/24 Resident #1 was sitting at the assisted dining table and refused to eat. The RN said Resident #1 appeared to be lethargic. She said Resident #1 would not wake up, and just blink, that was all. The RN said she was the one who tried to assist Resident #1 to eat and when she tried to put something in her mouth, she would not respond. She said the Resident #1 did not appear to be with it enough to chew. The RN said she was afraid Resident #1 would choke so she refused to feed her. She said she was not her nurse but had observed the resident was not her usual self for several days, and she was just assisting in the dining room. RN C said she thought Resident #1 was just having symptoms from the medications.<BR/>During an interview on 3/5/24 at 5:07 p.m. LVN G said Resident #1 had been sleepy for the last couple of days. She said she worked with the Resident #1 the day before she was hospitalized on [DATE] and the Resident seemed fine. She said Resident #1's vitals were within normal limits for Resident #1. She said Resident #1 was not coughing or wheezing and had no rattle. The LVN G said Resident #1's voice was raspy as always but not wet. She said the Resident #1 was put on some new medications because she would sit in the hallway and yell and scream. The LVN said when most residents that are put on the medications, they are usually sleepy the first few days. She said there were some changes with the Venlafaxine and it was discontinued. She said she administered the medication as prescribed. She said Resident #1 would wake up and respond when spoken to.<BR/>During an interview on 3/5/24 at 5:11 p.m. CNA B said she worked at the facility for about 1 year. She said when Resident #1 first arrived at the facility she would repeat things over and over. She said Resident #1 had a moderate decline. She said she was at the facility on 2/9/24 when Resident #1 was sent to the hospital. She said when she arrived that day at 2:00 p.m. Resident #1 could hardly do anything. She said Resident #1 was just sitting in the wheelchair with her head back and appeared to be asleep but was hard to awaken. She said it was like Resident #1 could not hold her head down at all. CNA B said Resident #1 had been kind of out of it (real sleepy and not herself, but she would respond) for the last couple of days, however on that day she would barley respond. She said all the nurses were aware the resident had a decline; Resident #1 would usually be placed right in front of the nurses' station. CNA B said the nurses said Resident #1 was like that because some medication they had put her on made her sleepy. CNA B said Resident #1 would not eat supper on 2/9/24, she would not open her mouth or hold her head down to take a bite. She had informed LVN A Resident #1 could not eat. She said that night around 8:00 p.m. when she was putting Resident #1 to bed, she had some black stuff coming out of her mouth and she told the nurse. CNA B said it was at that time the LVN A came and looked at Resident #1 and sent her out to the hospital. <BR/>During an interview on 3/11/24 at 11:20 a.m. the DON said she saw LVN A but did not talk to her about Resident #1. She said she thought the LVN could not complete a note or an assessment after the Resident #1 was deceased . The DON said it appeared LVN A came in at 2p on 2/9/24 and failed to assess the resident when a change in condition was noted or to document what was going on with Resident #1.<BR/>During a telephone interview on 3/11/24 at 11:25 a.m. LVN A said when she came to work on 2/9/24 at 2:00 p.m. Resident # 1 was in her wheelchair asleep and had her neck/head back. She said Resident #1 was usually up talking but she was not her normal self. She said when they went to supper the resident did not eat anything. She said around 8:00 p.m. she texted NP F and she told her Resident #1 need to be sent out. She said she texted the physician at the same time around 8:00 p.m. The LVN said she checked her vital signs and everything. She said she did not remember if she had written anything down or not. She said she worked PRN and did not know what was going on with Resident #1. She said she assessed her but did not complete the assessment because she did not have time. She said after they laid Residen t#1 down that night her breathing was shallow and her 02 sat was under 90. She said Resident #1 was laying in the bed reaching in the air. The LVN said Resident #1 did not have a fever and EMS did not say anything about her breathing. <BR/>During an interview on 3/11/24 at 11:44 a.m. NP F said she felt the nurses were good about reporting things, and she received mixed messages about Resident #1. She said one nurse would report one thing and one nurse would see something different. She said she had reports that Resident #1 would eat good one day and one day not. She said the reports that she received about Resident #1 were not consistent. She said she was shocked when they reported the resident had died, it was totally unexpected. On 2/9/24 at 8:04 p.m. she received a text from LVN A. She said the text stated Resident #1 was not acting herself, 02 stat was 87 at the time, bp was 117/78, and heart rate 67. NP F said Resident #1 was started on a high dose of Venlafaxine because she appeared to be able to tolerate high doses of medications. She said everyone was different, they held it, decreased it, watched it, and discontinued the medication. She said she was not aware if anyone called her to restart the medications or when she told the staff to start Resident #1 back on the Venlafaxine. However, from the calls she had received the resident did not tolerate the medications well and she had discontinued it on 2/7/24 due to reports of continued lethargic behaviors. She said she did want Resident #1 to be monitored for low blood pressure and fever for drug interactions with the Venlafaxine and Resident #1's current medication for possible serotonin overdose. She said the Serotonin Syndrome had several different symptoms and could cause a resident medical distress. She said that was why she wanted the resident checked for fever and low blood pressure. She did not know that those checks did not appear to be done. She said she had gotten some calls from LVN G and RN D about Resident #1 but no acute calls. <BR/>During an interview on 3/11/24 at 12:00 p.m. RN D said she had worked with Resident #1 the day before she had gone to the hospital. She said Resident #1 was sleepy but would respond. She said other than being sleepy she was her normal self. She said the resident did not have a cough and had taken her medications without incident. She had eaten only part of her lunch that day, but she did not note any distress. <BR/>During an interview on 3/11/24 at 12:05 p.m. CNA H said when she arrived at the facility on 2/8/24 at 6:00 a.m. She said Resident #1 was extremely hard to get up that morning. She said Resident #1 seemed overly tired. She said Resident #1 was less coherent. CNA H said normally Resident #1 wanted to go out to smoke or go to the dining room to wait on breakfast but said did not want to do any of those things. She said for the last few days Resident #1 would sleep quite a bit. She said most days she would sleep some because she may have been up the night before. She said on that day she was sleeping and not eating. CNA H said RN D was the nurse on 2/8/24 and she knew Resident #1 was more tired than usual because she had told her. She had also placed the resident close to the nurse's station. <BR/>During an interview and record review on 3/11/24 at 3:40 p.m. the DON said review of the EMS and hospital records indicated LVN A had told the hospital Resident #1 had a change in condition around 2:00 p.m. The DON said she was not made aware of the change until around 8:00 p.m. She could not say why the nurse had waited 6 hours before assessing Resident #1 and sending her out to the hospital. <BR/>During a telephone interview on 3/11/24 at 3:50 p.m. LVN A said she told the hospital the Resident #1 had thrown up at about 2:00 p.m. and it was black. They had chocolate cake but she did not know if it was the cake or not. She also told the hospital Resident #1 had a change in condition around 2p. <BR/>During an interview on 3/12/24 at 9:41 a.m. the NP F said there were no reports of any changes with Resident #1 until around 8:00 p.m. on 2/9/24.<BR/>During an interview on 3/12/24 at 10:01 the BOM said the family member texted her the day Resident #1 went to the hospital to say she seemed over medicated they could not get her to wake up. She said she had told the nurse. The family member had texted her again, but she did not recall exactly what the text said. <BR/>During a telephone interview on 3/12/24 at 10:30 a.m. a family member said on the day Resident #1 went to the hospital her family member called her crying and upset because Resident #1 could not seem to get her breath to talk. That Family member said they were there on 2/9/24 about 2 or 3 in the afternoon. The family member said whoever she talked to told her Resident #1 had been like that for two or three days. The family member said Resident #1 was sitting in the wheelchair with her head back and she could not get her to really wake up. The family member said Resident#1 had a bruise on her face that looked like it was a few days old. The aide told her the resident had fallen in her room a few days earlier. The family member said they wheeled Resident #1 out by the nurse's station because they were concerned, she was not doing well. The family member said they talked to the nurse behind the nurse's station and asked what was going on with Resident#1? The family member said she did not really get an answer and was upset and confused when she left the facility. She thought something was wrong, but the staff acted like Resident #1 was fine, but she was not. The family member said the Resident had black stuff coming out of her mouth. She said they could not get her head down so she could clean her mouth, it looked like she had food in her mouth. They said Resident #1's neck was in almost an awkward position held back and she did not appear to be able to lift her head. The family member said when Resident #1 arrived at the hospital food was stuck to the top of her mouth, and it was so bad they had to throw the dentures away. The food looked like it had been there for a long time. The family member said the Resident #1's neck was held in a back position when she was in the hospital even while lying in the bed. It was like her neck was paralyzed in that position.<BR/>During an interview on 3/13/24 at 1:21 p.m. CNA K said Resident #1 was not herself at all. She said some nurses they reported to would act and others would not. She said Resident #1 had a tremendous change. She was loud and very vocal. They changed her medications, and she was zonked out, sleeping like she was not in the world. She said they reported their concerns to the nurses, and they would say it was just the medication. CNA K said the last 3- or 4-days Resident #1 was in the facility, it did not matter if Resident #1 was up in the chair or in bed her head was back, her mouth was open, and she was asleep. <BR/>During an interview on 3/13/24 at 1:45 p.m. RN D said she was thinking Resident #1's problem was the change in medications. She had seen her in the hallway picking things out of the air and she was still asleep. She said she had not really assessed her but if someone told her black stuff was coming out of her mouth, she would have assessed her for sure.<BR/>During an interview on 3/13/24 at 4:26 p.m. RN C said she was not Resident #1's nurse on 2/9/24. She said at dinner she tried to feed Resident #1, and she could not eat. The RN said she refused to feed Resident #1 and told the aide not to even try. She said it appeared Resident #1 was unable to hold her head down to eat. She sat with her head back like she was asleep and was not responding appropriately at all. She said LVN A was in the dining room and heard the interactions about Resident #1 not being able to eat dinner. RN C said after the Resident #1 had gone to the hospital and LVN A asked if she had feed the resident anything. She said LVN A said something was coming out of Resident #1'smouth. RN C said Resident #1 had a change in condition, she was sleeping and could not be awaken, her head was back, and she could not eat. She said she asked the DON today what she should have done? She said Resident #1 was not her resident, and she noted a change in condition. LVN C said the DON told her if the other nurse did not assess the resident, then she needed to assess, make all the necessary calls and documentation.<BR/>Record review of the facilities change in a resident condition or status policy, last revised May 2017, indicated our facility shall promptly notify the resident attending physician changes in the resident medical condition. The nurse will notify the resident attending physician on call when there has been a significant change in the resident, physical, emotional, or mental condition. A significant change of condition is a major decline or improvement, in the resident status that will not normally resolve itself without intervention impacts more than one and impacts more than one area of the resident health. Prior to notifying the physician or healthcare provider the nurse will make detail observations and gather relevant pertinent information for the provider, including for example, information provided by the in-communication form, the nurse will record in the resident record information relative to changes in the resident medical mental condition or status.<BR/>The Administrator was notified on 03/12/24 at 1:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 03/12/24 at 1:05 p.m. and a Plan of Removal was requested. <BR/>The facility's Plan of Removal was accepted on 03/13/24 at 11:12 a.m. and included: <BR/>[Plan of Removal <BR/>F-684 <BR/>Action: <BR/>The Director of Infection Prevention will provide education on company's policy related to assessment of a resident when they experience a change of condition to the DCO. 3/12/2024 The employee that failed to follow the facility policies regarding parameters will receive not only the education outlined below, but will also receive disciplinary action. <BR/>In-service on company's policy related to assessment of a resident when they experience a change of condition to all nurses conducted by the DCO/Designee. A copy of the inservice regarding change of condition will be provided for review. The policy and procedure outlines examples of occurrences that would necessitate notification of a change of condition. If an aide reports a change in condition, the nurse is expected to evaluate the resident and make a determination of necessary additional treatment. The facility assessment form will be completed when residents are sent to the hospital. All nursing staff expected to be in-serviced prior to the next shift worked. All nursing staff expected to be in-serviced by 3/13/2024. This education will also be included in all new nurse orientation for any newly hired nurses. Nurse aides were re-educated on utilization of the Stop and Watch notification in Point Click Care for changes in condition on 3/13/24. Nurses were educated on reviewing the PCC dashboard for the automatically triggered alerts with visual demonstration on 3/13/24.<BR/>DCO/Designee to complete chart reviews daily during the clinical meeting to ensure thorough and accurate assessments are completed when a resident experiences a change of condition per policy. 3/12/2024. In reviewing resident charts, the DCO or designee will monitor for occurrences such as medication changes, falls and resident discharges to the ER. A chart audit was conducted by the DCO/Designee on 3/12/24 to see if any residents experienced a change in condition that required assessment. No additional concerns were identified. <BR/>The Medical Director has been notified of the immediate jeopardy and reviewed current policy and procedures assessment of a resident when experiencing a change of condition. Plan of action reviewed with Medical Director with no changes to the current policy. This practice will be reviewed monthly with the QA committee to ensure we are in compliance with assessments of residents who experience a change of condition per policy and procedures. 3/12/2024 ]<BR/>On 03/13/24 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:<BR/>Review of the staff disciplinary actions indicated they were completed. Review of the Chart audits on medications indicated they were completed and all residents on blood pressure medications had parameters in place. Review of the medication competencies on medication pass were completed for the staff that were present. <BR/>Review of disciplinary action for LVN A dated 3/13/24 indicated the employee had failed to notify the physician and provide an assessment for a resident prior to hospitalization. The employee will follow facility policy regarding physician notification and assessing a resident when they have a changing condition. The first employee will timely and accurately document all the Above in the computer system. Any future violations of this policy will result in termination. The form indicated spoke to the employee on the phone and she will be signed up upon return to work. <BR/>Interviews were conducted with facility staff on 3/13/14 between 12:59 p.m. and 4:59 p.m.<BR/>At 12:29 p.m. CNA I worked 6a to 2p<BR/>At 1:07 p.m. CNA J worked 6a to 2p<BR/>At 1:21p.m. CNA K worked 6a to 2p and 10 p to 6a<BR/>At 1:45 p.m. RN D worked 6a to 2p<BR/>At 2:16 p.m. LVN L worked 6a to 2p and 2p to 10 p<BR/>At 2:28 p.m. CNA M worked 2p to 10 p<BR/>At 2:41 p.m. CNA N worked 2p to 10 p<BR/>At 3:05 p.m. CNA O worked from 2p to 10 p<BR/>At 3:58 p.m. LVN P <BR/>At 4:12 p.m. LVN Q worked form 10 p to 6 a<BR/>At 4:20 p.m. LVN R worked form 10 p to 6a<BR/>At 4:26 p.m. RN C worked 2p to 10 p<BR/>At 4:37 p.m. worked 6a to 2 p<BR/>Interviews with nurses indicated they were knowledgeable about the in-services provided regarding residents being assessed in a timely manner. Contacting the physician and documenting the residents change in the facility computer system. Interviews with nurse aides indicated they were knowledgeable regarding reporting a change in condition and if the nurse did not act, they would notify the immediate supervisor. They were also knowledgeable about documenting the change in the facility computer system. <BR/>During an interview on 3/13/14 at 2:47 p.m. the Administrator said she worked at the facility for about two years. She said the incident with Resident #1 was not reported to her. She said they were all surprised the resident had gone to the hospital and passed away but did not think there were any issues at the facility regarding the Resident. She said if a resident admits, discharges, or passed away it was communicated in the morning meetings. She said they were going to train and educate and complete more monitoring of staff actions. She said they will conduct a more in depth review in the clinical meeting, we will tackle problems that they find or that are brought to their attention.<BR/>During an interview on 3/13/24 at 4:59 p.m. the DON said she completed chart audit, regarding blood pressure medications and went through to see who had parameters. She said they audited new orders on medications. The DON said residents that did not have blood pressure have parameters they put those in place. Had one resident had 120/80 as a blood pressure parameter and clarified with the doctor. She said she completed medication administration competency with nurses that have been in the building. The DON said nurses should use common nursing judgement in some situations. She said they will make sure these things did not happen going forward. They had implemented standing orders, for blood pressure medications. The DON said nurses were in serviced and reminded of things they should already be doing. She said daily she would print out order list to monitor and print out vitals daily just to look over. The DON said the aides were also in serviced and reminded of things they should have already been doing. She said the stop and watch alert is not new. She said all staff are aware if there was a change in condition with a resident to report it and if no action is taken go to the next level. <BR/>The Administrator and DON were informed the IJ was removed on 3/13/24 at 5:23 p.m.; however, the facility remained out of compliance with a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure that residents were free of significant medication errors for 2 of 13 residents (Residents #1 and Resident #93) reviewed for medication administration.<BR/>The facility failed to ensure Resident #1's Protonix (is used to treat certain conditions in which there is too much acid in the stomach) was scheduled before meals for optimal desired results. <BR/>The facility failed to ensure Resident #93's prescribed Midodrine (is used to treat low blood pressure (hypotension)) was not administered when her blood pressure was outside of the ordered parameters 2/6/25, 2/7/25, 2/8/25, 2/9/25, 2/10/25, and 2/11/25. <BR/>The facility failed to ensure Resident #93 was administered Midodrine with meals per the physician's order. <BR/>These failures could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.<BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet dated 01/10/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including Asperger's syndrome (is a term sometimes used to describe a developmental disorder that's part of the autism spectrum disorder (ASD)), muscle weakness, and constipation. <BR/>Record review of Resident #1's admission MDS assessment dated [DATE] indicated Resident #1 was understood and had the ability to understand others. Resident #1 had a BIMS score of 09 which indicated moderate cognitive impairment.<BR/>Record review of Resident #1's care plan dated 12/15/24 indicated Resident #1 had potential for complications, discomfort, related to GERD (is a common condition in which the stomach contents move up into the esophagus). Intervention included administer medications per MD orders and monitor for effectiveness. <BR/>Record review of Resident #1's consolidated physician order dated 2/10/25 indicated Protonix Tablet Delayed Release 40 MG, 1 tablet by mouth one time a day for GERD. Start 01/24/25.<BR/>Record review of Resident#1's MAR dated 01/01/25-01/31/25 indicated Protonix Tablet Delayed Release 40 MG, 1 tablet by mouth one time a day for GERD. Start 01/24/25. Resident #1 had 7 doses scheduled for 8am (1/24/25-1/30/25) and 1 dose scheduled for 9am (1/31/25). <BR/>Record review of Resident #1's MAR dated 02/01/25-02/28/25 indicated Protonix Tablet Delayed Release 40 MG, 1 tablet by mouth one time a day for GERD. Start 01/24/25. Resident #1 had 10 of 10 doses scheduled for 9am (2/1/25-2/10/25).<BR/>During an observation on 02/10/25 at 10:51 a.m., Resident #1 was lying in her bed watching television. Resident #1 did not respond to greetings. <BR/>During an observation on 02/11/25 at 10:06 a.m., Resident #1 was sitting up in her bed. Resident #1 still did not respond to greetings. <BR/>On 2/12/25 at 5:45 PM, called Resident #1's responsible party and unable to leave message because the mailbox was full. No return call was received before or after exit.<BR/>2. Record review of Resident #93's face sheet dated 02/11/25 indicated Resident #93 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #93 had diagnoses including acute kidney failure (when the kidneys suddenly can't filter waste products from the blood) and hypotension (low blood pressure). <BR/>Record review of the MDS indicated Resident #93 was admitted to the facility less than 21 days ago. No MDS for Resident #93 was completed prior to exit.<BR/>Record review of Resident #93's care plan dated 02/10/25 indicated Resident #93 had hypotension. Intervention included check blood pressure as ordered by the MD. <BR/>Record review of Resident #93's consolidated physician order dated 02/11/25 indicated Midodrine Tablet 10MG, give 1 tablet by mouth three times a day for treat hypotension. Hold for SBP (is the pressure in your arteries when your heart beats and pumps blood throughout your body) greater than 110 or DBP (is the pressure in the arteries when the heart rests between beats) greater than 80 and give with meals. Start 2/5/25. <BR/>Record review of Resident #93 MAR dated 2/1/25 and 2/28/25 indicated Midodrine Tablet 10MG, give 1 tablet by mouth three times a day to treat hypotension. Hold for SBP greater than 110 or DBP greater than 80 and give with meals. Start 2/5/25. Administration documented on 2/6/25 at 7am: 138/72 (ADCO), 2/7/25 at 7am: 130/65 (LVN A), 2/7/25 at 7pm: 116/72 (LVN E), 2/8/25 at 7am: 119/49(RN C), 2/8/25 at 1pm: 122/54 (RN C), 2/8/25 at 7pm: 119/67 (LVN E), 2/9/25 at 7pm: 120/70 (LVN E), 2/10/25 at 7am: 128/72(ADCO), 2/10/25 at 1pm: 132/78 (ADCO), and 2/11/25 at 7am: 152/86.<BR/>During an interview on 2/12/25 at 1:57 p.m., LVN D said Protonix should be scheduled to be given on an empty stomach, in the morning. She said the medications worked better on an empty stomach and before meals. She said Resident #1's Protonix should be scheduled at 6am. She said 9am was not a good time to administer Protonix. She said Resident #93's Midodrine was ordered to raise her blood pressure for hypotension. She said if Resident #93 was administered Midodrine and her blood pressure was greater than the ordered parameters, it placed her at risk for hypertension or stroke. She said the nurse should look at the physician order and follow the hold parameters and administration instructions before giving a medication. <BR/>During an interview on 2/12/25 at 5:49 p.m., the ADCO said Protonix should be given before breakfast or at least 30 minutes before a meal. She said Resident #1's Protonix should be scheduled for 6am. She said it should not be schedule for 9am. She said for the medication to work and prevent GERD it needed to administer before breakfast. She said Resident #93's Midodrine administration instruction said for it to be given with meals. She said Resident #93's current Midodrine schedule did not follow those instructions. She said she did not know why the doctor wanted it given with meals, but the facility should follow the orders. She said she already knew about the medication errors for Resident #93's Midodrine. She said she was embarrassed about not following Resident #93's Midodrine hold parameters. She said the medication administration order and parameters were supposed to be read before administration. She said she should have read the physician order more carefully. She said most blood pressure parameters are hold for less than the SBP or DBP not greater than. She said giving Resident #93 the Midodrine when her blood pressure was not low placed her at risk for a stroke. <BR/>During an interview on 2/12/25 at 6:57 p.m., the DCO P, from a sister facility, said Protonix should be given on an empty stomach, before breakfast. She said the medication was not effective or therapeutic when it was taken with food. She said she expected the nursing staff to read the physician's order and follow the hold parameters. She said Midodrine was for hypotension. She said if the resident was not experiencing hypotension and was still given the medication, it was not good. She said Resident #93 could have experienced hypertension. She said the ADCO, DCO Q, and pharmacy consult should be ensuring medications were timed correctly, and physician orders and hold parameters were followed. She said monitoring should be done with chart audits. <BR/>During an interview on 2/12/25 at 7:34 p.m., the EDO said she expected physician's orders to be followed by the nursing staff. She said the nursing management should be monitoring this process. <BR/>Record review of a facility's General Guidelines for Medication Administration policy dated 08/2020 indicated . Medications are administered as prescribed in accordance with good nursing principles and practices . Medications are administered in accordance with written orders of the prescriber . Medications are administered within 60 minutes of the scheduled administration time, except before, with, or after meal orders, which are administered based on mealtimes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure the residents has the right to be informed of the risks and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options he or she preferred, for 2 of 15 residents (Resident #19 and Resident #242) reviewed for resident rights.<BR/>1. The facility failed to ensure Resident #19's psychoactive (substances that, when taken in or administered into one's system, affect mental processes) medication therapy consents were completed properly upon admission and prior to the administration of Zyprexa ( antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder), Venlafaxine ( used to treat major depressive disorder, anxiety, and panic disorder), Trazodone ( used to treat depression), and Carbamazepine ( used to treat certain types of seizures and bipolar disorder). <BR/>2.The facility failed to obtain informed consent based on information of the benefits, risks, and options available for Resident #242 prior to administering Risperdal (is an antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder), Depakote (used to treat seizures and stabilize mood), and Buspirone (used to treat anxiety). <BR/>These failures could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. <BR/>Findings included: <BR/>1. Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including Schizoaffective Disorder (is a mental illness that can affect your thoughts, mood and behavior), Bipolar type, Bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), mild depressed, recurrent depressive disorder, generalized anxiety (you are worrying constantly and can't control the worrying), insomnia (is a common sleep disorder), and conversion disorder with seizures or convulsions (is a condition in which a person experiences physical and sensory problems, such as paralysis, numbness, blindness, deafness or seizures, with no underlying neurologic pathology). <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 received antipsychotic, antianxiety, and antidepressant during the last 7 days of the assessment period. <BR/>Record review of Resident #19's care plan dated 03/21/23, revised 04/10/23 indicated Resident #19 was at risk for adverse consequence related to receiving psychotropic medications. Intervention included administer psychotropic medications as ordered. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated:<BR/>*Carbamazepine 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23.<BR/>*Trazodone 100 mg, give 1 tablet by mouth at bedtime for insomnia, start date 03/18/23.<BR/>*Venlafaxine, give 225 mg by mouth one time a day for depression, start date 03/19/23. <BR/>*Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23. <BR/>* Zyprexa, give 20 mg by mouth at bedtime for increased mood, decreased anxiety, and agitation, start date 08/11/23.<BR/>* Zyprexa, give 50 mg by mouth in the morning for increased mood, decreased anxiety, and agitation, start date 08/12/23.<BR/>Record review of Resident #19's MAR dated 01/01/24-01/31/24 indicated:<BR/>*Carbamazepine 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23.<BR/>*Trazodone 100 mg, give 1 tablet by mouth at bedtime for insomnia, start date 03/18/23.<BR/>*Venlafaxine, give 225 mg by mouth one time a day for depression, start date 03/19/23. <BR/>*Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23. <BR/>* Zyprexa, give 20 mg by mouth at bedtime for increased mood, decreased anxiety, and agitation, start date 08/11/23.<BR/>* Zyprexa, give 50 mg by mouth in the morning for increased mood, decreased anxiety, and agitation, start date 08/12/23.<BR/>Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Zyprexa. The consent indicated Zyprexa .Schiz-affective .improved function ability .antipsychotic .the probable clinically significant side effects or risks associated with the medication included: stiffness of neck, confusion, muscle rigidity .black box warning .<BR/>Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Trazodone. The consent indicated Trazodone .Schizo-Affective .Sleep disorder . antidepressant . the probable clinically significant side effects or risks associated with the medication included: dry mouth, blurred vision . black box warning .<BR/>Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Carbamazepine. The consent indicated Carbamazepine .bipolar disorder .improved function ability .antimanic (are medications used as mood stabilizers in psychiatric conditions such as bipolar disorder and schizophrenia) . the probable clinically significant side effects or risks associated with the medication included: confusion, drowsiness, hypotension (low blood pressure) . black box warning .<BR/>Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Venlafaxine. The consent indicated Venlafaxine .Depression .improved function ability .antidepressant . the probable clinically significant side effects or risks associated with the medication included: dry mouth, blurred vision . black box warning .<BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said the LVNs, or upper nursing management were responsible for medication consents. She said when a verbal consent was done, the nurse who received the verbal consent signed and the ADCO or DCO signed behind them. She said she believed a medication could be given with one nurse signature for verbal consent. She said if the family visited, staff were supposed to try to get a hand signature. She said consents done correctly were important so family aware of current treatment. <BR/>During an interview on 01/10/24 at 2:25 p.m., the responsible party for Resident #19 said she did not recall giving verbal consent for Resident #19's medication immediately after admission. She said she remembered when her family member was transferred to the facility and was not called. She said the facility only told her when Resident #19 started medications but did not go over the consent form. <BR/>During an interview on 01/10/24 at 2:29 a.m., the DCO said nurses were responsible to get consent for medication when they were ordered. She said consent should also be obtained upon admission. She said consent for medication was important to make sure family was aware of risks and benefits of treatment. She said she expected staff to go over the consent form and explain risks and benefits with family before consent was received. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said she expected staff to get consent before giving medications. She said staff should go over risks and benefits before consent was received. She said it was important to give informed consent, so the resident or family understood what the resident was taking. <BR/>2. Record review of Resident #242's face sheet dated 1/08/24 indicated she was a [AGE] year-old female and admitted to the facility on [DATE] with diagnoses including heart failure, Bipolar disorder (associated with episodes of mood swings ranging from depressive or sad lows to manic or excited highs), schizoaffective disorder (combination of symptoms of schizophrenia (affects ability to think, feel and behave clearly) and mood disorder, such as depression or bipolar disorder), major depressive disorder (persistent depressed mood or loss of interest in activities, causing impairment in daily life), and dementia (progressive loss of intellectual functioning, impairment of memory and thinking, often with personality changes caused by disease of the brain).<BR/>Record review of Resident #242's admission MDS assessment revealed it had not been completed.<BR/>Record review of Resident #242's Baseline Care plan dated 1/03/24 revealed she used psychotropic medications.<BR/>Record review of Resident #242's Order summary report dated 1/08/24 revealed an order for: Risperdal 2 mg 1 tablet by mouth at bedtime for bipolar disorder with a start date of 1/03/24; Buspirone 5 mg 2 tablets three times daily for anxiety with a start date of 1/03/24, and Depakote 125 mg 4 tablets three times a day for behaviors with a start date of 1/04/24. <BR/>Record review of Resident #242's MAR dated 1/01/24-1/31/24 indicated Resident #242 had received: Risperdal 2 mg at bedtime since 1/03/24, Buspirone 5 mg 2 tablets three times daily since 1/03/24, Depakote 125 mg 4 tablets two times a day on 1/03/24 to 1/04/24, and Depakote 125 mg 4 tablets three times a day since 1/04/24. <BR/>Record review of a Behavioral Management-psychoactive medication therapy consent dated 1/04/24 indicated a verbal consent for the use of Risperdal was obtained from Resident #242's RP on 1/09/24. This verbal consent was obtained 6 days after admission and after administration of Risperdal to Resident #242.<BR/>Record review of a Behavioral Management-psychoactive medication therapy consent dated 1/04/24 indicated a verbal consent for the use of Buspirone was obtained from Resident #242's RP on 1/09/24. This verbal consent was obtained 6 days after admission and after administration of Buspirone to Resident #242.<BR/>Record review of a Behavioral Management-psychoactive medication therapy consent dated 1/04/24 indicated a verbal consent for the use of Depakote was obtained from Resident #242's RP on 1/09/24. This verbal consent was obtained 6 days after admission and after administration of Depakote to Resident #242.<BR/>On 1/08/24 at 2:27 PM and 1/10/23 at 12:36 PM, attempted to interview Resident #242's RP via phone. There was no answer, and a voicemail was left. Resident #242's RP did not return call prior to the exit of the facility. <BR/>During an interview on 1/09/24 at 11:30 AM, RN N said the admitting nurses were responsible for obtaining the consents for antipsychotics and psychotropic medications. RN N said the admitting nurse obtained consent by calling the RP for verbal consent or obtaining written consent from the RP if they were in the facility. RN N said the DCO was responsible for ensuring the antipsychotic and psychotropic medication consents were completed.<BR/>During an interview on 1/10/24 at 1:02 PM, the DCO said antipsychotic and psychotropic medication consents should be obtained upon admission and the medications should not be administered without obtaining proper informed consent. The DCO said she did not know what happened or why Resident #242's consents were not obtained upon admission. The DCO said she was the initial admitting nurse for Resident #242 and started the admission, but she did not complete it and turned it over to the next nurse. The DCO said it was a group effort to ensure proper informed consent was obtained for antipsychotic and psychotropic medications from the resident or their RP prior to administering the medications.<BR/>During an interview on 1/10/24 at 1:28 PM, the ADM said she would expect proper informed consent to be obtained prior to administering antipsychotic or psychotropic medications from the resident or their RP. <BR/>Requested a policy on antipsychotic and psychotropic medication consents from the DCO on 1/10/24 at 1:02 PM. <BR/>Requested a policy on antipsychotic and psychotropic medication consents from the ADM on 1/10/24 at 3:28 PM.<BR/>On 1/10/24 at 4:00 PM, the ADM said they did not have a policy on antipsychotic or psychotropic medication consents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 15 residents (Resident #19) reviewed for reasonable accommodations.<BR/>The facility failed to ensure Resident #19's call light was placed on her dominant side and hand without a contracture (is a fixed tightening of muscle, tendons, ligaments, or skin). <BR/>This failure could place residents at risk for unmet needs.<BR/>Findings included:<BR/>Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including contracture, left hand and ankle, abnormal posture, hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side, and muscle weakness. <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 had limited range of motion to both sides of her lower extremities. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 was frequently incontinent of urine and always incontinent of bowel. <BR/>Record review of Resident #19's care plan dated 03/21/23, revised on 04/10/23 indicated Resident #19 had history of falls and at risk for increased falls and fracture evidence by history of falls and physical impairment/immobility. Intervention included ensure call light is in reach and answer promptly. <BR/>During an observation and interview on 01/08/24 at 1:04 p.m., Resident #19 said she could not reach the call light sometimes and could not use her left hand. Resident #19 was lying in bed and her left arm appeared flaccid with no voluntary movement of her hand. Resident #19's call light was on her left side near her hand. <BR/>During an observation on 01/09/24 at 1:15 p.m., revealed Resident #19 was lying in her bed, asleep, with her call light placed in the middle of the bed, not near her right hand. <BR/>During an interview on 01/10/24 at 12:22 p.m., RCP O said the RCP, LVN or anyone who walked in the room should make sure the resident's call light was within reach or placed on the resident's non affected side. She said Resident #19's call light should be placed on her right side, which was not affect by her stroke. She said she liked to place her left hand on a pillow because she could not control it. She said if Resident #19's call light was placed on the wrong side of her body or not within reach, she could not get help. She said call lights not being within reach could cause residents to fall or not get their needs met. <BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said the RCP and LVN were responsible for making sure resident's call light were within reach. She said it would not be appropriate to place Resident #19's call light on her left side. She said when call lights were not within reach or on the resident's stroke affected side, they could fall, not get help, or staff attention.<BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said everyone was responsible for ensuring resident's call light were within reach. She said Resident #19's call light should be placed on her unaffected side. She said call lights being placed within reach was important to get the help they needed. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said she expected call lights to be within reach. She said call lights should be placed on the resident's dominant side. She said all staff should ensure it happened. She said staff should check call light placement every 2 hours and as needed during rounds. She said when call lights were not within reach, residents were not able to call for assistance. A call light policy was requested at this time, a policy was not received before or after exit. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 5 residents, (Resident #16) reviewed for PASRR Level 1 screenings.<BR/>The facility failed to complete a PASRR Level 1 screening for Resident #16 following a discharge from a mental health hospital with a new diagnosis of mental illness.<BR/>This failure could place residents at risk of not being evaluated for PASRR services and receiving needed services.<BR/>The findings were:<BR/>Record review of face sheet dated 01/09/24 revealed Resident #16 was [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Bipolar type (episodes of mania and sometimes depression) with an onset of 08/19/22, Major Depressive Disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and anxiety disorder. <BR/>Record review of a quarterly MDS dated [DATE] revealed Resident #16 had a BIMS of 15, which indicated the resident was cognitively intact. Resident #16 required supervision to set up assistance with most ADLs. <BR/>Record review of a care plan last revised on 09/18/23 indicated Resident #16 was at risk for adverse consequences related to receiving psychotropic medications due to diagnoses of anxiety, depression, paranoia, and psychotic/psychosis. <BR/>Record review of PASRR Level One Screening forms dated 03/02/17 did not indicate Resident #16 had a mental illness. Resident #16's electronic medical record did not indicate any further PASRR Level One Screening forms or a PASRR Evaluation. <BR/>Record review of a Discharge Summary from a behavioral hospital with an admission date of 08/04/22 and a discharge date [DATE] indicated Resident #16 had a diagnosis of bipolar disorder type 1 (Bipolar I disorder is defined by manic episodes that last for at least 7 days (nearly every day for most of the day) or by manic symptoms that are so severe that the person needs immediate medical care), recurrent, severe, with psychotic features.<BR/>During an interview on 01/09/24 at 2:15 p.m., the MDS Coordinator said the previous DON had entered the diagnosis into the electronic medical record for Resident #16. The MDS Coordinator said she was unaware of the diagnosis of schizoaffective disorder, bipolar type for the resident and there had not been a PASSR Level One Screening resubmission. She said there was not a PASSR evaluation for Resident #16. <BR/>During an interview on 01/10/24 at 11:57 a.m., the DON said after Resident #16's medical record was updated to reflect the resident had a diagnosis of schizoaffective disorder, bipolar type 1 and after the resident returned from the behavioral hospital with a diagnosis of bipolar disorder, she would have expected the resident to have been received a new PASRR Level One Screening and a PASSR Evaluation. She said a resident with a new diagnosis of mental illness not being re-evaluated appropriately could cause them to not receive needed PASSR services.<BR/>During an interview on 01/10/24 at 12:38 p.m., the Administrator said after a resident received a new mental illness diagnosis, she would have expected a new PASRR Level One Screening and a PASSR Evaluation to have been done for the resident. She said a resident with a mental illness not having a PASSR Evaluation could cause them to not get support and services they need.<BR/>Review of a PASSR facility policy dated 11/2023 indicated, .The purpose of this policy is to ensure PASRRs are being obtained and completed timely and accurately .Follow Texas PASRR Policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 15 residents reviewed for care plans. (Resident# 19, Resident #29)<BR/>The facility failed to implement Resident #19's care plan intervention to off-load (is described as lifting or pushing an area of high pressure away from the cause of the pressure) her heels when in bed.<BR/>The facility failed to care plan Resident # 19's diagnosis of Type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and use of insulin (therapy often is an important part of diabetes treatment), diuretic (are medicines that help reduce fluid buildup in the body), opioid (sometimes called narcotics, are a type of drug), and antiplatelet (are medications that prevent blood clots from forming) coded of her MDS. <BR/>The facility failed to care plan Resident #19's use of an anticonvulsant (are prescription medications that help treat and prevent seizures). <BR/>The facility failed to care plan Resident #29's use of an antiplatelet. <BR/>These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services.<BR/>Findings included:<BR/>1. Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Type 2 diabetes, edema (is swelling caused by too much fluid trapped in the body's tissues), cerebrovascular disease (is a term for conditions that affect blood flow to your brain), bipolar (causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), and conversion disorder (is a condition where a mental health issue causes physical symptoms) with seizures (is a sudden, uncontrolled burst of electrical activity in the brain) or convulsion (are rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 had diagnoses including diabetes mellitus and seizure disorder or epilepsy (is a brain condition that causes recurring seizures). The MDS indicated Resident #19 received scheduled pain medication regimen and experienced presence of pain in the last 5 days. The MDS indicated Resident #19 received diuretic, opioid, and antiplatelet medications during the last 7 days of the assessment period. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Clopidogrel (It is an antiplatelet drug. It helps keep blood flowing smoothly in your body) 75 mg, give 1 tablet by mouth one time a day for anticoagulation, start date 03/18/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine (is in a class of medications called anticonvulsants. It works by reducing abnormal electrical activity in the brain) 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Lasix (is a strong diuretic (water pill') and may cause dehydration and electrolyte imbalance) 20 mg, give 2 tablets by mouth one time a day for cerebrovascular disease, start date 03/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Gabapentin (is an anticonvulsant medication primarily used to treat partial seizures and neuropathic pain) 600 mg, give 1 tablet by mouth one time a day for neuropathy (happens when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged), start date 03/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Novolin (is a type of insulin used to control blood sugar) 100 units/ML (Insulin Regular (Human)), inject as per sliding scale, subcutaneously two times a day for diabetes type 2, start date 04/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Tramadol (is in a class of medications called opiate (narcotic) analgesics and used to treat moderate to severe pain that is not being relieved by other types of pain medicines) 50 mg, give 1 tablet by mouth three times a day for pain, start date 08/14/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Lantus (is a long-acting form of insulin), inject 30 unit subcutaneously at bedtime for diabetes type 2, start date 11/08/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Lantus, inject 40 unit subcutaneously in the morning for diabetes type 2, start date 11/08/23. <BR/>Record review of Resident #19's care plan dated 07/19/23 indicated Resident #19 had a DTI (is a form of pressure ulcer or pressure sore) to left heel. Intervention off-load heels while in bed. The care plan did not address Resident #19's diagnosis of Type 2 diabetes and use of an anticonvulsant and use of insulin, diuretic, opioid, and antiplatelet coded of her MDS. <BR/>During an observation and interview on 01/08/24 at 1:04 p.m., Resident #19 was lying in the bed on her back. Resident #19's feet were not off-loaded. She said the staff did not put anything underneath her heels but sometimes put heel protectors on after therapy. The heel protectors were on the bed next to Resident #19. Resident #19 said she had not had them on in a while. <BR/>During an observation and interview on 01/09/24 at 1:15 p.m., Resident #19 was lying in the bed on her back. Resident #19's feet were not off-loaded.<BR/>During an interview on 01/10/24 at 12:22 p.m., RCP O said the RCPs and LVNs were responsible for ensuring Resident #19's heels were floated. She said Resident #19 also had heel protectors she would wear. She said Resident #19 had sores on her feet and they were floating them to heal. She said floating a resident's heels kept the pressure off the area damaged. <BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said the nurse was responsible for floating Resident #19's heels or placing her heel protectors on. She said Resident #19 would sometimes refuse the heel protectors or would not float her heels for long periods of time. She said Resident #19 had a DTI and was paralyzed on her left side so floating her heels was important for prevention of skin breakdown. She said she did not know if nurses had access or could see care plans interventions. She said nursing staff knew resident care from morning meeting updates. She said implementing Resident #19 care plan intervention was important to prevent wounds or injuries. <BR/>2. Record review of Resident #29's face sheet printed 01/09/24 indicated Resident #29 was an [AGE] year-old male and was admitted on [DATE] and 05/31/22 with diagnosis including atherosclerotic heart disease of native coronary artery (is caused by plaque buildup in the wall of the arteries that supply blood to the heart (called coronary arteries)). <BR/>Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated Resident #29 was understood and sometimes had the ability to understand others. The MDS indicated Resident #29 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #29 required partial/moderate assistance for toilet hygiene and shower/bath self, supervision for personal hygiene, and independent for oral hygiene and eating. The MDS indicated Resident #29 received an antiplatelet during the last 7 days of the assessment period. <BR/>Record review of Resident #29's order summary dated 01/09/24 indicated Aspirin (is used to treat pain and reduce fever or inflammation. It is sometimes used to treat or prevent heart attacks, strokes, and chest pain) 81 mg, give 1 tablet by mouth one time a day for preventative, start date 12/18/20. <BR/>Record review of Resident #29's care plan printed 01/09/24 did not indicate use of an antiplatelet. <BR/>During an interview on 01/10/24 at 1:20 p.m., the CRS said she was responsible for MDSs and care plans. She said she only worked part time at the facility. She said she developed the comprehensive care plan from the CAAs on the MDS, medical diagnoses, physician's orders, activities, reviewed progress and social notes, and anything special in the resident's history. She said Resident #19's diagnoses and medications should be included on her care plan. She said comprehensive care plans were important to make sure residents received services and any special needs the staff needed to be aware of. She said Resident #29's use of an antiplatelet should have been added to his care plan. She said new nurses could look at a care plan and may not know the appropriate care for the resident if problem areas were not added to the care plan.<BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said the MDS Coordinator (CRS) and the DCO were responsible for comprehensive care plans. She said Resident #19's diagnoses and medications and Resident #29 use of an antiplatelet should be care planned. She said comprehensive care plans were important, so nurses were aware of the resident's issues. She said the nurses were responsible for care plan interventions to be implemented. She said sometimes Resident #19 refused to off-load her heels. She said staff were supposed to chart if Resident #19 refused. The DCO said LVNs were able to view residents' care plans on the facility's charting system but not RCPs. She said LVNs should inform RCPs of care plan interventions such as off-loading heels, so they knew to monitor. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said if an intervention was on a care plan, she expected it to be followed or done. She said if the information was on the MDS and was triggered (coded), she expected it to be on the care plan. She said nurses and nurse management was responsible for ensuring comprehensive care were complete and interventions are followed or done. She said diagnoses and medications had risked that had to be monitored and intervention developed. <BR/>Record review of a facility's Comprehensive Care Plan revised on 04/21 indicated .the interdisciplinary team will continue to develop the plan in conjunction with RAI (MDS 3.0) and CAAS .the IDT will review the healthcare practitioner's notes and orders and implement a comprehensive care plan to meet the residents' immediate needs including but not limited to .physician orders .pain management .specific care plan on the main reason for admission .<BR/>Record review of a facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .is for prevention and treatment of skin breakdown such as pressure injuries .prevention .dependent residents will have heels floated while in bed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 15 residents (Residents #34), reviewed for care plans.<BR/>The facility failed to revise and update Resident #34's comprehensive care plan for an anticoagulant medication (a medication that helps prevent blood clots). <BR/>This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome.<BR/>Findings included:<BR/>Record review of face sheet dated 01/08/24 indicated Resident #34 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses of myotonic muscular dystrophy (a genetic condition that causes progressive muscle weakness and wasting), dysphagia (difficulty swallowing), and atrial flutter (a type of abnormal heart rhythm). <BR/>Record review of physician's orders dated 01/08/24 indicated an order for Eliquis Oral Tablet 5 milligrams give 1 tablet by mouth two times a day with an order date and start date of 08/21/23. <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #34 was usually understood and understood others. The MDS indicated a BIMS of 08 which indicated moderate cognitive impairment. The MDS indicated the resident was taking an anticoagulant, which is a high-risk drug.<BR/>Record review of a care plan last revised on 12/28/23 for Resident #34 did not indicate the use of an anticoagulant. <BR/>During an interview on 01/10/24 at 10:58 a.m., the MDS Coordinator said she was responsible for updating care plans. She said she may have overlooked the fact that Resident #34 was on an anticoagulant and failed to add it to the care plan. She said she was not sure when the Eliquis had been prescribed. She said she reviewed the 24-hour reports for the residents for any new problems that need to be added to each residents' care plan. She said new nurses could look at a care plan and may not know the appropriate care for the resident if problem areas were not added to the care plan. She said a nurse may not know to monitor for bruising for someone taking anticoagulants.<BR/>During an interview on 01/10/24 at 11:57 a.m., the DON said a care plan was used to plan the necessary care for each resident. She said she would have expected the anticoagulant for Resident #34 to have been added to his care plan. <BR/>During an interview on 01/10/24 at 12:38 p.m., the Administrator said she would have expected for an anticoagulant to have been care planned. She said it was the responsibility of the nurse manager to update care plans. She said Eliquis had risks that have to be monitored. <BR/>Review of a Comprehensive Care Plan facility policy dated 1/20/21 indicated, .The Care Plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis .The Interdisciplinary Team will review the healthcare practitioner's notes and orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a Comprehensive Care Plan to meet the residents' immediate care needs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 4 residents (Resident #19) reviewed for range of motion and mobility<BR/>The facility failed to ensure Resident #19 had on a hand device. <BR/>This failure had the potential to affect resident with limited ROM by placing them at risk for a decline in their functional abilities.<BR/>Findings included:<BR/>Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including contracture, left hand and ankle, abnormal posture, hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side, and muscle weakness. <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 had limited range of motion to both sides of her lower extremities. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene.<BR/>Record review of Resident #19's care plan dated 04/10/23 indicated Resident #19 had limited physical mobility related to stroke and weakness. Interventions included provide gentle range of motion as tolerated with daily care and monitor/document/report as needed any signs/symptoms of immobility. <BR/>Record review of Resident #19's order summary date 01/09/24 indicated remove hand device at bedtime, start date 03/18/23. <BR/>During an interview and observation on 01/08/24 at 1:04 p.m., Resident #19 was lying in bed with no hand device on her left hand. A hand device was noticed on the empty bed next to the resident. Resident #19 said the CNAs (RCPs) normally put the brace on her hand. She said she normally wore it for 2 hours and took it off for 2 hours. She said she had not had the brace on since yesterday. <BR/>During an interview and observation on 01/09/24 at 1:15 p.m., Resident #19 was lying in bed with no hand device on her left hand. A hand device was not visualized in the room. Resident #19 said she did not know where her hand device was and had not had it on today. <BR/>During an interview on 01/09/24 at 4:04 p.m., the Director of Rehabilitation Department/Certified Occupational Therapist said the CNAs (RCPs) were responsible for putting on Resident #19's hand device. She said the hand brace was supposed to be on as long as Resident #19 tolerated it.<BR/>During an interview on 01/10/24 at 12:22 p.m., RCP O said Resident #19 and staff were the ones who asked for a hand brace for her left hand. She said the RCP and LVN were responsible for putting the device on and off. She said only the LVN could see the order of the length of time the device was supposed to be on. She said Resident #19 was supposed to have on her hand brace every day and all day until she asked for it to be removed. She said sometimes they did alternate it off and on by a couple hours if she was in pain. She said the brace was important because her hand was contracted.<BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said the nurses were primarily responsible for placement of the hand device. She said the RCP should let the nurse know if it got dirty or something so it could get changed. She said she placed a rolled towel in Resident #19's hand and did not know about a hand device. She said the hand device should be put on every shift and given a break when Resident #19 complained of discomfort or pain but then reapplied. She said the hand device was important to prevent further contractures. <BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said the LVN was responsible for the hand device. She said sometimes Resident #19 refused the hand device. She said if Resident #19 refused the hand device, it should be documented in the facility's charting system. She said the hand device was important to prevent breakdown and increased contracture. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said the RCP was responsible for applying Resident #19's hand device and the nurse should monitor when its off and on. She said the hand device was important, so the contracture did not get worse. A policy for contracture management was requested at the time, a policy was not received before or after exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 2 residents (Resident #23) who were reviewed for indwelling urinary catheter care.<BR/>The facility failed to ensure CNA F followed appropriate procedures and infection control during foley catheter care for Resident #23. <BR/>This failure could place residents at risk for urinary tract infections.<BR/>Findings included:<BR/>Record review of Resident #23's face sheet dated 1/09/23 indicated Resident #23 was a [AGE] year-old female and admitted on [DATE] with diagnoses including paralytic syndrome (unable to move) following a cerebrovascular disease (problem with blood flow to the brain causing damage to the brain), paraplegia (complete or partial loss of muscle function to all or part of the trunk, legs, or pelvic organs), reduced mobility, and hypertension (high blood pressure).<BR/>Record review of Resident #23's quarterly MDS assessment dated [DATE] indicated Resident #23 was usually understood and usually understood others. The MDS indicated Resident #23 had a BIMS score of 13 which indicated she was cognitively intact. The MDS indicated Resident #23 required maximal assistance with toileting and bathing. The MDS indicated Resident #23 required total assistance dressing her lower body. The MDS indicated Resident #23 had an indwelling catheter, was always incontinent of urine, and was frequently incontinent of bowel.<BR/>Record review of Resident #23's care plan revised 11/17/23 indicated Resident #23 was incontinent and at risk for skin breakdown with intervention to monitor for signs and symptoms of infection and notify physician promptly. The care plan revealed Resident #23 was on an antibiotic for a urinary tract infection. Resident #23's care plan revealed there were no focused area or interventions for her foley catheter.<BR/>Record review of Resident #23's order summary report dated 1/09/24 did not reveal an order for a foley catheter.<BR/>Record review of Resident #23's progress notes dated 11/14/23 revealed the nurse had received an order from Resident #23's urologist to place a foley catheter and change it monthly and to start on Macrobid (antibiotic) 100 mg twice a day for seven days for a urinary tract infection.<BR/>During an observation and interview on 1/08/24 at 10:39 AM, Resident #23 was sitting up in her bed and a foley catheter drainage bag was hanging from the side of her bed with a privacy bag. Resident #23 said she had the foley catheter because she was unable to control her bladder or move her lower body. <BR/>During an observation on 01/09/24 at 10:30 AM, CNA F performed foley catheter care on Resident #23 with ADCO C in the room also. CNA F washed her hands, applied gloves, and placed opened trash bags on the BST. CNA F then with her same gloved hands grabbed and moved the BST closer, then pulled back Resident #23's covers, grabbed a package of incontinent wipes off of Resident #23's nightstand and pulled out 4 wipes and then laid the wipes on the resident's incontinent pad. CNA F using the same gloves, then held the bedsheet over the resident's pelvic area with her left hand and used her right hand to pick up a wipe off the incontinent pad and wiped the foley catheter starting at the point closest to Resident and slid the wipe down the foley catheter away from the resident and then placed it in the trash bag on the BST and repeated this process three times. CNA F using the same gloves, then pulled Resident #23's adult brief up between her legs and fastened the sticky tabs and then pulled up the bedsheet over the resident. CNA F then removed her gloves and pulled the rest of the covers up over the resident.<BR/>During an interview on 1/09/24 at 10:48 AM, CNA F said she usually changed her gloves at least twice when performing foley catheter care, but only changed gloves once because she was nervous. CNA F said she laid the incontinent wipes on Resident #23's incontinent pad because she had changed the resident's incontinent pad after Resident #23 had a bowel movement not long prior to going to provide foley catheter care, so she knew it was clean. CNA F said by not changing her gloves prior to starting foley care she could have transferred bacteria to the foley catheter, and the resident could get sick. CNA F said the purpose of cleaning the foley catheter was to prevent infections. <BR/>During an interview on 1/10/24 at 10:55 AM, LVN B said staff should change gloves after touching other surfaces in a resident's room, such as a BST or bedding, prior to performing foley catheter care. LVN B said it would not be appropriate to place incontinent wipes to be used to perform foley catheter care on the resident's incontinent pad. LVN B said it would be cross-contamination and could give the resident a UTI. <BR/>During an interview on 1/10/24 at 1:02 PM, the DCO said CNA F did not perform appropriate foley catheter care and should have changed her gloves prior to starting the foley catheter care after touching multiple surfaces. The DCO said CNA F should not have laid the incontinent wipes on the incontinent pad or handled Resident #23's sheet without removing or changing her gloves. The DCO said improper foley catheter care could cause infections, such as a UTI. <BR/>During an interview on 1/10/24 at 1:28 PM, the ADM said CNA F should have changed her gloves after touching multiple surfaces in Resident #23's room prior to and after performing foley catheter care. The ADM said once you touch multiple things, the gloves were no longer clean. The ADM said by not performing proper foley catheter care, it could pose an increased risk of infection to the resident.<BR/>During an interview on 1/10/24 at 3:45 PM, ADCO C said she had saw enough during the foley catheter care provided by CNA F for Resident #23 to know she needed to do an in-service with her staff on foley catheter care. ADCO C said CNA F did not change her gloves after touching multiple other surfaces prior to performing foley catheter care. ADCO C said CNA F should not have placed the incontinent wipes on the resident's incontinent pad or used the wipes off the incontinent pad. ADCO C said CNA F should not have touched Resident #23's sheet with the same gloves used to clean the foley catheter. ADCO C said the trash bags should have not been placed on the resident's BST either. ADCO C said the foley catheter care that was provided by CNA F for Resident #23 was an infection control issue and could increase the resident's risk of developing a UTI.<BR/>Requested competency or skills check list for CNA F for foley catheter care from the DCO on 1/10/24 at 1:02 PM.<BR/>Requested competency or skills check list for CNA F for foley catheter care from the ADM on 1/10/24 at 3:28 PM and at 4:00 PM the ADM said they did not have competency or skills check list for CNA F for foley catheter care.<BR/>Record review of the facility's policy titled Catheters-Insertion and Care: Indwelling, Straight, Supra-Pubic, and External dated 4/2021 revealed . it was the policy of the community that the resident with a urinary catheter be provided services in a safe and appropriate manner to minimize the risks of urinary tract complications . physician order was required for all catheters . order should include type of catheter, size of catheter and size of bulb, frequency to change catheter and drainage bag .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 15 residents reviewed for respiratory care. (Resident #13 and Resident #19)<BR/>1.The facility failed to ensure Resident #13's yankauer suction catheter (hard-plastic tip with handle used to suction secretions from the mouth) was properly stored.<BR/>2. The facility failed to ensure Resident #19 had a filter (the air passes through a series of filters that remove impurities, ensuring that the oxygen delivered to the patient is of high quality) in the oxygen concentrator (take air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe). <BR/>3. The facility failed to ensure Resident #19's compartment that held the oxygen concentrator filter did not have white, fuzzy material. <BR/>These failures could place residents at risk of respiratory complications or respiratory infection. <BR/>Findings included:<BR/>1. Record review of Resident #13's face sheet dated 1/08/24 revealed he was an [AGE] year-old male, who admitted to the facility on [DATE]. Resident #13 had diagnoses of COPD (chronic obstructive pulmonary disease -constriction of the airways and difficulty or discomfort in breathing), hypertension (high blood pressure), history of cerebral infarction (disruption or lack of blood supply to the brain causing parts of the brain to die, also called a stroke), right sided hemiplegia (unable to move right side of body), and weakness.<BR/>Record review of Resident #13's quarterly MDS dated [DATE] revealed he was understood and understood others. Resident #13 had a BIMS of 11 which indicated he had moderate cognitive impairment. Resident #13 was dependent on someone to perform most ADLs. Resident #13 was receiving hospice care (end of life care). <BR/>Record review of Resident #13's undated care plan revealed he had shortness of breath with an intervention to maintain a clear airway and to suction as needed to clear secretions.<BR/>Record review of Resident #13's Order Summary Report dated 1/09/24 revealed an order to admit to hospice dated 8/22/22. <BR/>During an observation on 1/09/24 at 8:48 AM revealed Resident #13's lying in bed, unable to communicate. There was a yankauer suction catheter laid directly on top of his BST (not bagged) with tubing attached to a suction machine with approximately 3 inches of yellow tinged fluid in the collection canister.<BR/>During an observation on 1/09/24 at 9:25 AM revealed Resident #13 lying in bed, unable to communicate, and his yankauer suction catheter continued to be laid directly on top of his BST (not bagged) with tubing attached to a suction machine with approximately 3 inches of yellow tinged fluid in the collection canister.<BR/>During an observation on 1/09/24 at 10:54 AM revealed Resident #13 sitting up in bed, unable to communicate and his yankauer suction catheter continued to be laid directly on top of his BST (not bagged) with tubing attached to a suction machine with approximately 3 inches of yellow tinged fluid in the collection canister.<BR/>During an interview on 1/10/24 at 10:55 AM, LVN B said she had worked at the facility for three months and normally worked the 6 AM-2 PM. LVN B said Resident #13 was on hospice services and she was performing frequent checks on him because he was nearing end of life. LVN B said Resident #13 already had the suction machine in his room prior to her 6 AM-2 PM shift on 1/09/24 and the yankauer suction catheter was already lying directly on the BST. LVN B said she had not used the yankauer suction catheter to suction his mouth during her shift. She said the yankauer suction catheter should be stored in a plastic bag with the resident's name on it to prevent the growth and/or spread of infection. LVN B said it would not be appropriate for a yankauer suction catheter to be laid directly on the BST because it was equipment used in the resident's mouth. LVN B said the yankauer suction catheter should have been thrown in the trash when she saw it lying directly on the BST to ensure it was not used on Resident #13 by other staff.<BR/>During an interview on 1/10/24 at 11:22 AM, RN E said she had worked at the facility about a year and normally worked the 6 AM-2 PM shift. RN E said the yankauer suction catheter should be stored in packaging or a plastic bag to prevent the growth of bacteria. RN E said it would not be proper procedure to lay a used uncovered yankauer suction catheter on a BST. RN E said you would be contaminating the BST and the yankauer suction catheter. RN E said the yankauer suction catheter should be properly stored to keep it clean due to it was used to suction the resident's mouth. RN E said using a contaminated yankauer suction catheter in a resident's mouth would increase the risk of infection to the resident. <BR/>During an interview on 1/10/24 at 1:02 PM, the DCO said Resident #13's yankauer suction catheter should have been replaced after being found lying directly on the BST and not properly stored due to it was then contaminated. The DON said the yankauer suction catheter should be stored in a plastic bag or something, not directly on top of the BST due to possible infection control issues and increased risk of infection to the resident. <BR/>During an interview on 1/10/24 at 1:28 PM, the ADM said she would expect Resident #13's yankauer suction catheter to have been stored properly in something and not laid directly on the BST. The ADM said not storing the yankauer suction catheter properly posed an increased risk of infection to the resident. <BR/>During an interview on 1/10/24 at 3:04 PM, LVN D said she had worked at the facility for 5-6 years PRN and normally worked the 10 PM-6 AM shift. LVN D said she had worked the 10 PM-6 AM on 1/8/24 and provided care to Resident #13. LVN D said the suction machine with the yankauer suction catheter was already in his room when she came in on her shift and the suction canister had about two inches of yellow secretions in it. LVN D said she used the yankauer suction catheter a little on him, kept his head of bed elevated, and kept him comfortable on her shift. LVN D said the yankauer suction catheter was already lying on the BST when she went into Resident #13's room, but she used the yankauer suction catheter in his mouth but was not able to suction any secretions back from his mouth. LVN D asked surveyor was I not supposed to use it after it sat on his BST? LVN D said she was not sure what the policy said but she probably should have thrown it in the trash and obtained a new one before putting it in his mouth. LVN D said by placing the yankauer suction catheter in his mouth after it had laid directly on the BST, it placed the resident at an increased risk of infection from cross-contamination.<BR/>2.Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses cerebrovascular disease (is a term for conditions that affect blood flow to your brain), morbid (severe) obesity due to excess calories, hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side. <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 experienced shortness of breath or troubled breathing with exertion. The MDS indicated Resident #19 had oxygen therapy within the last 14 days while a resident in the facility. <BR/>Record review of Resident #19's care plan dated 04/10/23 indicated Resident #19 had oxygen therapy related to cerebral vascular accident (stroke) and obesity. Intervention included give medications as ordered by physician. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated clean/change oxygen concentrator filters every night shift every Sunday, start date 03/19/23. <BR/>Record review of Resident #19's TAR dated 01/01/24-01/31/24 indicated clean/change oxygen concentrator filters every night every Sun (01/07/24 LVN Q). <BR/>During an observation on 01/08/24 at 1:04 p.m., Resident #19 was lying in her bed with a nasal cannula on which was connected to an oxygen concentrator. The oxygen concentrator did not have a filter and the compartment that held the filter, had a small amount of white, fuzzy material. <BR/>During an observation on 01/09/24 at 11:30 a.m., Resident #19 was lying in her bed with a nasal cannula on which was connected to an oxygen concentrator. The oxygen concentrator did not have a filter and the compartment that held the filter, had a small amount of white, fuzzy material. <BR/>During an observation on 01/09/24 at 1:15 p.m., Resident #19 was lying in her bed with a nasal cannula on which was connected to an oxygen concentrator. The oxygen concentrator did not<BR/>have a filter and the compartment that held the filter, had a small amount of white, fuzzy material. <BR/>On 01/10/24 at 12:05 p.m., attempted to contact LVN Q by phone, left message with no return call before or after exit.<BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said she mostly worked the 2pm-10pm shift but had worked all the shifts. She said the filters on concentrators were supposed to be cleaned by the Sunday night shift nurse. She said the nurse who cleaned the filter should make sure the resident had a filter also. She said a resident while no filter or filter area with fuzzy, white material placed them at risk for upper respiratory infection like pneumonia. <BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said the oxygen concentrator filters were cleaned on Sunday nights by the nursing staff and as needed. She said the nurses should ensure the resident had a filter in their oxygen concentrator. She said the RCPs could also notify the charge nurse if they noticed the filter missing or dirty. She said the filter was important to filter the good and bad things in the air. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said staff members who changed the oxygen tubing should also check the filter. She said there was no potential harm to the resident if the oxygen concentrator did not have a filter, but it could eventually affect how the machine worked.<BR/>Review of the facility's Respiratory policy titled Suctioning dated 04/2021 indicated . policy of this community that oral suctioning of a resident's mouth . would be provided to remove mucus, drainage or saliva away from the resident's airway . connect tubing to suction machine . put on glove and attach catheter to connecting tubing, taking care not to contaminate suction catheter . <BR/>Record review of a facility's Oxygen Therapy policy dated 04/21 indicated .wash filters from oxygen concentrators every 7 days in warm soapy water .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 of 5 residents (Resident #19, Resident #25, and Resident #29) reviewed for unnecessary psychotropic medications (are medications that affect the mind, emotions, and behavior).<BR/>The facility failed to ensure Resident #19 had behavior monitoring for her prescribed antianxiety (treats anxiety disorders), anticonvulsant (are prescription medications that help treat and prevent seizures), and antipsychotic (are the main class of drugs used to treat people with schizophrenia) medications. <BR/>The facility failed to ensure Resident #19 had side effect monitoring for her prescribed antianxiety, anticonvulsant, and antipsychotic medications. <BR/>The facility failed to ensure Resident #25 had an appropriate diagnosis for his prescribed Quetiapine (Seroquel; is an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and depression) 50 mg. <BR/>The facility failed to ensure Resident #25 had an anxiety diagnosis for his prescribed antianxiety medication. <BR/>The facility failed to ensure Resident #25's prn Lorazepam (is used to treat anxiety) was ordered for 14 days.<BR/>The facility failed to ensure Resident #25 had behavior monitoring for his prescribed psychotropic medications. <BR/>The facility failed to ensure Resident #25 had side effect monitoring for his prescribed psychotropic medications.<BR/>The facility failed to ensure Resident #29 had a documented diagnosis for the use of his prescribed Seroquel (Quetiapine) 25 mg.<BR/>These failures could put residents at risk of receiving unnecessary psychotropic medications.<BR/>Findings included:<BR/>1. Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including Schizoaffective Disorder (is a mental illness that can affect your thoughts, mood and behavior), Bipolar type, Bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), mild depressed, recurrent depressive disorder (a depressed mood or loss of pleasure or interest in activities for long periods of time), generalized anxiety (you are worrying constantly and can't control the worrying), insomnia (is a common sleep disorder), and conversion disorder with seizures or convulsions (is a condition in which a person experiences physical and sensory problems, such as paralysis, numbness, blindness, deafness or seizures, with no underlying neurologic pathology). The face sheet did not indicate a diagnosis of anxiety. <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 received antipsychotic, antianxiety, and antidepressant during the last 7 days of the assessment period. <BR/>Record review of Resident #19's care plan dated 03/21/23, revised 04/10/23 indicated Resident #19 was at risk for adverse consequence related to receiving psychotropic medications. Interventions included monitor side effects of anti-depressant (a type of medicine used to treat clinical depression) and antipsychotic. Monitor/document/report prn adverse reactions to antidepressant and psychotropic, monitor/record occurrence for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, verbal/aggression towards staff/others, etc.,) and document per facility protocol. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine (is used to treat certain types of seizures and bipolar disorder) 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Gabapentin (works in the brain to prevent seizures and relieve pain for certain conditions in the nervous system) 600 mg, give 1 tablet by mouth one time a day for neuropathy (happens when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged). <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Zyprexa (is an antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder), give 20 mg by mouth at bedtime for increased mood, decreased anxiety, and agitation, start date 08/11/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Buspirone (is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety) 10 mg, give 1 tablet by mouth three times a day for antianxiety, start date 08/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated monitor resident for side effect of muscle rigidity, change in appetite, sleep disturbance, tardive dyskinesia (is an uncommon side effect of certain medicines), seizures, cardiac changes every shift, start date 03/18/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated monitor resident for behaviors including but not limited to crying, withdrawn, and unrealistic fears every shift for depression, start date 03/19/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated monitor resident for behavior of unrealistic fears, yelling/screaming, hallucinations every shift: see diagnosis, start date 08/28/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 did not indicate behavioral monitoring for Buspirone (antianxiety), Carbamazepine (anticonvulsant), Gabapentin (anticonvulsant), Zyprexa (antipsychotic). <BR/>Record review of Resident #19's order summary dated 01/09/24 did not indicate side effect monitoring for Buspirone (antianxiety), Carbamazepine (anticonvulsant), Gabapentin (anticonvulsant), Zyprexa (antipsychotic). <BR/>2. Record review of Resident#25's face sheet printed on 01/09/24 indicated Resident #25 was an [AGE] year-old male and was admitted on [DATE] with diagnoses including Parkinson's disease (is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) with dyskinesia, Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), moderate, with other behavioral disturbance, and Alzheimer's disease (is a type of dementia that affects memory, thinking and behavior). <BR/>Record review of Resident #25's quarterly MDS assessment dated [DATE] indicated Resident #25 was usually understood and usually had the ability to understand others. The MDS indicated Resident #25 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #25 did not have display behaviors. The MDS indicated Resident #25 was dependent for walking and substantial/maximal assistance for toilet transfer, chair/bed to chair transfer, and sit to stand. The MDS indicated Resident #25 received an antipsychotic during the last 7 days of the assessment period. <BR/>Record review of Resident #25's care plan dated 12/27/23 indicated Resident #25 was at risk for adverse consequence related to receiving psychotropic medication. I [Resident #25] am currently taking psychotropic medication with diagnosis of anxiety and dementia with behaviors. Intervention administers psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift. <BR/>Record review of Resident #25's order summary dated 01/09/24 indicated Lorazepam 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxiety/sundowners, start date 12/13/23. <BR/>Record review of Resident #25 order summary dated 01/09/24 indicated Quetiapine 50mg, give 1 tablet by mouth at bedtime for behaviors, start date 12/27/23. <BR/>Record review of Resident #25 order summary dated 01/09/24 did not indicate behavior monitoring for psychotropic medications.<BR/>Record review of Resident #25 order summary dated 01/09/24 did not indicate side effect monitoring for psychotropic medications.<BR/>Record review of Resident #25's MAR dated 01/01/24-01/31/24 indicated Lorazepam 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxiety/sundowners. Dose given 01/01/24, 01/02/24, 01/04/24, 01/05/24, 01/06/24, 01/07/24, 01/09/24, 01/10/24. <BR/>3. Record review of Resident #29's face sheet dated printed 01/09/24 indicated Resident #29 was an [AGE] year-old male and admitted on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mild, with agitation, delusional disorder (is a type of psychotic disorder), and psychosis (is when people lose some contact with reality). The face sheet did not indicate schizoaffective disorder (is a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). The face sheet indicated MD S was Resident #29's primary physician. <BR/>Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated Resident #29 was understood and sometimes had the ability to understand others. The MDS indicated Resident #29 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS did not indicate Resident #29 had psychosis or behavioral symptoms. The MDS indicated Resident #29 required partial/moderate assistance for toilet hygiene and shower/bath self, supervision for personal hygiene, and independent for oral hygiene and eating. The MDS indicated Resident #29 received an antipsychotic during the last 7 days of the assessment period. <BR/>Record review of Resident #29's care plan dated 01/09/23 indicated Resident #29 was at risk for adverse consequence related to receiving psychotropic medication. I [Resident #29] am currently taking psychotropic medication with diagnosis of depression and psychotic/psychosis. Intervention administers psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift. <BR/>Record review of Resident #29's order summary dated 01/09/24 indicated Seroquel 25 mg, give 1 tablet by mouth at bedtime for schizoaffective, start date 09/30/23. <BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said she used diagnoses list in the chart to add to orders she received. She said sometimes MD and NP sent order with diagnoses already added. She said nurses were responsible for ordering and doing behavior and side effect monitoring. She said the behavior and side effect monitoring should be done by drug classification. She said it was important to do behavior and side effect monitoring for each drug class because each classification had different side effects monitor and behaviors it treated. She said prn psychotropic meds could be ordered for 14 days for hospice residents. She said she was not sure about other residents. She said she did not know why prn psychotropic meds needed 14 days stop dates. She said the MDS coordinator (CRS), NP, and MD made sure residents had appropriate diagnosis for antipsychotic meds and would let the staff know if it was not appropriate. She said antipsychotic meds should have appropriate diagnoses to make sure the resident gets the right medication and know if the black box warnings applied to the resident. <BR/>During an interview on 01/10/24 at 1:20 p.m., the CRS said if she found an inappropriate diagnoses while reviewing the chart, she notified staff of the issue. She said Resident #25 diagnosis of dementia with behaviors was not an appropriate diagnosis for Seroquel. She said the Resident #29 did not have Schizoaffective as a listed diagnosis on his chart.<BR/>On 01/10/24 at 2:23 p.m., attempted to contact MD S by phone, no return call before or after exit. <BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said nurse were responsible for doing behavior and side effect monitoring. She said the nurse who received the order should make sure to add behavior and side effect monitoring. She said behavioral and side effect monitoring should be for each drug classification. She said it was important to have side effect monitoring to have information to relay to the doctor. She said it was important to have behavioral monitoring to know if a medication worked or needed. She said an antianxiety prn medication should have 14 days stop date. She said the nurse who received the prn order and before administration of the antianxiety med should make sure it had a stop day. She said she monitored prn orders and 14 days stop dates. She said she must have missed Resident #25's Lorazepam order. She said 14 days stop date were important to reassess the need of the medication. She said it could risk the resident getting a medication they did not need. She said the CRS looked at orders for appropriate diagnoses. She said appropriate diagnoses and medications were important to treat the actual diagnosis. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said if the resident was care planned for side effect and behavior monitoring, it should be done. She said monitoring should be documented in notes and followed up on. She said monitoring should be done by drug class. She said it was the nurse responsibility for monitoring of psychotropic medications. She said nursing management should be ensuring nurses were doing the monitoring. She said nursing management should be doing chart audits and if issues found, do in-services with the staff. She said prn meds should be 14 days so they could be reassessed for the need of it. She said diagnosis added to the resident chart should come from the physician. <BR/>Record review of a facility's Psychotropic Medication Review policy dated 04/20 indicated .careful assessment as to whether the medication is necessary and pharmacologically appropriate .comply with state and federal regulations related to the use .to include regular review for continued need, appropriate dosage, side effects, risk and/or benefits .monitors psychotropic drug use noting and adverse effects .reviews of the use of the medication with IDT on monthly basis .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 15 residents (Resident #14) and 1 of 1 treatment carts reviewed for drug storage. <BR/>The facility failed to securely store over the counter medication Neosporin for Resident #14.<BR/>LVN D failed to securely lock the wound treatment cart.<BR/>These failures could place residents at risk for adverse reactions. <BR/>Findings included:<BR/>1. Record review of the face sheet 1/8/2024 indicated Resident #14 was [AGE] years old and was admitted on [DATE] with diagnoses including Ataxia (poor muscle control), Functional urinary incontinence (involuntary leakage of urine due to environment or physical barriers to toileting), History of falling, lack of coordination, and diabetes.<BR/>Record review of the MDS dated [DATE] indicated Resident # 14 was usually understood and understood by others. Resident #14 indicated a BIMS score of 5 indicating Resident #14 was cognitively impaired. Resident #14 MDS indicated moderate hearing loss that required hearing appliance and for the speaker to increase volume and speak distinctly.<BR/>Record review of Order Summary Report dated 1/10/2024 for Resident #14 did not indicate an order for Neosporin. Record review of a Medication Administration Record (MAR) for January 2024 indicated Resident #14 did not indicate an intervention or order for Neosporin.<BR/>During an observation and interview on 1/10/2024 at 10:23 a.m., Resident #14 was sitting in recliner. There were 2 - tubes of Neosporin on bedside table. The Neosporin tubes was yellow and white. There was no label identifying orders or resident identifying information. The Neosporin did not have a resident identifying label. The resident said she kept the two ointments at her bedside table, so she uses the ointment on her arms and face as needed for an itch. The resident did not have a roommate at time of interview or observation. Resident #14 said she had the ointment since she was admitted on [DATE].<BR/>During Interview on 1/10/2024 at 11:18 a.m. LVN B said she was not aware Resident #14 had Neosporin on her bedside table. She said the Neosporin should be stored in the medication cart and would require an order. LVN said if medication is identified in a resident's room, staff should remove the medication and explain to resident the importance of notifying staff of any medication brought in facility. During an interview on 1/10/2024 at 11:27 a.m. CNA A who has worked Resident #14's hall said she never seen ointment sitting on Resident #14's bedside table. She said that residents are not supposed to have medications in their room and if identified by staff, it should be removed and given to the charge nurse or her boss.<BR/>During Interview on 1/10/2024 at 11:39 a.m. the DON said normally residents are not supposed to have medications in room unless they have order for self-administering medication. The DON said medication is supposed to be stored on the wound care cart and expects aids to report to nurse, then the nurse is to go in the room and identify if the resident is supposed to have the medication. The DON said she expects the nurses to check the orders, call the family to identify where the medication came from or if ordered. The DON said the resident can have medications in room if determined they are able to self-administer. DON said the physician is the one who makes the determination if a resident can self-administer. The DON said having medications in room without staff knowledge could cause harm such as an adverse reaction or allergic breakout.<BR/>During Interview on 1/10/2024 at 12:30 pm Administrator _ SP said she expects the nurse to notify charge nurse if a resident has medication that is not prescribed in room. She said normally the medications are stored on treatment cart or medication cart unless the resident has an order to have the medication in the room. She said the physician is the one who makes the determination if a resident can self-medicate, and we would need to know about it to provide the best care.<BR/>2. During an observation on 01/09/24 at 11:20 a.m., the wound treatment cart was sitting in the hall outside of room [ROOM NUMBER]. The cart was unlocked with a ring of keys laying on top of the cart. There were no staff members present. The door to room [ROOM NUMBER] was closed. There were no residents in the hall. There were rooms across the hall and near 309 that were occupied by residents. In drawer # 1 there was a tube of Santyl 250 units (a medication used to remove damaged tissue from chronic skin ulcers and severely burned areas), Nystatin cream (a medicated cream or ointment that treats fungal or yeast infections in your skin), 1 tube of Triamcinolone Acetonide Cream 0.1 % (medication used to help relieve redness, itching, swelling, or other discomfort caused by skin condition), 2 bottles Nyamyc 100,000 units per gram (a medicated cream or ointment that treats fungal or yeast infections in your skin), 6 boxes of BPCO Ointment (a medication used as a wound dressing for topical use used to manage chronic and acute wounds, and dermal ulcers), 1 box of Hydrocortisone Cream (a topical medication skin conditions that cause swelling, redness, itching and rashes), Therahoney gel (a medication used to treat wounds and other skin conditions), 2 boxes of hemorrhoidal cream (a cream used to treat swollen veins in your lower rectum) . Drawer 2 had 2 boxes Nyamyc 100,000 usp units per gram, 2 bottles of Betadine (a topical antiseptic that provides infection protection against a variety of germs for minor cuts, scrapes, and burns), Drawer 3 contained various supplies and wound dressings, the 4th drawer had one spray bottle of wound cleanser, 1 bottle of Dakin's solution (a dilute sodium hypochlorite (NaClO) solution commonly known as bleach), and various wound care supplies, and the 5th drawer contained H-chlor 0.125 solution (the same as Dakin's solution) along with various dressing and wound care supplies.<BR/>During an interview on 01/09/24 at 11:25 a.m., RN L said she had been in room [ROOM NUMBER] providing wound care. She said during wound care she found another place on the resident that required a bandage. She said she had to come out of the room during care to get the supplies from the cart. She said she was just in a hurry. She said leaving the cart unlocked could cause problems if a resident got a hold of something in the cart.<BR/>During an interview on 01/10/24 at 11:57 a.m., the DON said all carts should be locked when the nurses were not present, and the nurse should take the keys with them. She said the cart should be locked any time a nurse walks away from the cart. She said any cart being left unlocked could make it to where anyone could take or misplace anything that was in the cart.<BR/>During an interview on 01/10/24 at 12:38 p.m., the Administrator said if a nurse was not using a medication cart or treatment cart then the cart should be locked. She said a resident could get something out of an unlocked cart they should not have. <BR/>Review of a Bedside Medication Storage facility policy # 4.3 Effective date 09-2018 and revised date 08-2020 indicated, .Bedside medication storage is permitted for residents who wish to self-administer medications, upon written order of the prescriber and once self-administration skills have been assessed and deemed .<BR/>Review of a Storage of Medications facility policy dated 09/2018 indicated, .Medications and biologicals are stored safely, securely and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility did not immediately notify the physician and resident representative of a significant change in in the resident's mental or psychosocial status for 1 of 15 residents (Resident #5) reviewed for resident rights. <BR/>The facility failed to inform the attending Physician and the residents representative for Resident #5 when she barricaded herself in her room on 10/22/2023. <BR/>This failure could place residents at risk for not receiving appropriate care and interventions. <BR/>Findings included :<BR/>Record Review of Resident #5 Face Sheet dated 1/8/2024 indicated Resident #5 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #5's diagnosis included Alzheimer's disease with late onset (progressive decline in episodic memory that begins after the age of 64), Dementia in other diseases classified elsewhere (general term for loss of memory, language, and problem-solving abilities), unspecified severity, without behavioral disturbances and other abnormalities of gait and mobility. <BR/>Record review of Resident #5's Quarterly MDS assessment dated [DATE] indicated resident was understood and usually able to understand others. The MDS indicated a BIMS score of 3 indicating Resident #5 was severely cognitive impaired. Resident #5's MDS indicated physical behaviors, verbal behaviors and other behavior symptoms not directed toward others for 1-3 days during the look back period. <BR/>Record Review of Resident #5's care plan revised date 10/23/2023 indicated Resident #5's focus of care on Alzheimer's with late onset with fluctuations between stages with interventions initiated on 6/28/2023 of resident can move around room or facility with use if a walker but requires assist for long distances with occasional use of wheelchair. Resident #5's Care plan revised on 8/4/2023 indicating the resident's mobility will be improved/restored by use of adaptive equipment such as crutches, cane, walker, or wheelchair. Resident #5's care plan revised on 7/31/2023 indicated to monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, except course, declines in function. Resident #5's Care plan revised on 8/4/2023 indicating the resident's mobility will be improved/restored by use of adaptive equipment such as crutches, cane, walker, or wheelchair. Resident #5's care plan revised on 7/31/2023 indicated to monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, except course, declines in function. Resident #5's care plan indicated impaired cognitive function and thought processes but did not address behavioral issues. <BR/>Record Review of the facility investigation summary provided by the Administrator on 1/8/2024, not dated or signed by the author, indicated an incident involving Resident #5 occurred on 10/22/2023, on the night shift. The report indicated Resident #5 refused care during the entire night shift on 10/22/2023, where Resident #5 barricaded herself in her room. The night shift reported they were able to check on Resident #5 through a small opening in the door. Resident #5's representative made an allegation of neglect to the facility's DCO on 10/23/2023 at 1:30 pm. He reportedly made the statement that he did not believe that the staff adequately checked on/monitored Resident #5 during the previous night. The investigation summary indicated that a thorough review of all statements by residents and staff did not support the allegations of neglect. Actions taken post-investigation reflected: all community staff were provided with in-service education on resident abuse and neglect, education on notifying the DCO and/or ADCO immediately if a resident barricaded themselves in their room. The DCO completed 1:1 education with the charge nurse on duty during time of investigation. <BR/>Record Review of a witness statement, dated/signed by CNA M on 10/25/2023, indicated CNA M made first rounds at an unknown time. Resident #5 refused care x 2 attempts and then was reported to the charge nurse. At 12 am the resident was still sitting in her chair with the door open and continued to refuse care and was reported to charge nurse. The next round started at 2 am and the door was closed. The CNA attempted to open the door but could not and notified the charge nurse. Multiple attempts between rounds were made according to the statement. During med pass rounds starting at 4 am, CNA M still could not get in the door and reported to the charge nurse. CNA M went to the room before leaving their shift and reported to 6 a.m.-2 p.m. shift aide about not being able to gain access to room. <BR/>Record Review of Resident #5 Progress note dated 10/23/2023 at 11:52 p.m. revealed LVN G noted that Resident #5 was sitting in front of the restroom door falling asleep in her chair. LVN G offered to assist Resident #5 to bed, and the resident refused. Resident #5 told LVN G that she did not want to be bothered. LVN G gave Resident #5 a moment to calm down, then returned to her room and Resident #5 had the door open slightly with her wheel to her wheelchair blocking the door and refused care. LVN G noted he would attempt contact later. <BR/>Record Review of Resident #5 Progress Note dated 10/23/2023 12:22 am revealed LVN G noted Resident #5 refused assistance and slammed the door and parked the wheelchair behind the closed door and would not open the door. Resident #5 refused to move from behind the door. <BR/>Record review of Resident #5 Progress note dated 10/23/2023 at 2:25 am revealed LVN G documented that Resident #5 was still behind door in her wheelchair. <BR/>Record review of Resident #5 Progress note dated 10/23/2023 at 4:45 am revealed LVN G documented he received report from the RCP who attempted to speak with Resident #5 through the door but could not make out what Resident #5 was saying. LVN G attempted to push on the door while turning the doorknob and was able to get the door open enough just to see Resident #5. Resident #5 was still seated in wheelchair behind the door holding the curtain. Resident #5 yelled Don't do that, I'm putting my socks on. LVN G said ok and advised Resident #5 he would be back to give her time to calm down. At 5:15 am after passing morning medications, LVN G returned to room to see if Resident #5 had moved. Resident #5 remained seated right behind the door in her wheelchair. Resident #5 stated Leave me alone. LVN G reported during the morning shift change that the resident blocked the door and did not want to be bothered. LVN G noted that Resident #5 was still awake and alert sitting in wheelchair at the end of shift. <BR/>Record review of Resident #5 Progress note dated 10/23/2023 at 8:30 am revealed LVN H noted that LVN G reported at 6:15 am during the morning shift change that Resident #5 was sitting in wheelchair against the door throughout the night and would not let anyone in room. After the report was received at 6:15 am, LVN H went to Resident #5 room and was able to push the door open about 2 inches, enough to see her feet stretched out in front of her and could see her striped shirt. LVN H noted it appeared Resident #5 was sitting on the floor with her right shoulder against the door. LVN H asked Resident #5 to move away from the door so she could come in. Resident #5 yelled Give me a minute, don't do that. LVN H notified the DCO and ADCO at 6:19 am and explained the situation. LVN H returned to the room and where Resident #5 continued to refuse to move. LVN H notified the resident's hospice provider at 6:47 am. LVN H called the DCO again at 6:54 am and LVN H called Resident #5'srepresentative to notify him of the situation. Representative arrived at facility at approximately at 7:30 am and Plant Operation Manager J was able to the open window from the outside to get into room and open the door. LVN H documented she observed Resident #5 sitting on her bottom on the floor with her right shoulder toward door and feet stretched out in front of her. Resident #5 was observed to have multiple red markings on back of right shoulder and she c/o pain but was able to move her arm. Vital signs documented at 8:30 am reflected blood pressure 136/85 , HR 92, RR 18 Temperature 97.6 degrees Fahrenheit, and Oxygen 94% Room Air. LVN H noted that Resident #5 appeared more confused than normal. Resident #5 was assisted into her wheelchair and onto the bed. The RCP and ADCO noted to have washed Resident #5 up and changed her clothes. Resident #5 was served breakfast and given her morning medications. <BR/>Record review of In-service dated 10/23/2023 RE: Notification. Description- Nurses and RCP's: Anytime a resident is in a room barricaded please notify the DCO and ADCO immediately. <BR/>Record Review of Resident #5's Hospice Comprehensive Assessment and Plan of Care Updated report dated 6/30/2023 revealed Resident #5 had become more forgetful, delusional, and confused resulting in more combative behaviors toward staff providing ADL care. <BR/>Record Review of progress notes from 10/9/2023 to 1/10/2024 revealed resident had behaviors of refusing care, medications, and increased episodes of crying. Resident #5 did not have any previous reports of barricading herself in her room. <BR/>Observation of Resident #5 on 1/9/2024 at 8:00 am revealed the resident was observed sitting up in bed eating breakfast. Resident #5 said she had a good night and smiled during the conversation. <BR/>Observation of Resident #5's room on 1/9/2024 at 10:25 am with Plant Operations Manager J revealed the bathroom door swung open toward the hinges of entrance of Resident #5's room door which blocked the opening of the entrance door. Observed the entrance door opening approximately 2 inches when the bathroom door was fully opened. <BR/>Attempted Interview with CNA M on 1/9/2024 at 1:09 PM but was unable to leave a message and did not receive a return call by exit date 1/10/2024.<BR/>During an interview on 1/8/2024 at 1:28 PM, Resident #5 said she did not have any concerns about facility other than she has lots of falls. Resident #5 said she was not interested in talking. <BR/>During an interview on 1/8/2024 at 2: 04 PM, Resident #5's RP said the facility reported to him on 10/23/2023 Resident #5 had barricaded herself in her room the previous night. Resident #5's RP said a male nurse was taking care of her that night. Resident #5 was lying down on the other side of the door. Resident #5's RP said that the maintenance man walked by while he was there, and they decided to walk around to window and determined it was open. Resident #5's RP said that his mother was on the floor against the door and was wet of urine. Resident #5's RP said the nurse did not notify him that his mother was barricaded in her room, refused access to staff, and refused to take her medications throughout the night. Resident #5's RP said if he had been notified, earlier in the situation, he could have come to facility and intervened preventing his mother from lying in the floor for extended period of time in her own urine. <BR/>During an interview on 1/9/2024 at 11:53 AM, LVN H said it was reported by the night shift nurse that the resident had barricaded self in her room and Resident # 5 was in her wheelchair. LVN H went down to check on the situation and was only able to open the door about an inch. She stated that the night shift nurse had already left. LVN G reported to her that he was able to see the resident in her wheelchair 20 minutes prior. LVN H said she felt like Resident #5 was on the floor when she attempted to visualize Resident #5 inside her room. LVN H immediately notified the DCO, Physician or representative. LVN H said Resident #5's RP arrived at facility and the Plant Operations Manager and Resident #5's RP went to the window and was able to gain access through the outside window. LVN H reported Resident #5 was wet from incontinence. LVN H said Resident #5 was confused and said Resident #5 had been experiencing hallucinations, talking about people trying to hurt her all night. LVN H said not being able to access the resident could result in fall with injury such as hitting head or worse injury. <BR/>During an interview on 1/9/2024 at 1:09 PM, LVN G said he arrived at facility on 10/22/2023 at 9:30 p.m . and the resident was sitting in her wheelchair. LVN G said he made his rounds to first check vital signs. LVN G said that he did not observe weakness with Resident #5. LVN G said the aide came in at 10 p.m. and made rounds and filled ice. LVN G said Resident #5 was agitated and upset the whole night. LVN G said the resident's bedroom door was wide open all night. LVN G said Resident #5 has an attitude and did not want to be bothered. LVN G said he noticed between 3:30 a.m. - 4 am that her door was closed, and Resident #5 was up all night. LVN G said after Resident #5's door was observed closed, he attempted to open the door and Resident #5 told him Stop, I am back here. LVN G said he was able to open the door enough to stick his head in and visualize her sitting up in her wheelchair. LVN G said he was not able to pass morning medications to the resident due to her barricading herself in room and only reported to the oncoming nurse. <BR/>During an interview on 1/10/2024 at 1:30 PM, LVN G said he relayed information to the nurse the next morning concerning Resident #5 being barricaded behind the door and refusing care. LVN G said CNA M did report Resident #5 was refusing care and she refused care all night. LVN G said he made 3 attempts to provide care. LVN G was unable to determine how many times a resident refuses care before contacting the family, physician, or administrator per the facility policy. LVN G said he received advice from staff that was on duty at the time on what to do. LVN G said he spoke with another nurse on another unit. LVN G said that he did have access to an on-call nurse after-hours. LVN G said that he was hoping to coach Resident #5 down to a better mood and did not call the on-call nurse. LVN G said he felt it was appropriate care at the time, so he sent CNA M to check and coach Resident #5. LVN G said he does not feel Resident #5 wants a male nurse. LVN G said he was concerned Resident #5 may have some sundowners . (Increased confusion with Alzheimer's and dementia may experience from dusk through night)<BR/>During an interview on 1/9/2024 at 3:12 PM, the DCO said she expected the staff to call and report to the DCN/ADCO/Admin for help and guidance on a barricaded resident. The DCO said she was unsure of any policy on barricaded residents. The DCO said she expected staff to notify family of a barricaded resident. The DCO said she expected staff to notify the family if the resident refused care 3 times and that included monitoring the resident. The DCO said if a resident was barricaded behind a door and not monitored appropriately, she could have adverse symptoms such as shortness of breath , elimination issues, cardiovascular issues, depending on disease process, including death. DCO said she was updated on Resident #5's condition once she was able to be assessed.<BR/>During an interview on 1/9/2024 at 3:33 PM, the ADCO said the morning shift nurse reported to her that Resident #5 was barricaded behind the closed door throughout the night. The ADCO said she expected the night shift nurse to report any issues after-hours to the on-call nurse or administration. The ADCO said LVN G reported that he could see part of her such as her legs. The ADCO said after 3 attempts, LVN G should have contacted the ADCO/DCO/ADM. The ADCO said with Resident #5 barricaded behind a closed door could result in adverse events such as stop breathing, injury or death. <BR/>During an interview on 1/10/2024 at 12:20 PM, the Administrator said she expected the nurse and staff to report changes in condition to the family, MD, and administration. Administrator said Resident #5 had the right to refuse care but she expected in this situation, that after a couple of hours, the family, MD and ADM or nurse on-call to be notified. The Administrator said LVN G was able to see the resident through a crack in the door and was able to visualize her. Administrator said their ability to monitor Resident #5 was limited. <BR/>Record review of a policy titled Incident and Accidents, dated 3/1/2017 revealed Accidents or incidents involving residents shall be investigated and reported to the Executive Director of Operations .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 5 resident's (Resident #34) reviewed for PASRR.<BR/>The facility failed to submit NFSS forms timely for Resident #34.<BR/>This failure could place residents identified at a level II for PASRR evaluation at risk for their specialized services not being provided in a timely manner.<BR/>Findings included:<BR/>Record review of face sheet dated 01/08/24 indicated Resident #34 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses of myotonic muscular dystrophy (a genetic condition that causes progressive muscle weakness and wasting), dysphagia (difficulty swallowing), and lack of coordination. <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #34 was usually understood and understood others. The MDS indicated a BIMS of 08 which indicated moderate cognitive impairment. The MDS indicated Resident #34 required partial/moderate assistance with rolling left to right, sit to lying, and lying to sitting on side of bed. Resident #34 required partial/moderate assistance with upper body dressing and substantial/maximal assistance with bathing. Distinct Calendar Days of Therapy, was marked 5, meaning Resident #34 did receive occupational, speech, or physical therapy during the 7 days of the assessment. In section G0400, the MDS indicated Resident #34 received 0 individual minutes, concurrent minutes, and group minutes for Speech-Language Pathology and Audiology Services and 0 individual minutes, concurrent minutes, and group minutes for occupational therapy. Both had a therapy start date of 11/09/23. <BR/>Record review of physician's orders dated 01/08/24 for Resident #34 indicated an order with a start date of 07/10/23 indicated:<BR/>An order dated 07/10/23, OT (occupational therapy) to eval and treat as indicated.<BR/>An order dated 07/10/23, OT clarification: Patient to receive skilled OT services 3x week x 30 days (3 times a week for 30 days) for treatment .to include therapeutic activity, therapeutic exercise, neuro re-ed (neurological re-education), group activity and self-care training.<BR/>An order dated 08/09/23, OT clarification: Recertification completed; PT (patient) to continue to receive OT services 3x/week (3 times a week) to include ther ex (therapeutic exercise), group therapy, neuro re-ed, self-care training, and ther act (therapeutic activity).<BR/>An order dated 04/05/23, ST (speech therapy) order clarification: Skilled speech therapy to address speech production and clarity with diet evaluation and changes as needed. <BR/>An order dated 11/16/23, ST eval and treat effective 11/09/23.<BR/>Record review of a care plan last revised on 12/28/23 indicated Resident #34 had an ADL self-care performance deficit related to disease processes. There was an intervention for PT/OT to evaluate and treat as per physician's orders. The care plan did not address PASRR. <BR/>Record review of a PASRR Comprehensive Service Plan form dated 07/06/23 indicated a quarterly meeting was held. The meeting was attended by Resident #34, a PASSR Health Coordinator, the Social Worker, the DON, and the Director of the Rehabilitation department. The Nursing Facility Specialized Services section indicated specialized occupational therapy and specialized speech therapy were recommended. <BR/>Record review of Simple LTC portal (portal used to submit PASRR service requests) for Resident #34 indicated notes dated 07/24/23:<BR/>* .NFSS Form for Occupational Therapy was not submitted within 30 calendar days of the IDT meeting. <BR/>* .NFSS Form for Physical Therapy was not submitted within 30 calendar days of the IDT meeting.<BR/>* .NFSS Form for Speech Therapy was not submitted within 30 calendar days of the IDT meeting.<BR/>* Form submitted. There was no indication if this form was for physical therapy, occupation therapy, or speech therapy. <BR/>Record review of the Simple LTC portal for Resident #34 dated 7/25/23 indicated a note from the PASSR Unit, Each request must have its own, unique and original signatures and signature pages. You may not use typed or digitally written signatures, stamps, or copied signatures. Please complete the following steps. Q. Upload a valid completed signature page that is original,, ensure signatures are legible and the signature dates match the portal, and resubmit. 2. Set all appropriate tabs that are in Pending Denial status to Pending State Review before 07/31/23 to avoid a system -generated denial. <BR/>Record review of a letter dated 07/27/23 from the PASRR Unit to Resident #34 indicated, .We have received a request for PASRR nursing facility specialized services The following service or items have been denied .Occupational Therapy. Reason for Denial: We needed more information to review your request. We didn't receive the information by the deadline .Speech Therapy .Denied .We needed more information to review your request. We didn't receive the information by the deadline .<BR/>Record review of a letter dated 07/28/23 from the PASRR Unit to Resident #34 indicated, .The following services or items have been approved .Physical Therapy .<BR/>Record review of an email correspondence from the PASSR Unit to the MDS coordinator dated 06/26/23 indicated, .Provides must complete a Nursing Facility Specialized Services (NFSS) for to request PASRR nursing facility specialized services . A training link was included in the email. <BR/>During an interview on 01/09/24 at 1:12 p.m., the Director of Rehabilitation department/Certified Occupational Therapist said Resident #34 had always received physical therapy, occupation therapy, and speech therapy. She said the services were covered by his Medicare. She said Medicare would not approve further services. She said they started the process to have the services approved through PASSR specialized services. <BR/>During an interview on 01/09/24 at 2:15 p.m., the MDS Coordinator said the process to obtain PASSR services for a PASSR positive resident would be to hold a meeting with local health authority to determine if services were needed. She said then a care plan meeting would be held. She said therapy then picked them up and filled out the NFSS form to get it approved. She said Resident #34 had been in the hospital and when he came back to the facility, they used his Part B services until those services were up and there was a new meeting to determine the services needed. She said she had not received any correspondence or letter concerning denial. <BR/>During an interview 01/10/24 at 8:15 a.m., the Director of Rehabilitation department/Certified Occupational Therapist said Resident #34 received therapy from April - June 27, 2023 She said it was funded through his Part B . She said Resident #34 received occupational therapy 7/10/23 - 8/10/23 and speech therapy 7/11/23 - 8/10/23. She said on 8/10/23 Resident #34 was admitted to the hospital. When he was readmitted to the facility, he received all therapies through Part B until the benefits were exhausted. She said at this time they were working on getting him recertified through PASSR services. She said she was unaware that she had to fill at a NFSS for each service.<BR/>During an interview on 01/10/24 at 10:58 a.m., the MDS Coordinator said the Director of Rehabilitation department/Certified Occupational Therapist was responsible for submitting the NFSS forms for residents. She said she was only in the facility 2 days a week and she was not sure why the occupational therapy NFSS or the speech therapy NFSS forms were not submitted. She said the appropriate forms not being submitted could cause a resident to not receive needed services.<BR/>During an interview on 01/10/24 at 11:57 a.m., the DON said the MDS Coordinator, and the Social Worker were responsible for submitting the NFSS forms to the PASSR Unit. She said she would have expected the requested forms to have been submitted. She said the forms not being submitted could cause a resident to receive specialized services.<BR/>During an interview on 01/10/24 at 12:38 p.m., the Administrator said Director of Rehabilitation department/Certified Occupational Therapist was responsible for submitting NFSS forms. She said she would have expected for the forms to have been summited if they were requested from the PASSR unit. She said the NFSS form not being summitted could cause a resident to not receive therapy services. <BR/>Review of a facility PASSR facility policy dated 11/2023 indicated, .Follow Texas PASSR Policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASSR status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 15 resident reviewed for ADLs. (Resident #19)<BR/>The facility failed remove Resident #19's unwanted facial hair.<BR/>The facility failed to provide Resident #19 her schedule bath/showers.<BR/>These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.<BR/>Findings included:<BR/>Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side and muscle weakness.<BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene.<BR/>Record review of Resident #19's care plan dated 04/10/23 indicated Resident #19 had limited physical mobility related to stroke and weakness. Intervention included Resident #19 was non-weight bearing. The care plan did not address ADL care and intervention. <BR/>Record review of Resident #19's ADL bathing report dated 12/11/23-01/08/24 indicated no documentation for Resident #19 for 6 out of 13 scheduled bath/showers. The ADL bathing report indicated Resident #19's shower days were Mondays, Wednesdays, and Fridays. <BR/>Record review of Resident #19's shower sheets from 12/11/23-01/08/24 indicated 12/11/23 (bed bath), 12/13/23 (refused shower, received bed bath, shaved), 12/18/23, 12/22/23 (bed bath), 12/28/23 (bed bath), 01/03/24 (showered, shampoo), 01/05/24, 01/08/24 (bed bath). <BR/>During an interview and observation on 01/08/24 at 1:04 p.m., Resident #19 was lying in her bed in a hospital gown with food on her hand and the bed. Resident #19 said she did not get enough baths. She said her baths were on Mondays, Wednesdays, and Fridays but she only got them once or twice a week. Resident #19 had small amount of black, curly hair on both side of her mouth. Resident #19 said she wanted it (facial hair) off. <BR/>During an observation on 01/09/24 at 11:30 a.m., Resident #19 was lying in her bed in a hospital gown with a small amount of black, curly hair on both side of her mouth. <BR/>During an observation on 01/09/24 at 1:15 p.m., Resident #19 was lying in her bed in a hospital gown with a small amount of black, curly hair on both side of her mouth. <BR/>During an interview on 01/10/24 at 12:22 p.m., RCP O said RCPs were responsible for giving residents bath or showers and removing facial hair. She said Resident #19 refused showers at least once a shift when she worked. She said Resident #19 let the RCPs remove her facial hair. She said ADL care was charted on the facility's charting system. She said the ADCO and DCO decided the shower scheduled. She said the shower schedule was posted at the nurse's station with the resident's day and which shift. She said the facility just started using shower sheets also to document resident's showers. She said ADL care was important for hygiene. She said sometimes if the facility only had 2 RCPs on the floor, things did not get done like resident's shower and baths. <BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said RCPs were responsible for ADL care of residents. She said if the resident refused, the RCP was supposed to notify the nurse and the nurse was supposed to also ask then document if the resident still refused. She said Resident #19 refused to get up for showers but would get a bed bath instead. She said Resident #19 rarely refused to have her facial hair removed. She said refusals were documented on shower sheets. She said ADL care was important for the resident's dignity and to smell good. <BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said the RCP was responsible for ADL care. She said residents should get bed bath daily and showers three times a week. She said she was not sure when women were shaved. She said ADL care was documented in the facility's charting system. She said she was not sure if Resident #19 refused to have her facial hair removed but she refused showers but would do bed baths. She said bed baths and showers were supposed to be charted in the facility's charting system. She said shower sheets were supposed to be done for all bath and showers. She said shower/baths were important to promote cleanliness. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said RCP was responsible for ADL care. She said she expected the staff to follow the shower schedule unless the resident refused. She said facial hair should be removed as needed. She said nurses and nursing management should make rounds to ensure resident were be provided ADL care. A policy regarding ADL for shower/bath and facial hair was requested at this time, the policy was not received before or after exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 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 for 2 of 2 residents reviewed for transmission-based precautions. (Resident #6 and Resident #9)<BR/>The facility failed to isolate Resident #6 and Resident #9 after urine cultures (test checks urine for germs (microorganisms) that cause infections) revealed ESBL (enzymes break down and destroy some commonly used antibiotics) in their urine.<BR/>This failure could place residents at risk for being exposed to health complications and infectious diseases. <BR/>Findings included:<BR/>1. Record review of Resident #6's face sheet printed on 01/10/24 indicated Resident #6 was an [AGE] year-old female and admitted on [DATE] with diagnoses including senile degeneration of brain (a progressive decline in a person's ability to think and remember can be due to a wide range of brain conditions) and need for assistance with personal care.<BR/>Record review of Resident #6's annual MDS assessment dated [DATE] indicated Resident #6 was understood and understood others. The MDS indicated Resident #6 had a BIMS score of 06 which indicated severe cognitive impairment. The MDS indicated Resident #6 was dependent for toilet hygiene and was always incontinent of urine and bowel. <BR/>Record review of Resident #6's care plan dated 10/30/21 indicated Resident #6 was frequently incontinent and at risk for skin breakdown. Intervention labs as ordered. <BR/>Record review of Resident #6's order summary dated 12/01/23-01/10/24 indicated urinalysis (s a test that examines the visual, chemical and microscopic aspects of your urine)with culture (is a test to find germs (such as bacteria or a fungus) that can cause an infection) and sensitivity (checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection), ordered date 12/18/23. The order summary did not indicate isolation for ESBL in the urine. <BR/>Record review of Resident #6's culture and sensitivity results dated 12/19/23 indicated .high pathogens detected .Escherichia coli .antibiotic notes .ESBL (Extended Spectrum Beta-lactamase detected .are usually multi-drug resistant .<BR/>2. Record review of Resident #9's face sheet printed 01/16/24 indicated Resident #9 was a [AGE] year-old male and admitted on [DATE] with diagnoses including schizoaffective disorder (is a mental health condition with symptoms of both schizophrenia and mood disorders), acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), and overactive bladder (is a collection of symptoms that may affect how often you pee and your urgency). <BR/>Record review of Resident #9's quarterly MDS assessment dated [DATE] indicated Resident #9 was understood and understood others. The MDS indicated Resident #9 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #9 required partial/moderate assistance for toileting hygiene and was occasionally incontinent of urine and bowel. <BR/>Record review of Resident #9's care plan dated 01/17/23 indicated Resident #9 had occasional bladder incontinence and was at risk for skin breakdown. Intervention included monitor/document for signs and symptoms of urinary tract infection. <BR/>Record review of Resident #9's order summary dated 01/10/24 did not indicate isolation for ESBL in the urine.<BR/>Record review of Resident #9's culture and sensitivity results dated 11/14/23 indicated .high pathogens detected .Escherichia coli .antibiotic notes .ESBL (Extended Spectrum Beta-lactamase detected .are usually multi-drug resistant .<BR/>During an interview on 01/10/24 at 9:45 a.m., the DCO said the ADCO was the ICP, but she was unavailable due to being out sick today. She said the facility did not notice Resident #6 or Resident #9's lab results that said they had ESBL in their urine. She said the ICP was responsible for reviewing lab results. She said the ICP and LVNs were responsible for developing and implementing interventions to address the results. She said so neither Resident #6 nor Resident #9 were placed on contact isolation. She said it was the facility's policy to place residents with ESBL on contact isolation. She said she was not sure of the duration of the contact isolation period. She said Resident #6 and Resident #9 should have been placed on contact isolation to prevent the spread of ESBL. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said after reviewing the lab results of Resident #6 and Resident #9, she said she felt the lab needed a better way to relay information like ESBL. She said the ICP was responsible for reviewing lab results and coordinating the treatment. She said not placing the resident on contact isolation could have allowed ESBL to spread and other resident to spread it. <BR/>Record review of a facility's Transmission-Based Precaution for Infections policy revised on 10/24/22 indicated .contact .in addition to standard precaution, use Contact precautions (gown, gloves, mask, or face shield if splashing could occur) for resident known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact .the above included epidemiologically important organisms (Multidrug-resistant organisms) .physician order is required to begin transmission-based precaution and to end .add transmission-based precaution to care plan with all interventions based on type .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents the right to be free from misappropriation of property for one of eight residents (Resident #1) reviewed for misappropriation of property.<BR/>The facility failed to prevent a diversion (misappropriation) of Resident #1's Hydrocodone-Acetaminophen 10-325mg tablets (a combined hydrocodone/acetaminophen narcotic pain reliever on 07/01/23. <BR/>This failure could place residents at risk for decreased quality life, unrelieved pain, and dignity. <BR/>The noncompliance was identified as PNC. The noncompliance began on 06/30/23 and ended on 07/05/23. The facility had corrected the noncompliance before the survey began.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 07/30/23, indicated Resident #1 was a [AGE] year-old male, admitted on [DATE]. He had diagnoses that included osteomyelitis of the vertebra, sacral, and sacrococcygeal region (a serious infection of the bone that can be extremely painful that occurred in the base of the spine by the tailbone), unilateral primary osteoarthritis - left knee (a condition in which the cartilage within a joint begins to break down and the underlying bone begins to change), pressure ulcer of sacral region - stage 4 (a wound in the sacral region[portion of the spine between the lower back and tailbone] that has extended as deep as the muscle, tendon, or bone), and type 2 diabetes mellitus (a condition in which the body does not use insulin properly, causing elevated blood sugars).<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 05/18/23, indicated he was able to make himself understood and he was usually able to understand others. He had a BIMS score of 13, which indicated his cognition was intact. He did not exhibit behavioral symptoms such as rejection of care or physical or verbal aggression. Resident #1 required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing , toileting, and personal hygiene. He was independent in eating. The MDS further indicated that Resident #1 had pain or hurting frequently in the last 5 days before the assessment. He took opioid medications 7 of 7 days of the assessment. <BR/>Record review of Resident #1's care plan, initiated on 11/07/22, and revised on 12/12/22, indicated a focus of I have potential for pain . as evidenced by Joint pain, muscle spasms, and significant pressure injuries. The goal was that Resident #1's pain and discomfort would be relieved within 1 hour after intervention. Interventions included: Assess characteristics of pain, discuss with resident factors that precipitate pain and what may reduce it, administer pain medications as ordered, discuss with resident the need to request pain medications before pain becomes severe, discuss with physician that for maximum pain relief pain medication are best given around the clock, with PRNs for breakthrough pain, and monitor for potential side effects of pain medication. <BR/>Record review of Resident #1's physician's orders, dated 07/30/23, indicated he had this order:<BR/>*Hydrocodone-Acetaminophen Tablet 10-325mg - Give 1 tablet by mouth every 6 hours as needed for pain. The start date was 11/03/22. There was no end date. <BR/>Record review of Resident #1's June 2023 MAR indicated Resident #1 was administered his hydrocodone-acetaminophen tablet medication at least one time a day on June 1st, and June 3rd through June 30th. <BR/>Record Review of Resident #1's July 2023 MAR indicated Resident #1 was administered his hydrocodone-acetaminophen tablet medication at least one time a day on July 1st through the 13th, July 15th through the 24th, and July 26th through the 28th. <BR/>During an interview on 07/29/23 at 10:55AM, Resident #1 said he was upset about his missing Norco (hydrocodone-acetaminophen) medication, and he was worried that the money for that came out of his pocket. He said he has not had any problems receiving his medication.<BR/>During an interview on 07/29/23 at 1:59PM, the Administrator said she was unable to provide the narcotic sheet for the missing Norco (hydrocodone-acetaminophen) medication. She said both the medication card and the narcotic sheet had gone missing. She said the reason they noticed they were missing was because the resident's new card that had been ordered and came in and it was noticed that the partial card was missing. She said they figured that 4 pills went missing because when the medication was ordered the sheet showed that there were 6 pills left, and they checked Resident #1's MAR and 2 more pills had been marked as given. <BR/>During an interview on 07/29/23 at 2:22 PM, LVA A said she worked 06/30/23 and 07/01/23 on the 2-10 shift. LVN A said she did not count with LVN C at the end of her shift on 6/30/23 around 10:00PM. She said she did count at the beginning of her shift with RN B on 06/30/23 around 2:00PM. She said she remembered the partial card of Resident #1's Norco (hydrocodone-acetaminophen) medication because she remembered giving it to Resident #1 during her shift. She said she thought LVN C took it because RN B told her RN B did not notice it was missing during her shift the morning of 07/01/23<BR/>During an interview 07/29/23 at 2:35PM, RN B said she worked the 6-2 shift on 06/30/23 and 07/01/23. She said she finished her shift on 07/01/23 at 2:00PM and counted with LVN A. She said they counted the narcotics and noticed the partial card of the hydrocodone-acetaminophen medication and the count sheet was missing. She said she did count narcotics on 07/01/23 at the 6AM shift change with LVN C, but she did not notice both the partial card of the medication and the count sheet was missing. She said she was trying to get started on her shift and did not think about it. She said she thinks it probably went missing on LVN C's shift. She was unable to provide a reason for why she felt that way. <BR/>During an interview on 07/29/23 at 2:42PM, LVN C said he was working the 10P-6A shift on 6/30/23-07/01/23. He said he did not count with LVN A at the beginning of his shift at 10PM because LVN A was not feeling good and was in a rush to leave. He said he did count the narcotics at the end of his shift at 6AM with RN B and the count was correct. He said he worked PRN at the facility and has worked there for about 8 years. He said he had never had anything like that happen in the time he had worked as a nurse. He said LVN A was going around the facility telling everyone he was the one that took the medication. He said the facility has not found him guilty and the facility does not call him for work anymore. He said he has been a nurse for 23 years. He said the process for counting the narcotics was that the nurse that was leaving holds the book and the oncoming nurse counts the cards. He said it would be possible to miss a missing narcotic if someone took the card and the sheet. <BR/>During an interview on 07/29/23 at 2:58PM, LVN D said the process for counting the narcotics at shift change was the off going nurse counts the book and the oncoming nurse counts the cards. They go through all the controlled medications. She said if someone took the card and the count sheet it would be possible to miss that a medication was missing. <BR/>During an interview on 07/29/23 at 3:00PM, LVN E said the process for counting the narcotics was that the off going nurse counted the book and the oncoming nurse counts the medication cards. She said it would be possible to miss a medication if the card and the sheet were taken out of the cart. <BR/>During an interview on 07/29/23 at 3:03PM, RN F said the process for counting narcotics was that the offgoing nurse counts from the book and the oncoming nurse counts the medication cards. She said they count all the cards at each shift change and they were supposed to keep the empty cards when the medication runs out for the DON to remove from the cart. She said she counted the amount of cards at each shift change to make sure no one has taken a card out of the cart. She said if someone took the card and the sheet out that it would be possible to miss that a medication was missing.<BR/>During an interview on 07/29/23 at 9:28AM, the Administrator said she did not have a copy of the police report related to the drug diversion and was unable to provide one at that time. She said she should have obtained a copy before, but it was the weekend and the administrative staff at the police department were not in on the weekend. She said there were copies of the interviews that the police took when they were on site in the PIR.<BR/>During an interview on 07/29/23 at 9:34AM, LVN G said she gave narcotics during her shifts. She said the process for checking narcotics at shift change was that the off going nurse checks the sheets in the book and the oncoming nurse checks the medication cards. She said that it was possible to miss a narcotic that was missing if someone had taken the card and the drug sheet. She said she signed out the medication from the count sheet as soon as she pulled it out of the cart. She said if there was missing pain medication a resident could suffer unnecessary pain and ineffective pain management. She said the nurse that has the keys was responsible for ensuring the narcotics were accounted for correctly and do not go missing.<BR/>During an interview on 07/29/23 at 9:43AM, LVN E said a resident could suffer pain if their medication went missing, and they may not be able to get it. She said they would be at risk for ineffective pain management. She said the nurse that had the keys was responsible for ensuring the narcotics do not go missing and that they were counted. <BR/>During an interview on 07/29/23 at 9:59AM, the Administrator said none of the 3 nurses that had access to the keys when the alleged drug diversion occurred had any prior incidents with missing medications in their personnel file.<BR/>During an interview on 07/29/23 at 10:15AM, LVN A said the process for counting narcotics was the nurses would give and take report, then the off going nurse counts the sheets, and the oncoming nurse counts the cards. She said she counted the amount of cards to ensure someone did not take a card and sheet. She said the nurses also keep the empty cards to give to the DON to waste the card. The nurses were responsible for ensuring that the narcotic counts were right and that none have gone missing. The resident could suffer uncontrolled pain and ineffective pain management if medications go missing. <BR/>During an interview on 07/30/23 at 10:18AM, LVN C said the charge nurse and anyone that had possession of the keys was responsible for counting the narcotics and ensuring that the narcotics were not missing or diverted. He said the residents could suffer pain, and ineffective pain management. <BR/>During an interview on 07/30/23 at 12:23PM, the DON said she did not think she had any competencies on the 3 nurses that were identified in the alleged drug diversion related to counting narcotics. She said they were definitely taught about how to sign out the narcotics and to count narcotics at shift change. <BR/>During an interview on 07/30/23 at 12:25PM, the DON said she spoke with the corporate nurse and she said that there was not a competency or any proof that they taught the nurses to count controlled medications at the end of each shift or that they needed to be signed out. She said it was something that nurses learned in nursing school. She was unable to find it in any of the onboarding processes.<BR/>During an interview on 07/30/23 at 1:11PM, the ADON said she got the call when LVN A came into work at 2PM on 07/01/23. LVN A told the ADON there was a missing card of hydrocodone-acetaminophen medication. LVN A told the DON she believed someone may have taken the card and the count sheet. The ADON said she notified the Administrator and DON and came up to the facility. She said she searched all over the facility and was unable to find either the card or the medication sheet . She said she checked the other medications for any discrepancies. On 07/01/23 Both RN B and LVN A were drug tested first and she notified LVN C to come in for a drug test. She said she called the police and they did an investigation on 07/01/23. The ADON said she contacted the physician about the possible diversion. She said the replacement medication card came in that day so the resident did not go without his pain medication. She said she questioned the nurses. RN B missed that the card was missing. LVN C could not remember if there was a card missing. LVN A and LVN C did not count on 06/30/23 because LVN A was not feeling good. She said the officer told them on 07/01/23 to get the urine tested in an outside lab. She said since then they had put in place a new count sheet to count every card that was in the narcotic box and they were not allowed to take the count sheets or the empty cards out of the cart. These in-services were taught on 07/03/23 and 07/05/23. She said the DON was to remove the empty cards from the carts daily Monday through Friday. She said they had not identified anyone that may have diverted the drug. She said all the staff that give medications were in-serviced on the new procedure. She said before the change of procedure, it was clearly possible that someone could take a medication card and the sheet and the nurses could not notice that a medication was gone. She said she was not aware of any previous incidents like that for the three identified nurses. She said the nurse who had the keys in their possession were responsible for keeping the narcotics locked and ensuring none were taken. She said both the off going and oncoming nurse were responsible for ensuring the narcotic count was correct at shift change. She said residents could suffer unnecessary pain and ineffective pain management if their pain medications go missing. She said if a pain medication went missing they would attempt to get other pain medication as ordered out of the E-kit. <BR/>During an interview on 07/30/23 at 1:24PM, the DON said she was out of town on vacation and was called about 4 hydrocodone-acetaminophen tablets missing. She called the regional director to find out the process and how to move forward. The Administrator was notified. She asked the ADON and Administrator if she needed to come into the building to assist, and they told her to stay on her vacation. She said she came back to work the following Monday on 07/03/23 and did in-services with the staff. She said they changed to the new count sheets after the drug diversion event and the nurses were supposed to turn in the empty medication cards and the count sheets to the DON when a medication runs out. She said those were then verified and turned into medical records to be filed. She said the nurses were supposed to count the amount of cards in the cart to ensure that a card and sheet were not taken out. These inservices were completed on 07/03/23 and 07/05/23. She said before the incident and changes to the procedure, someone clearly could have taken a card out and the sheet without the nurses noticing. She said the three nurses did not have any prior incidents like that in their personnel files. She said the nurse that has the keys was responsible for ensuring that the narcotic count was correct and that none have gone missing. She said the DON was also responsible for correct narcotic counts. She said at shift change both the off going and oncoming nurses were responsible for doing a narcotic count and making sure it was correct. She said if a pain medication went missing, the resident could go without the pain medication. She said they would have to pull the medication out of the electronic med cart. If the medication was not in the electronic med cart then they would have to call the pharmacy and get the medication there stat. She said the resident could suffer unnecessary pain and ineffective pain management until the medication arrived.<BR/>During an interview on 07/30/23 at 1:37PM, the Administrator said on 7/1/23 about 2:00PM she was called by the ADON. She was notified about a missing partial card of Resident #1's medication. They were missing some Norco. The ADON said the oncoming nurse LVN A when counting with RN B found that there was a missing card of the Norco. There were 6 left when RN B ordered the new medication and they saw that 2 were given and they figured that 4 pills of Norco were gone. They identified 3 nurses had access to the keys, LVN A, LVN C, and RN B. They had them submit to a drug test on 07/01/23 and then sent it to a lab and they were all negative. They then notified the police on 07/01/23. They audited all the other narcotics and were unable to find any other discrepancies. They disciplined all three nurses because each nurse had a part in the failure. They implemented a new procedure to count the amount of cards and ensure that no one has taken the card and the sheet on 07/05/23. They also kept the empty cards for the DON to remove and ensure that none have gone missing. QAPI team met on 07/14/23 and they agreed with the changes and did not make any other changes. She said the nurses did not have any other incidents like that happen before. The nurses were responsible for counting the narcotics. The DON and the ADON were responsible for oversight and monitoring of the narcotics and that the nurses were doing the narcotic counts. If a drug was taken then they would check for pain medication in the electronic cart, and if they did not have any ordered medication in there they would check with the doctor to see if there was something else suitable for the resident. She also said there was a pharmacy down the road they could possibly get the medication from.<BR/>Record review of a facility inservice, dated 07/05/23, was taught by the DON that the Nurses were to keep empty narcotic medication cards and the sign off sheet until the DON removes the empty card and sheet from the medication cart. <BR/>Record review of a facility inservice, dated 07/03/23, was taught by the DON to nurses that there was a new count sheet to be used at shift changes that included a new procedure to count the amount of narcotic medication cards in the medication carts. <BR/>Record review of a QAPI team sign-in sheet, dated 07/14/23, indicated the QAPI team met on 07/14/23, and met from 10:00AM to 10:30AM. Attendees included the ADON, DON, Administrator, and the medical director. <BR/>Record review of the Facility's policy, Discrepancies, Loss, and/or Diversion of Medications, effective September 2018, and revised August 2020, stated:<BR/>Policy<BR/>All discrepancies, suspected loss, and/or diversion of medications, irrespective of drug type or class, are immediately investigated and a report filed .<BR/> .Procedures<BR/>Immediately upon discovery or suspicion of a discrepancy, suspected loss or diversion, the Administrator, DON, and consultant pharmacist are notified and an investigation conducted. The DON leads the investigation .<BR/> .II. Loss of Supply of a Medication<BR/>1. The DON investigates the suspected loss and researches all the records related to medication receipt, its use since receipt, and all persons involved with medication administration and the supply of medication and identifies the last known point in time that the medication was available. The pharmacy should be notified and the pharmacy should verify that the medication was dispenses. A thorough search is conducted in all drug storage areas, the resident's room, and any other locations where medications may have been used/placed during medication administration in an attempt to locate any missing container or medication supply. <BR/>2. If the supply cannot be found after a thorough investigation has been completed, a supply must be obtained for the resident.<BR/>3. Document the loss and the investigation process. Notify the prescriber and family if doses have been missed and/or follow facility policy. <BR/>4. If the loss involves a controlled substance, all the controlled drug accountability procedures and documentation should be reviewed and audited. If the audit reveals a particular individual or individuals who might be suspected of involvement with the loss, appropriate disciplinary actions are taken and deferred to human resource policies. <BR/>5. Appropriate agencies, required by state and federal law, will be notified .<BR/>Record review of the Facility's policy, Storage of Controlled Substances, effective September 2018, and revised August 2020, stated:<BR/>Policy<BR/>Medications classified by the Drug Enforcement Agency (DEA) as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations.<BR/>Procedures .<BR/>5. Unless otherwise indicated in a facility policy and/or as required by state regulations, the following will be performed:<BR/>a. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel and is documented .<BR/>7. Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and documented on a Control Count Sheet (or similar form) or in accordance with facility policy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure the residents has the right to be informed of the risks and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options he or she preferred, for 2 of 15 residents (Resident #19 and Resident #242) reviewed for resident rights.<BR/>1. The facility failed to ensure Resident #19's psychoactive (substances that, when taken in or administered into one's system, affect mental processes) medication therapy consents were completed properly upon admission and prior to the administration of Zyprexa ( antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder), Venlafaxine ( used to treat major depressive disorder, anxiety, and panic disorder), Trazodone ( used to treat depression), and Carbamazepine ( used to treat certain types of seizures and bipolar disorder). <BR/>2.The facility failed to obtain informed consent based on information of the benefits, risks, and options available for Resident #242 prior to administering Risperdal (is an antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder), Depakote (used to treat seizures and stabilize mood), and Buspirone (used to treat anxiety). <BR/>These failures could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. <BR/>Findings included: <BR/>1. Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including Schizoaffective Disorder (is a mental illness that can affect your thoughts, mood and behavior), Bipolar type, Bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), mild depressed, recurrent depressive disorder, generalized anxiety (you are worrying constantly and can't control the worrying), insomnia (is a common sleep disorder), and conversion disorder with seizures or convulsions (is a condition in which a person experiences physical and sensory problems, such as paralysis, numbness, blindness, deafness or seizures, with no underlying neurologic pathology). <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 received antipsychotic, antianxiety, and antidepressant during the last 7 days of the assessment period. <BR/>Record review of Resident #19's care plan dated 03/21/23, revised 04/10/23 indicated Resident #19 was at risk for adverse consequence related to receiving psychotropic medications. Intervention included administer psychotropic medications as ordered. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated:<BR/>*Carbamazepine 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23.<BR/>*Trazodone 100 mg, give 1 tablet by mouth at bedtime for insomnia, start date 03/18/23.<BR/>*Venlafaxine, give 225 mg by mouth one time a day for depression, start date 03/19/23. <BR/>*Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23. <BR/>* Zyprexa, give 20 mg by mouth at bedtime for increased mood, decreased anxiety, and agitation, start date 08/11/23.<BR/>* Zyprexa, give 50 mg by mouth in the morning for increased mood, decreased anxiety, and agitation, start date 08/12/23.<BR/>Record review of Resident #19's MAR dated 01/01/24-01/31/24 indicated:<BR/>*Carbamazepine 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23.<BR/>*Trazodone 100 mg, give 1 tablet by mouth at bedtime for insomnia, start date 03/18/23.<BR/>*Venlafaxine, give 225 mg by mouth one time a day for depression, start date 03/19/23. <BR/>*Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23. <BR/>* Zyprexa, give 20 mg by mouth at bedtime for increased mood, decreased anxiety, and agitation, start date 08/11/23.<BR/>* Zyprexa, give 50 mg by mouth in the morning for increased mood, decreased anxiety, and agitation, start date 08/12/23.<BR/>Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Zyprexa. The consent indicated Zyprexa .Schiz-affective .improved function ability .antipsychotic .the probable clinically significant side effects or risks associated with the medication included: stiffness of neck, confusion, muscle rigidity .black box warning .<BR/>Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Trazodone. The consent indicated Trazodone .Schizo-Affective .Sleep disorder . antidepressant . the probable clinically significant side effects or risks associated with the medication included: dry mouth, blurred vision . black box warning .<BR/>Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Carbamazepine. The consent indicated Carbamazepine .bipolar disorder .improved function ability .antimanic (are medications used as mood stabilizers in psychiatric conditions such as bipolar disorder and schizophrenia) . the probable clinically significant side effects or risks associated with the medication included: confusion, drowsiness, hypotension (low blood pressure) . black box warning .<BR/>Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Venlafaxine. The consent indicated Venlafaxine .Depression .improved function ability .antidepressant . the probable clinically significant side effects or risks associated with the medication included: dry mouth, blurred vision . black box warning .<BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said the LVNs, or upper nursing management were responsible for medication consents. She said when a verbal consent was done, the nurse who received the verbal consent signed and the ADCO or DCO signed behind them. She said she believed a medication could be given with one nurse signature for verbal consent. She said if the family visited, staff were supposed to try to get a hand signature. She said consents done correctly were important so family aware of current treatment. <BR/>During an interview on 01/10/24 at 2:25 p.m., the responsible party for Resident #19 said she did not recall giving verbal consent for Resident #19's medication immediately after admission. She said she remembered when her family member was transferred to the facility and was not called. She said the facility only told her when Resident #19 started medications but did not go over the consent form. <BR/>During an interview on 01/10/24 at 2:29 a.m., the DCO said nurses were responsible to get consent for medication when they were ordered. She said consent should also be obtained upon admission. She said consent for medication was important to make sure family was aware of risks and benefits of treatment. She said she expected staff to go over the consent form and explain risks and benefits with family before consent was received. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said she expected staff to get consent before giving medications. She said staff should go over risks and benefits before consent was received. She said it was important to give informed consent, so the resident or family understood what the resident was taking. <BR/>2. Record review of Resident #242's face sheet dated 1/08/24 indicated she was a [AGE] year-old female and admitted to the facility on [DATE] with diagnoses including heart failure, Bipolar disorder (associated with episodes of mood swings ranging from depressive or sad lows to manic or excited highs), schizoaffective disorder (combination of symptoms of schizophrenia (affects ability to think, feel and behave clearly) and mood disorder, such as depression or bipolar disorder), major depressive disorder (persistent depressed mood or loss of interest in activities, causing impairment in daily life), and dementia (progressive loss of intellectual functioning, impairment of memory and thinking, often with personality changes caused by disease of the brain).<BR/>Record review of Resident #242's admission MDS assessment revealed it had not been completed.<BR/>Record review of Resident #242's Baseline Care plan dated 1/03/24 revealed she used psychotropic medications.<BR/>Record review of Resident #242's Order summary report dated 1/08/24 revealed an order for: Risperdal 2 mg 1 tablet by mouth at bedtime for bipolar disorder with a start date of 1/03/24; Buspirone 5 mg 2 tablets three times daily for anxiety with a start date of 1/03/24, and Depakote 125 mg 4 tablets three times a day for behaviors with a start date of 1/04/24. <BR/>Record review of Resident #242's MAR dated 1/01/24-1/31/24 indicated Resident #242 had received: Risperdal 2 mg at bedtime since 1/03/24, Buspirone 5 mg 2 tablets three times daily since 1/03/24, Depakote 125 mg 4 tablets two times a day on 1/03/24 to 1/04/24, and Depakote 125 mg 4 tablets three times a day since 1/04/24. <BR/>Record review of a Behavioral Management-psychoactive medication therapy consent dated 1/04/24 indicated a verbal consent for the use of Risperdal was obtained from Resident #242's RP on 1/09/24. This verbal consent was obtained 6 days after admission and after administration of Risperdal to Resident #242.<BR/>Record review of a Behavioral Management-psychoactive medication therapy consent dated 1/04/24 indicated a verbal consent for the use of Buspirone was obtained from Resident #242's RP on 1/09/24. This verbal consent was obtained 6 days after admission and after administration of Buspirone to Resident #242.<BR/>Record review of a Behavioral Management-psychoactive medication therapy consent dated 1/04/24 indicated a verbal consent for the use of Depakote was obtained from Resident #242's RP on 1/09/24. This verbal consent was obtained 6 days after admission and after administration of Depakote to Resident #242.<BR/>On 1/08/24 at 2:27 PM and 1/10/23 at 12:36 PM, attempted to interview Resident #242's RP via phone. There was no answer, and a voicemail was left. Resident #242's RP did not return call prior to the exit of the facility. <BR/>During an interview on 1/09/24 at 11:30 AM, RN N said the admitting nurses were responsible for obtaining the consents for antipsychotics and psychotropic medications. RN N said the admitting nurse obtained consent by calling the RP for verbal consent or obtaining written consent from the RP if they were in the facility. RN N said the DCO was responsible for ensuring the antipsychotic and psychotropic medication consents were completed.<BR/>During an interview on 1/10/24 at 1:02 PM, the DCO said antipsychotic and psychotropic medication consents should be obtained upon admission and the medications should not be administered without obtaining proper informed consent. The DCO said she did not know what happened or why Resident #242's consents were not obtained upon admission. The DCO said she was the initial admitting nurse for Resident #242 and started the admission, but she did not complete it and turned it over to the next nurse. The DCO said it was a group effort to ensure proper informed consent was obtained for antipsychotic and psychotropic medications from the resident or their RP prior to administering the medications.<BR/>During an interview on 1/10/24 at 1:28 PM, the ADM said she would expect proper informed consent to be obtained prior to administering antipsychotic or psychotropic medications from the resident or their RP. <BR/>Requested a policy on antipsychotic and psychotropic medication consents from the DCO on 1/10/24 at 1:02 PM. <BR/>Requested a policy on antipsychotic and psychotropic medication consents from the ADM on 1/10/24 at 3:28 PM.<BR/>On 1/10/24 at 4:00 PM, the ADM said they did not have a policy on antipsychotic or psychotropic medication consents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment are reported immediately or not later than 2 hours for 1 of 6 residents reviewed for abuse and neglect. (Resident #1)<BR/>The facility staff (RCP A, LVN B, and the Social Worker) failed to report an allegation of abuse immediately to the Abuse Coordinator after Resident #1 alleged that RCP D threw a blanket on her face and told her to shut the hell up.<BR/>This failure could place residents at risk for abuse and neglect. <BR/>Findings included:<BR/>Record review of a face sheet dated 04/09/25 revealed Resident #1 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including schizoaffective disorder bipolar type (combines symptoms of both schizophrenia (like hallucinations and delusions) and bipolar disorder (like mania and depression), diabetes, and high blood pressure. <BR/>Record review of a quarterly MDS dated [DATE] revealed Resident #1 was understood and understood others. The MDS revealed a BIMS score of 9, indicating moderate cognitive impairment. The MDS indicated Resident #1 required substantial to maximal assistance with most ADLs. <BR/>Record review of a care plan last revised on 04/10/25 revealed Resident #1 was verbally aggressive related to schizoaffective disorder and mental/emotional illness, ineffective coping skill and poor impulse control with past history of verbal disruption, screaming, cursing, making accusations, telling family untruths about staff and other residents. This focus area of the care plan was last revised on 04/17/23. <BR/>Record review of an undated and untimed written statement of LVN B indicated, On 4/1/25 the 6-2 RCP (RCP A) told me that (Resident #1) had a complaint against (RCP D), the 10-6 rcp from the previous night. I went to speak with (Resident #1), and she stated that the night before (RCP D) threw a blanket at her head and told her to shut the hell up. I asked he if she was okay, and she said yes. She did not have any notable injuries. I asked her why (RCP D) would have done that, and she said she did not know. I informed her that I would tell the administrative team, and someone would come speak to her. I then went to the social worker's office and reported what the resident had told me. The statement indicated it was obtained by the DCO and the ADCO. The statement was signed by the DCO and the ADCO. <BR/>Record review of an undated and untimed statement by the Social Worker indicated, Resident (Resident #1) state that she wanted to tell me about (RCP D) last night. (RCP D) got mad at her because she told her to pick up the bowls and stuff. (RCP D) threw a blanket at her, and it hit the top of her, and she didn't say she was sorry. The statement was signed by the Social Worker. <BR/>Record review of a Disciplinary Action Record dated 04/01/25 indicated RCP D was suspended pending investigation of physical abuse allegation made by a resident. The record indicated RCP D was notified of the suspension by phone on 04/01/25 at 2:41 p.m. The record was signed by the ADCO and the DCO. <BR/>Record review of a police Incident Report dated 04/01/25 at 3:19 p.m. indicated .On April 1, 2025, (police officer) was dispatched to (the facility). Upon arrival, I was met by the Administrator (EDO) .(the EDO) stated that there was an incident where a resident (Resident #1) accused a worker of hitting her in the face with a blanket .(Resident #1) state that a nurse, (RCP D) got mad at her because she asked her to clean her room and take her food tray. (Resident #1) stated that at this point, (RCP D) who was standing in the hallway, threw a blanket and hit her in the face with it .(RCP 1) said in her statement that she was doing rounds and that she would come back to pick up trays after she was finished .(RCP D) said in her statement .she overheard (Resident #1) calling to someone to bring her a blanket and that is when (RCP D) got the blanket and went into the room. (RCP D) said that when she unfolded the blanket, she fanned it up and the edge of it brushed against (Resident #1's) face. (RCP D) said that she was sorry for that immediately and said it was an accident. (Resident #1) was not in any pain or discomfort when (RCP D) left the room according to her statement. Based on my interviews and observations, I believe that this was an unintentional accident and that (RCP D) did fan the blanket, but there was no intention to harm (Resident #1).<BR/>Record review of an undated Investigation Summary indicated, .Based upon the outcome of the investigation, it was determined that several facility employees failed to follow policy and procedure of notifying the Abuse Coordinator immediately when a suspected/actual resident abuse allegation occurs. The employees received individualized education from the EDO. The social services director was sent home once this was discovered and allowed to return after the investigation was complete. The EDO provided 1:1 education to this employee upon return.<BR/>Record review of an In-service & Education Record dated 04/02/25 at 9:45 a.m. indicated the EDO educated the Social Worker on .All allegations of abuse, neglect or misappropriation must be reported timely to the Abuse Coordinator EDO is the Abuse Coordinator. The DCO will serve in this capacity in the absence of the EDO .Failure to comply with this requirement will result in disciplinary action to include possible immediate termination .<BR/>Record review of an In-service & Education record dated 04/01/25 indicated the DCO educated LVN B on Any allegations of abuse/neglect/misappropriation must be reported to Abuse Prevention Coordinator .<BR/>During an observation and interview on 04/09/25 at 10:20 a.m., Resident #1 was resting in bed. There was no bruising or signs of abuse. She said on 3/31/25 she asked RCP D if she would pick up her meal tray. She said when RCP D came in the room she then asked for a blanket. She said RCP D threw the blanket on her and did not spread it out. She said RCP D did not say anything to her. She said she was not injured in any way. She said she reported the incident the next morning to RCP A and RCP A reported it to LVN B. She said RCP D no longer provided care to her and she was ok with it. She said she was not afraid to live in the facility. She said she had no other issues with any staff members.<BR/>During an interview on 04/09/25 at 10:59 a.m., LVN B said she did not know the specific date of the incident concerning Resident #1. She said RCP A came to her and told her what Resident #1 had reported to her. LVN B said RCP A told her that Resident #1 said RCP D threw a blanket over her head and told her to shut the hell up. She said Resident #1 did not like RCP D. She said she went in to talk to Resident #1. She said Resident #1 told her that RCP D threw a blanket at her head and told her to shut the hell up. She said Resident #1 told her she did not like RCP D, and she was going to try to get another aide in trouble because she did not like her either. She said the EDO (the Abuse Coordinator) was not in the facility at the time, so she did not report the allegation to her. She said she reported the incident immediately to the social worker. She said she was told later that she should have reported the incident to the EDO.<BR/>During an interview on 04/09/25 at 11:33 a.m., the Social Worker said she interviewed Resident #1 on the morning of 4/1/25 after the incident was reported to her by LVN B. She said LVN B told her Resident #1 was upset with RCP D. The Social Worker said Resident #1 told RCP D threw a blanket on her head. She said the only other thing she told her was that RCP D did not apologize. She said Resident #1 never told her that RCP D said to shut the hell up. The Social Worker said Resident #1 always upset with someone. She said the resident made false accusations against staff. She said she knew the allegation was reported to her before the morning meeting. She said she was disciplined for not reporting the allegation to the EDO. She said she never reported the allegation to the Administrator and did not know how she found out. She just brought me into the office. <BR/>During an interview on 04/09/2025 at 12:40 p.m., the Social Worker said she said she just did not pay enough attention to what LVN B was telling her. She said she thought LVN B was reporting the behavior of Resident #1 and not that RCP D may have done something abusive. She said she did not realize that it was an abuse allegation until after she was called into the EDO's office. She said she interviewed the resident after leaving the EDO's office and that was when Resident #1 told her that RCP D had thrown the blanket.<BR/>During an attempted interview on 04/09/2025 at 1:55 p.m., a call was made to interview RCP A. There was no answer. Left a detailed message requesting a return call. A return call was not received. <BR/>During an interview on 04/09/2025 at 2:27 p.m., RCP D said she did not know anything about the allegation made by Resident #1 until she was questioned about it. She said she never threw a blanket. She said she never told the resident to shut up. She Resident #1 was upset with her because she did not pick up the evening meal tray as fast as she wanted her too. She said she did bring Resident #1 a blanket and when she spread the blanket out it did cover her face. She said she immediately removed the blanket and told her she did not mean for that to happen. She said she apologized to the resident. She said she had been reassigned and would not be providing care to Resident #1.<BR/>During an interview on 04/09/2025 at 2:41 p.m., LVN B said RCP A reported the allegation made by Resident #1 at approximately 10:00 a.m. She said she reported the incident immediately to the Social Worker. She said she did not report it to the EDO because she was not at the facility at the time. She said she was told later that she still should have notified the EDO. She said she really was not thinking about abuse. She said she was thinking more about the resident's behaviors and had been told to report any behaviors to the social worker. She said she then told the DCO at approximately 12:45 p.m.<BR/>During an interview on 04/09/25 at 2:51 p.m., the DCO said the allegation of abuse made by Resident #1 was reported to the state on 04/01/25 but happened on 03/31/25. She said Resident #1 had asked to speak to her. She said Resident #1 told her RCP D got a blanket and threw it on her from the hallway. She said there were no witnesses to the incident. She said RCP D told her she fanned the blanket out and it went in the resident's face accidently. She said she pulled the blanket down immediately. She said when she first started interviewing RCP D, she did not know what she was talking about. The DCO said she found out about the allegation at approximately 1:00 p.m. on 04/01/25. She said she talked to LVN B. She said LVN B told her she was following instructions from a previous DCO to report any behaviors of Resident #1 to the Social Worker. She said Resident 1's version differed depending on who she told the allegation to. She said she was the one who reported the incident to the EDO. She said she would have expected for the Social Worker to have reported the incident to the EDO immediately after it was reported to her by LVN B. She said allegations of abuse not being reported timely could lead to abuse possibly continuing if it was actually occurring.<BR/>During an interview on 04/09/25 at 3:28 p.m., the EDO said Resident #1 alleged that evening (03/31/25) RCP D threw a blanket from the hallway that landed on her head and told her to shut the hell up. She said RCP D said she got the resident a blanket. Unfolded the blanket, fluffed it out and touched the resident on the face. RCP D said she removed the blanket and said she was sorry. She said Resident #1 then reported the allegation of abuse to RCP A. The EDO said she was not in the building at the moment. She said RCP A told LVN B about the allegation made by Resident #1. She said LVN B ended up reporting the allegation to the Social Worker. She said once she found out about the allegation, she sent the Social Worker home and did a one on one with her after she returned to worked. She said LVN B and RCP A was given one on one education also. She said it was about three hours from the time the allegation was made to RCP A and LVN B and the time she found out about the allegation. She said the DCO was who reported it to her around 1:00 p.m. She said she would have expected RCP A, LVN B, and the Social Worker to have reported the allegation to her sooner. She said she was out of the facility, but her number was at the desk, and they could have called her. She said she expected all allegations of abuse to be reported to her immediately. She said allegations not being reported timely limited her options to intervene and take action. <BR/>Record review of an Abuse facility policy last revised on 01/01/23 indicated, .The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure .All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 15 residents reviewed for care plans. (Resident# 19, Resident #29)<BR/>The facility failed to implement Resident #19's care plan intervention to off-load (is described as lifting or pushing an area of high pressure away from the cause of the pressure) her heels when in bed.<BR/>The facility failed to care plan Resident # 19's diagnosis of Type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and use of insulin (therapy often is an important part of diabetes treatment), diuretic (are medicines that help reduce fluid buildup in the body), opioid (sometimes called narcotics, are a type of drug), and antiplatelet (are medications that prevent blood clots from forming) coded of her MDS. <BR/>The facility failed to care plan Resident #19's use of an anticonvulsant (are prescription medications that help treat and prevent seizures). <BR/>The facility failed to care plan Resident #29's use of an antiplatelet. <BR/>These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services.<BR/>Findings included:<BR/>1. Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Type 2 diabetes, edema (is swelling caused by too much fluid trapped in the body's tissues), cerebrovascular disease (is a term for conditions that affect blood flow to your brain), bipolar (causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), and conversion disorder (is a condition where a mental health issue causes physical symptoms) with seizures (is a sudden, uncontrolled burst of electrical activity in the brain) or convulsion (are rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 had diagnoses including diabetes mellitus and seizure disorder or epilepsy (is a brain condition that causes recurring seizures). The MDS indicated Resident #19 received scheduled pain medication regimen and experienced presence of pain in the last 5 days. The MDS indicated Resident #19 received diuretic, opioid, and antiplatelet medications during the last 7 days of the assessment period. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Clopidogrel (It is an antiplatelet drug. It helps keep blood flowing smoothly in your body) 75 mg, give 1 tablet by mouth one time a day for anticoagulation, start date 03/18/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine (is in a class of medications called anticonvulsants. It works by reducing abnormal electrical activity in the brain) 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Lasix (is a strong diuretic (water pill') and may cause dehydration and electrolyte imbalance) 20 mg, give 2 tablets by mouth one time a day for cerebrovascular disease, start date 03/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Gabapentin (is an anticonvulsant medication primarily used to treat partial seizures and neuropathic pain) 600 mg, give 1 tablet by mouth one time a day for neuropathy (happens when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged), start date 03/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Novolin (is a type of insulin used to control blood sugar) 100 units/ML (Insulin Regular (Human)), inject as per sliding scale, subcutaneously two times a day for diabetes type 2, start date 04/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Tramadol (is in a class of medications called opiate (narcotic) analgesics and used to treat moderate to severe pain that is not being relieved by other types of pain medicines) 50 mg, give 1 tablet by mouth three times a day for pain, start date 08/14/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Lantus (is a long-acting form of insulin), inject 30 unit subcutaneously at bedtime for diabetes type 2, start date 11/08/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Lantus, inject 40 unit subcutaneously in the morning for diabetes type 2, start date 11/08/23. <BR/>Record review of Resident #19's care plan dated 07/19/23 indicated Resident #19 had a DTI (is a form of pressure ulcer or pressure sore) to left heel. Intervention off-load heels while in bed. The care plan did not address Resident #19's diagnosis of Type 2 diabetes and use of an anticonvulsant and use of insulin, diuretic, opioid, and antiplatelet coded of her MDS. <BR/>During an observation and interview on 01/08/24 at 1:04 p.m., Resident #19 was lying in the bed on her back. Resident #19's feet were not off-loaded. She said the staff did not put anything underneath her heels but sometimes put heel protectors on after therapy. The heel protectors were on the bed next to Resident #19. Resident #19 said she had not had them on in a while. <BR/>During an observation and interview on 01/09/24 at 1:15 p.m., Resident #19 was lying in the bed on her back. Resident #19's feet were not off-loaded.<BR/>During an interview on 01/10/24 at 12:22 p.m., RCP O said the RCPs and LVNs were responsible for ensuring Resident #19's heels were floated. She said Resident #19 also had heel protectors she would wear. She said Resident #19 had sores on her feet and they were floating them to heal. She said floating a resident's heels kept the pressure off the area damaged. <BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said the nurse was responsible for floating Resident #19's heels or placing her heel protectors on. She said Resident #19 would sometimes refuse the heel protectors or would not float her heels for long periods of time. She said Resident #19 had a DTI and was paralyzed on her left side so floating her heels was important for prevention of skin breakdown. She said she did not know if nurses had access or could see care plans interventions. She said nursing staff knew resident care from morning meeting updates. She said implementing Resident #19 care plan intervention was important to prevent wounds or injuries. <BR/>2. Record review of Resident #29's face sheet printed 01/09/24 indicated Resident #29 was an [AGE] year-old male and was admitted on [DATE] and 05/31/22 with diagnosis including atherosclerotic heart disease of native coronary artery (is caused by plaque buildup in the wall of the arteries that supply blood to the heart (called coronary arteries)). <BR/>Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated Resident #29 was understood and sometimes had the ability to understand others. The MDS indicated Resident #29 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #29 required partial/moderate assistance for toilet hygiene and shower/bath self, supervision for personal hygiene, and independent for oral hygiene and eating. The MDS indicated Resident #29 received an antiplatelet during the last 7 days of the assessment period. <BR/>Record review of Resident #29's order summary dated 01/09/24 indicated Aspirin (is used to treat pain and reduce fever or inflammation. It is sometimes used to treat or prevent heart attacks, strokes, and chest pain) 81 mg, give 1 tablet by mouth one time a day for preventative, start date 12/18/20. <BR/>Record review of Resident #29's care plan printed 01/09/24 did not indicate use of an antiplatelet. <BR/>During an interview on 01/10/24 at 1:20 p.m., the CRS said she was responsible for MDSs and care plans. She said she only worked part time at the facility. She said she developed the comprehensive care plan from the CAAs on the MDS, medical diagnoses, physician's orders, activities, reviewed progress and social notes, and anything special in the resident's history. She said Resident #19's diagnoses and medications should be included on her care plan. She said comprehensive care plans were important to make sure residents received services and any special needs the staff needed to be aware of. She said Resident #29's use of an antiplatelet should have been added to his care plan. She said new nurses could look at a care plan and may not know the appropriate care for the resident if problem areas were not added to the care plan.<BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said the MDS Coordinator (CRS) and the DCO were responsible for comprehensive care plans. She said Resident #19's diagnoses and medications and Resident #29 use of an antiplatelet should be care planned. She said comprehensive care plans were important, so nurses were aware of the resident's issues. She said the nurses were responsible for care plan interventions to be implemented. She said sometimes Resident #19 refused to off-load her heels. She said staff were supposed to chart if Resident #19 refused. The DCO said LVNs were able to view residents' care plans on the facility's charting system but not RCPs. She said LVNs should inform RCPs of care plan interventions such as off-loading heels, so they knew to monitor. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said if an intervention was on a care plan, she expected it to be followed or done. She said if the information was on the MDS and was triggered (coded), she expected it to be on the care plan. She said nurses and nurse management was responsible for ensuring comprehensive care were complete and interventions are followed or done. She said diagnoses and medications had risked that had to be monitored and intervention developed. <BR/>Record review of a facility's Comprehensive Care Plan revised on 04/21 indicated .the interdisciplinary team will continue to develop the plan in conjunction with RAI (MDS 3.0) and CAAS .the IDT will review the healthcare practitioner's notes and orders and implement a comprehensive care plan to meet the residents' immediate needs including but not limited to .physician orders .pain management .specific care plan on the main reason for admission .<BR/>Record review of a facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .is for prevention and treatment of skin breakdown such as pressure injuries .prevention .dependent residents will have heels floated while in bed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 15 resident reviewed for ADLs. (Resident #19)<BR/>The facility failed remove Resident #19's unwanted facial hair.<BR/>The facility failed to provide Resident #19 her schedule bath/showers.<BR/>These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.<BR/>Findings included:<BR/>Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side and muscle weakness.<BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene.<BR/>Record review of Resident #19's care plan dated 04/10/23 indicated Resident #19 had limited physical mobility related to stroke and weakness. Intervention included Resident #19 was non-weight bearing. The care plan did not address ADL care and intervention. <BR/>Record review of Resident #19's ADL bathing report dated 12/11/23-01/08/24 indicated no documentation for Resident #19 for 6 out of 13 scheduled bath/showers. The ADL bathing report indicated Resident #19's shower days were Mondays, Wednesdays, and Fridays. <BR/>Record review of Resident #19's shower sheets from 12/11/23-01/08/24 indicated 12/11/23 (bed bath), 12/13/23 (refused shower, received bed bath, shaved), 12/18/23, 12/22/23 (bed bath), 12/28/23 (bed bath), 01/03/24 (showered, shampoo), 01/05/24, 01/08/24 (bed bath). <BR/>During an interview and observation on 01/08/24 at 1:04 p.m., Resident #19 was lying in her bed in a hospital gown with food on her hand and the bed. Resident #19 said she did not get enough baths. She said her baths were on Mondays, Wednesdays, and Fridays but she only got them once or twice a week. Resident #19 had small amount of black, curly hair on both side of her mouth. Resident #19 said she wanted it (facial hair) off. <BR/>During an observation on 01/09/24 at 11:30 a.m., Resident #19 was lying in her bed in a hospital gown with a small amount of black, curly hair on both side of her mouth. <BR/>During an observation on 01/09/24 at 1:15 p.m., Resident #19 was lying in her bed in a hospital gown with a small amount of black, curly hair on both side of her mouth. <BR/>During an interview on 01/10/24 at 12:22 p.m., RCP O said RCPs were responsible for giving residents bath or showers and removing facial hair. She said Resident #19 refused showers at least once a shift when she worked. She said Resident #19 let the RCPs remove her facial hair. She said ADL care was charted on the facility's charting system. She said the ADCO and DCO decided the shower scheduled. She said the shower schedule was posted at the nurse's station with the resident's day and which shift. She said the facility just started using shower sheets also to document resident's showers. She said ADL care was important for hygiene. She said sometimes if the facility only had 2 RCPs on the floor, things did not get done like resident's shower and baths. <BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said RCPs were responsible for ADL care of residents. She said if the resident refused, the RCP was supposed to notify the nurse and the nurse was supposed to also ask then document if the resident still refused. She said Resident #19 refused to get up for showers but would get a bed bath instead. She said Resident #19 rarely refused to have her facial hair removed. She said refusals were documented on shower sheets. She said ADL care was important for the resident's dignity and to smell good. <BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said the RCP was responsible for ADL care. She said residents should get bed bath daily and showers three times a week. She said she was not sure when women were shaved. She said ADL care was documented in the facility's charting system. She said she was not sure if Resident #19 refused to have her facial hair removed but she refused showers but would do bed baths. She said bed baths and showers were supposed to be charted in the facility's charting system. She said shower sheets were supposed to be done for all bath and showers. She said shower/baths were important to promote cleanliness. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said RCP was responsible for ADL care. She said she expected the staff to follow the shower schedule unless the resident refused. She said facial hair should be removed as needed. She said nurses and nursing management should make rounds to ensure resident were be provided ADL care. A policy regarding ADL for shower/bath and facial hair was requested at this time, the policy was not received before or after exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide services by sufficient numbers of other nursing personnel, which included but not limited to nurse aides, on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans for 5 of 13 residents (Residents #2, #12, #7, #11 and #30) reviewed for care and services. <BR/>The facility failed to provide sufficient staff on the 6 a.m.-2 p.m. on Saturdays and Sundays from 07/02/2022-10/30/2022, the 2 p.m. to 10 p.m. shift on Saturdays and Sundays from 07/02/2022-10/30/2022, and the 10 p.m. to 6 a.m. shift on Saturdays and Sundays from <BR/>07/02/2022-10/30/2022 to meet the needs of the residents who required assistance with activities of daily living, bathing, and personal hygiene. <BR/>These failures could place residents at risk of infection, skin breakdown, low self-esteem, depression, embarrassment, and psychological harm. <BR/>Findings include:<BR/>1. During an observation on 11/06/22 at 9:00 a.m., Upon entrance into the facility, revealed a pungent odor of urine and feces, that was overwhelming, all the way down the hall and made the state surveyors eyes water from the ammonia smell.<BR/>Record review of the Facility Assessment Tool, updated 05/17/2022, revealed the facility's average census for the past 12 months was 41 residents and the number of staff needed to work was 6 Charge Nurses and 10 CNAs in a 24-hour period. <BR/>Record review of the Weekend Staffing Sheets, dated 7/2/2022 to 10/30/2022, showed the following staff worked on each shift: <BR/>*07/02/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*07/03/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*07/09/2022 (6a.m.-2p.m.) 3 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*07/10/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 3 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*07/16/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*07/17/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*07/23/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*07/24/2022 (6a.m.-2p.m.) 3CNAs, (2 p.m. -10 p.m.) 1 CNA and 2 CNAs (10 p.m.-6 a.m.)<BR/>*07/30/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 3 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*08/06/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 3 CNAs and 1 CNA (10 p.m.-6 a.m.)<BR/>*08/07/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 1 CNA (10 p.m.-6 a.m.)<BR/>*08/13/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 3 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*08/14/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 1 CNA (10 p.m.-6 a.m.)<BR/>*08/20/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 3 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*08/21/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*08/27/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*08/28/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 3 CNAs and 1 CNA (10 p.m.-6 a.m.)<BR/>*09/03/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*09/04/2022 (6a.m.-2p.m.) 2CNAs, (2 p.m. -10 p.m.) 3 CNA and 2 CNAs (10 p.m.-6 a.m.)<BR/>*09/10/2022 (6a.m.-2p.m.) 4 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*09/11/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 2.5 CNAs and 2 CNA (10 p.m.-6 a.m.)<BR/>*09/17/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 1 CNA (10 p.m.-6 a.m.)<BR/>*09/18/2022 (6a.m.-2p.m.) 2 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*09/24/2022 (6a.m.-2p.m.) 3 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*09/25/2022 (6a.m.-2p.m.) 3 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 1 CNA (10 p.m.-6 a.m.)<BR/>*10/01/2022 (6a.m.-2p.m.) 3 CNAs, (2 p.m. -10 p.m.) 2.5 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*10/02/2022 (6a.m.-2p.m.) 3 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*10/08/2022 (6a.m.-2p.m.) 3 CNAs, (2 p.m. -10 p.m.) 3 CNAs and 1 CNA (10 p.m.-6 a.m.)<BR/>*10/09/2022 (6a.m.-2p.m.) 2CNAs, (2 p.m. -10 p.m.) 4 CNA and 2 CNAs (10 p.m.-6 a.m.)<BR/>*10/15/2022 (6a.m.-2p.m.) 3 CNAs, (2 p.m. -10 p.m.) 3 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*10/16/2022 (6a.m.-2p.m.) 3 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 1 CNA (10 p.m.-6 a.m.)<BR/>*10/22/2022 (6a.m.-2p.m.) 4 CNAs, (2 p.m. -10 p.m.) 3 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>*10/23/2022 (6a.m.-2p.m.) 4 CNAs, (2 p.m. -10 p.m.) 2.5 CNAs and 1 CNAs (10 p.m.-6 a.m.)<BR/>*10/29/2022 (6a.m.-2p.m.) 3 CNAs, (2 p.m. -10 p.m.) 4 CNAs and 1CNA (10 p.m.-6 a.m.)<BR/>*10/30/2022 (6a.m.-2p.m.) 3 CNAs, (2 p.m. -10 p.m.) 2 CNAs and 2 CNAs (10 p.m.-6 a.m.)<BR/>Record review of the CMS 672 dated 11/06/2022 indicated a census of 37 residents with the following:<BR/>*28 residents required assist of one or two staff for bathing.<BR/>*9 residents were dependent for bathing.<BR/>*28 residents required assist of one or two staff for dressing.<BR/>*9 residents were dependent for dressing.<BR/>*29 residents required assist of one or two staff for transfers.<BR/>*7 residents were dependent for transfers.<BR/>*24 residents required assist of one or two staff for toilet use.<BR/>*13 residents were dependent for toilet use.<BR/>*36 residents required assist of one or two staff for eating: and<BR/>*1 resident was dependent for eating.<BR/>A review of a document titled Employee Monthly Schedule on 11/09/2022 at 12:00 p.m. revealed the following vacant positions:<BR/>6 a.m. - 2 p.m.- 2 Nurse positions, 2 CNA positions<BR/>2 p.m.- 10 p.m.- 2 Nurse positions, 2 CNA positions<BR/>10 p.m.- 6 a.m.- 1 Nurse position, 0 CNA positions<BR/>2. Record review of a face sheet dated 11/09/2022 revealed Resident #2 was an [AGE] year-old, female and admitted on [DATE] with diagnoses that included anxiety (intense, excessive, and persistent worry and fear about everyday situations), chronic obstructive pyelonephritis (continuing pyogenic infection of the kidney that occurs almost exclusively in patients with major anatomic abnormalities), and hypertension.<BR/>Record review of the quarterly MDS dated [DATE] revealed Resident #2 was understood and understands others. The MDS revealed Resident #2 had a BIMS score of 15 which indicated no cognitive impairment. The MDS revealed Resident #2 required dependent assistance of one staff for bathing and limited assistance of one staff for transfer and toileting. The MDS revealed Resident #2 had impairment of range of motion to both lower extremities. <BR/>Record review of the care plan dated 10/31/2022 titled ADLs indicated that Resident #2 required extensive assistance for bathing.<BR/>Record review of a document titled documentation survey report dated September 2022 revealed Resident #2 was scheduled to be given a bath on the 6 a.m. to 2 p.m. on Monday, Wednesday, and Friday. The document revealed 13 (09//02/2022, 09/05/2022, 09/07/2022, 09/09/2022, 09/12/2022, 09/14/2022, 09/16/2022, 09/19/2022, 09/21/2022, 09/23/2022, 09/26/2022, 09/28/2022, and 09/30/2022) days Resident #2 was scheduled to be bathed. The document also revealed 5 (09/05/2022, 09/10/2022, 09/11/2022, 09/16/2022, 09/27/2022) days a bath was given.<BR/>Record review of a document titled documentation survey report dated October 2022 revealed Resident #2 was scheduled to be given a bath on the 6 a.m. to 2 p.m. on Monday, Wednesday, and Friday. The document revealed 13 (10/03/2022, 10/05/2022,10/07/2022, 10/10/2022, 10/14/2022, 10/17/2022, 10/19/2022, 10/21/2022, 10/24/2022, 10/26/2022, 10/28/2022, 10/31/2022) days Resident #2 was scheduled to be bathed. The document also revealed 2 (10/19/2022 and 10/21/2022) days a bath was given.<BR/>Record review of a document titled documentation survey report dated November 2022 revealed Resident #2 was scheduled to be given a bath on the 6 a.m. to 2 p.m. on Monday, Wednesday, and Friday. The document revealed 3 (11/02/2022, 11/04/2022, and 11/07/2022) days Resident #2 was scheduled to be bathed. The document also revealed no bathes were given.<BR/>During interview and observation on 11/06/2022 at 9:45 a.m., Resident #2 stated staffing was horrible in the facility. Resident # 2 stated getting ice passed, getting her call light answered, getting her colostomy supplies, and getting medication were very difficult. Resident #2 stated she waited over an hour to have her call light answered on many occasions (10+) over the past few months. Resident #2 stated she had gone 2 shifts with no ice and water until she was forced to become rude to get ice passed. Resident #2 stated she waited 2 days for someone to bring colostomy supplies to her a few weeks prior. Resident # 2 stated she no longer allowed the medication aide to pass her medication to her because she was hours late each day with medications. Resident #2 stated she only got a bath once every other week because the shower aide was pulled to the floor to be a CNA almost daily. Resident #2 stated if the shower aide was pulled to work the floor, no showers were given on the hall. Resident #2 stated not getting a bath was upsetting because she was incontinent of urine and needed her skin cleaned at least twice per week to keep her skin from itching. Resident #2 had no ice or water in her water pitcher.<BR/>During an observation on 11/06/2022 at 11:45 a.m., Resident #2 had no water or ice in her water pitcher on her bedside table. <BR/>3. Record review of a face sheet dated 11/09/2022 revealed Resident #12 was a [AGE] year old, male and admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), contracture to right elbow (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).<BR/>Record review of the quarterly MDS dated [DATE] revealed Resident #12 was understood and understood others. The MDS revealed Resident #12 had a BIMS score of 14 which indicated no cognitive impairment. The MDS revealed Resident #12 required dependent assistance of one staff for bathing. The MDS revealed Resident #12 had impairment of range of motion to both lower extremities and one side of upper extremities. <BR/>Record review of the care plan dated 10/27/2022 titled ADLs indicated that Resident #12 required extensive assistance for bathing.<BR/>Record review of a document titled documentation survey report dated September 2022 revealed Resident #12 was scheduled to be given a bath on the 10 p.m. to 6 a.m. on Monday, Wednesday, and Friday. The document revealed 13 (09//02/2022, 09/05/2022, 09/07/2022, 09/09/2022, 09/12/2022, 09/14/2022, 09/16/2022, 09/19/2022, 09/21/2022, 09/23/2022, 09/26/2022, 09/28/2022, and 09/30/2022) days Resident #12 was scheduled to be bathed. The document also revealed 2 (09/05/2022, and 09/12/2022) days a bath was given.<BR/>Record review of a document titled documentation survey report dated October 2022 revealed Resident #12 was scheduled to be given a bath on the 10 p.m. to 6 a.m. on Monday, Wednesday, and Friday. The document revealed 13 (10/03/2022, 10/05/2022,10/07/2022, 10/10/2022, 10/14/2022, 10/17/2022, 10/19/2022, 10/21/2022, 10/24/2022, 10/26/2022, 10/28/2022, 10/31/2022) days Resident #12 was scheduled to be bathed. The document also revealed 2 (10/05/2022 and 10/17/2022) days a bath was given.<BR/>Record review of a document titled documentation survey report dated November 2022 revealed Resident #2 was scheduled to be given a bath on the 10 p.m. to 6 a.m. on Monday, Wednesday, and Friday. The document revealed 3 (11/02/2022, 11/04/2022, and 11/07/2022) days Resident #2 was scheduled to be bathed. The document also revealed 1 (11/04/2022) bath was given.<BR/>During interview on 11/06/2022 at 9:45 a.m., Resident #12 stated he had not had a bath in several weeks. Resident #12 stated CNAs from the facility had not given him a bath in the absence of the hospice aide coming. Resident #12 stated the CNAs told him they were short staffed, and he would have to wait for the hospice CNA to come.<BR/>4. Record review of the face sheet dated 11/08/2022 indicated Resident #7 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including dementia, legal blindness, and reduced mobility.<BR/>Record review of the MDS dated [DATE] indicated Resident #7 usually understood others and was sometimes understood. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 0, indicating Resident #7 was severely cognitively impaired. The MDS indicated Resident #7 required extensive assistance with personal hygiene and was totally dependent upon staff for bathing. <BR/>The care plan dated 8/4/2022 indicated Resident #7 had an ADL self-care performance deficit related to disease processes and blindness. The resident required total assistance from staff for bathing and personal hygiene every day and as necessary. <BR/>Record review of Progress Notes from 11/02/2022 - 11/08/2022 for Resident #7 did not indicate any refusals of care, including bathing or personal hygiene. <BR/>Record review of an ADL Documentation Survey Report from 11/01/2022 - 11/08/2022 for Resident #7 did not indicate any refusals of bathing or personal hygiene.<BR/>5. Record review of the face sheet dated 11/08/2022 indicated Resident #11 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including depression, muscle weakness, and need for assistance with personal care. <BR/>Record review of the MDS dated [DATE] indicated Resident #11 understood others and was understood. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 3, indicating Resident #11 was severely cognitively impaired. The MDS indicated Resident #11 required extensive assistance with personal hygiene. The MDS indicated bathing did not occur. <BR/>The care plan dated 7/20/2022 indicated Resident #11 had an ADL self-care performance deficit. The care plan indicated Resident #11 was totally dependent on staff for bathing/showering. The care plan did not address personal hygiene. <BR/>Record review of Progress Notes from 11/02/2022 - 11/08/2022 for Resident #11 did not indicate any refusals of care, including bathing or personal hygiene. <BR/>Record review of an ADL Documentation Survey Report from 11/01/2022 - 11/08/2022 for Resident #11 did not indicate any refusals of bathing or personal hygiene.<BR/>During an observation on 11/06/2022 at 11:19 a.m., Resident #11 was asleep in bed. There was a patch of many white hairs approximately 0.5 centimeters in length on her chin. <BR/>During an observation on 11/06/2022 at 1:37 p.m., Resident #11 was sitting in a wheelchair in room. There was a patch of many white hairs approximately 0.5 centimeters in length on her chin.<BR/>During an observation on 11/06/2022 at 1:40 p.m., Resident #11 was resting in her bed in her room. There were scattered hairs approximated 0.5 centimeters to her chin. <BR/>During an observation on 11/07/2022 at 2:38 p.m., Resident #11 was sleeping in bed. There were scattered hairs approximated 0.5 centimeters to her chin.<BR/>During an observation on 11/08/2022 at 9:29 a.m., Resident #11 was sitting in a common area. There were scattered hairs approximated 0.5 centimeters to her chin.<BR/>During an observation on 11/08/2022 at 9:44 a.m., Resident #11 was sitting in a common area. There was a patch of many white hairs approximately 0.5 centimeters in length on her chin.<BR/>During an observation on 11/09/2022 at 7:59 a.m., Resident #11 was sitting in a common area. There were scattered hairs approximated 0.5 centimeters to her chin.<BR/>6. Record review of the face sheet dated 11/07/22 revealed Resident #30 was [AGE] years old female and admitted on [DATE] with diagnoses including muscle wasting and atrophy (shortening), lack of coordination, and need for assistance with personal care.<BR/>Record review of Resident #30's quarterly MDS dated [DATE] revealed she was understood and understood others. The MDS revealed Resident #30 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS revealed Resident #30 required extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing.<BR/>Record review of Resident #30's care plan problem date of initiated 10/04/21 and revision on 02/18/22 revealed ADL self-care performance deficit related to decreased mobility related to pain. Intervention included bathing/showering: provide sponge bath when a full bath or shower cannot be tolerated. <BR/>Record review of the Resident #30's ADL-bathing report dated October 2022 revealed she preferred showers on Mondays, Wednesdays, and Fridays. The bathing report revealed Resident #30 received 7 (10/6, 10/8, 10/13, 10/14, 10/25, 10/28, 10/31) showers out of 13 scheduled days. <BR/>During an observation and interview on 11/07/22 at 1:12 p.m., Resident #30 was in her room, in her wheelchair. Resident #30 had a short patch of hair on her chin. Resident #30 said she got her scheduled showers in November. When more detailed questions were asked, she seemed unable to form an answer.<BR/>During an interview on 11/08/22 at 10:29 a.m., CNA E said she had been employed by the facility since January 2012. She said Resident #30 had scheduled showers on Mondays, Wednesdays, and Fridays. She said Resident #30 did not refuse showers or shaving. She said the facility only had one shower aide and was short staffed so Resident #30 may have not gotten shaved with her last shower. She said she should not have chin hair and would not like it if she realized it was there. She said before her mental and physical decline, she used to pluck her chin hair with tweezers. She said any staff member who noticed her chin hair should have removed it. <BR/>During an interview on 11/09/2022 at 11:12 a.m., CNA A stated staffing had been a challenge for several months. CNA A explained most of the time (4 out of 5 shifts) she worked a hall alone with 18-22 people. CNA A stated she was asked to work over every time she worked, and she had worked over several times per week for the last 4 months. CNA A stated the residents needed someone to take care for them and she could not leave them without an aide. CNA A stated the most difficult tasks about her job when the facility was short staffed was getting people that were 2 person transfers up on her own and getting everyone bathed. CNA A stated she had to either wait on the nurse to finish medication pass to assist with transfers or get a CNA form the other hall to help, leaving no CNA on that hall temporarily. CNA A stated there were times baths were missed but they did their best to get to everyone. CNA A stated each CNA gave 3 bathes on each shift and occasionally the facility staffed a shower aide that did the bathes for the CNAs. CNA A stated there were 9 residents on hospice that were bathed by a hospice CNA when they showed up. CNA A stated there was normally 2-3 CNAs on 6 a.m. to 2 p.m. and 2-3 CNAs on 2 p.m. to 10 p.m. CNA A stated on the days the facility had 3 CNAs it was possible to complete all tasks including bathing. CNA A stated when there were only 2 CNAs on the shift it was not usual for bathes to be missed. <BR/>During an interview on 11/09/2022 at 10:10 a.m., the AD (Activities Director) stated she was often pulled from activities to the floor to assist with CNA work. The AD stated everyone who worked at the facility wore many hats. The AD stated the short staff affected her ability to provide activities about 2-3 times per week. The AD stated there were times cancelling or postponing activities upsets some of the residents, but it could not be helped.<BR/>During an interview on 11/09/2022 at 11:30 a.m., LVN B stated there were many days only one CNA worked each hallway. LVN B stated the facility tried to assign a shower aide on the day shift during the week, but more times than not the shower aide was pulled to work as a CNA on the floor. LVN B stated the facility struggled with staffing issues over the last 6 to 9 months and the residents at times had missed baths. LVN B stated she helped where she could when she was not passing medications, doing assessments, and doing wound care. LVN B stated she was only part time, but the facility called and asked her to work every week.<BR/>During an interview on 11/09/2022 at 11:45 a.m., the DON stated she struggled with staffing each day since she began 16 days prior. The DON stated she worked the floor from call ins and vacant spots as a nurse and CNA 6 of the last 16 days. The DON stated the residents getting the care they needed was her focus. The DON stated several systems in the facility needed to be reviewed and revamped since they had been ignored for an undetermined amount of time. The DON stated the previous DON had to work the floor as a CNA, shower aide, transportation aide and nurse and systems like weights, skin, psychotropic medication, infection control and staff education had gotten behind. The DON had identified several areas that needed quality improvement programs put in place and planned to do so soon. The DON stated not getting your call light answered, not getting fresh ice and water, not getting a bath, and not getting out of bed daily could affect a resident's psychosocial wellbeing, as well as their skin integrity. <BR/>During an interview on 11/09/2022 at 12:30 p.m., the Administrator stated not getting assistance with ADLs, bathing, and having fresh water and ice could lead to depression and dehydration. The Administrator stated she had been at the facility since June of 2022 and staffing had been horrible. The Administrator stated they had an ad on Indeed, recently approved a wage increase, and recently went back to using staffing agency. The Administrator stated the staffing agency did not call and the nurses and CNAs would just not show up. The Administrator stated the DON was currently the only nursing department head and she had to fill in for all nurses and CNAs that did not show up to work. The Administrator stated she knew this could put the DON behind in monitoring her systems like weights, psychotropic medications, pressure ulcers, and infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure medication error rates were not 5 percent or greater. There were 5 errors out of 27 opportunities, which resulted in an 18.52 percent medication error rate which involved 1 of 4 residents (Resident #8) reviewed for medications. <BR/>1. The facility failed to ensure Resident #8 received her Metoclopramide (a medication that works by increasing the movements or contractions of the stomach and intestines. It relieves symptoms such as nausea, vomiting, heartburn, a feeling of fullness after meals, and loss of appetite) before a meal. <BR/>2. The facility failed to ensure Resident #8 received GlyMax (metabolic oral supplement) instead of Miralax (provides constipation relief).<BR/>3. The facility failed to ensure Resident #8's medication administration record was accurate.<BR/>4. The facility failed to ensure Resident #8 rinsed her mouth after use of her Advair inhaler (is a combination medicine used to prevent asthma attacks).<BR/>5. The facility failed to ensure Resident #8's Vitamin D3 50,000 units (is a fat-soluble vitamin that helps your body absorb calcium and phosphorus) and Refresh tears (artificial tears) were available. <BR/>These failures could place residents at risk for inaccurate drug administration.<BR/>Findings include:<BR/>Record review of Resident #8's face sheet, dated 11/09/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), vitamin deficiency (the condition of a long-term lack of a vitamin), and gastro-esophageal reflux disease (in which stomach acid moves into the esophagus, causes discomfort and may lead to precancerous changes in the lining of the esophagus). <BR/>Record review of Resident #8's consolidated physician orders, dated 11/09/22, revealed Advair Diskus Aerosol Breath Activated 250-50 mcg/dose 1 inhalation inhale orally every 12 hours for shortness of breath rinse mouth and spit after each use dated 11/08/19.<BR/>Record review of Resident #8's consolidated physician orders, dated 11/09/22, revealed Reglan (Metoclopramide) 5 mg by mouth before meals for gastro-esophageal reflux disease, dated 11/13/21. <BR/>Record review of Resident #8's consolidated physician orders, dated 11/09/22, revealed Refresh Tears Solution 0.5% instill 1 drop in both eyes two times a day for dry eyes, dated 08/05/20.<BR/>Record review of Resident #8's consolidated physician orders, dated 11/09/22, revealed Vitamin D3 Capsule 50000 unit give 1 capsule by mouth one time a day every Mon, Thurs for supplement, dated 06/07/19.<BR/>Record review of Resident #8's consolidated physician orders, dated 11/09/22, did not reveal an order for GlyMax Powder (Glycine).<BR/>Record review of Resident #8's MAR, dated 11/01/22-11/30/22, revealed GlyMax Powder (Glycine) give 17 grams by mouth one time a day for constipation, with start date of 07/20/21. Resident #8's MAR revealed GlyMax Powder had been given 11/1/22-11/7/22. <BR/>Record review of Resident #8's MAR, dated 11/01/22-11/30/22, revealed Reglan (Metoclopramide) 5 mg by mouth before meals (0700, 1130,1630) for gastro-esophageal reflux disease, dated 11/13/21. Resident#8's MAR revealed Reglan was charted given at 0700 on 11/07/22. <BR/>Record review of Resident #8's MAR, dated 11/01/22-11/30/22, revealed Refresh Tears Solution 0.5% instill 1 drop in both eyes two times a day for dry eyes, dated 08/05/20. Resident #8's MAR revealed administration comment of medication not available on 11/07/22. <BR/>Record review of Resident #8's MAR, dated 11/01/22-11/30/22, revealed Vitamin D3 Capsule 50000 unit give 1 capsule by mouth one time a day every Mon, Thurs for supplement dated 06/07/19. Resident #8's MAR revealed administration comment of medication not available on 11/07/22.<BR/>Record review of Resident #8's MAR, dated 11/01/22-11/30/22, revealed Advair Diskus Aerosol Breath Activated 250-50 mcg/dose 1 inhalation inhale orally every 12 hours for shortness of breath rinse mouth and spit after each use, dated 11/08/19.<BR/>Record review of the quarterly MDS, dated [DATE], revealed Resident #8 was understood and understood others. Resident #8 had a BIMS of 10, which indicated mild cognitive impairment. Resident #8 required extensive assistance for bed mobility, transfer, dressing, toilet uses, and personal hygiene but total dependence for bathing. <BR/>Record review of the care plan, dated 08/05/19, revealed Resident #8 had potential complications and discomfort related to diagnosis of GERD. Intervention included administer medication per MD orders and monitor effectiveness. <BR/>Record review of the care plan, dated 07/01/19, revealed Resident #8 has COPD related to history of long-term smoker. Intervention included educate resident/family/caregivers regarding side effects and overuse of inhalers and nebulizers. <BR/>Record review of the care plan, dated 11/09/22, did not address vitamin deficiency, constipation, or dry eyes.<BR/>During an observation and interview on 11/07/22 at 8:18 a.m., LVN M said she was agency staff and had only worked at the facility one other time. LVN M prepared Resident #8 medication for administration. LVN M administered Metoclopramide 5 mg tablet, MiraLAX 17 g mixed in water, and gave Advair inhaler to administer 1 puff. Resident #8 did not rinse her mouth out after administration. LVN M noticed Resident #8 did not have Vitamin D3 50,000 unit and Refresh tears available on the cart. LVN M left the medication cart said she was going to ask another staff member where she could find more Vitamin D3 50,000 and Refresh tears. At 8:30 a.m., LVN M returned and said the facility did not have Vitamin D3 50,000 unit or Refresh tears on site. <BR/>During an interview on 11/09/22 at 10:30 a.m., LVN D said Metoclopramide (Reglan) should be given 30 minutes before meals to be more effective. She said Resident #8's orders specifically stated, before meals for GERD. She said the medication helped with acid reflux and digestion. She said when it was given after a resident had eaten then it was not as effective. She said this could cause the resident to experience discomfort or pain. She said when a resident used certain types of inhalers, the resident should rinse their mouth afterwards. She said it was important to rinse to clean the medicine out of the mouth. She said it was not good for medication in the inhaler to be left in the mouth. She said she assumed the order for GlyMax was the generic name for MiraLAX. She said she did not know Glymax and MiraLAX were two different medications. She said she could only assume because it said give related to constipation, the order should be MiraLAX. She said the order had been incorrect since 2021. She said the nurse who received the order should have noticed the error and every nurse afterwards who gave MiraLAX. She said it was important to give the correct medication to monitor for the correct side effects, could receive a medication they were allergic to, and the resident was not getting treatment for the issue. She said the medical record staff ordered medical supplies and over the counter medications. She said the facility did not frequently have ordered medication in stock. She said the medications should be available because it was a doctor's order to follow. She said it was the nurse's responsibility to notify the medical record staff when residents over the counter medications were getting low. <BR/>During an interview on 11/09/22 at 10:55 a.m., the Medical Record Staff Member said she was responsible for ordering medical supplies and over the counter medications. She said she checked the medication storeroom daily to see what medications were low and needed to be ordered. She said she ordered on Monday and supplies arrived on Wednesday and Thursday. She said nurses should notify her when medications were almost out on the medication carts because she did not look in those. She said she tried to keep 4 extra bottles of medications in the storeroom if they were not too expensive. She said she did not notice Vitamin D3 50000 unit and Refresh tears being out of stock because someone took the last bottles, and the shelves were not labeled. She said because Resident #8 was not getting her prescribed medications, she was possibly not getting enough D3 and had dry eyes. She said the DON told her the facility was out of Vitamin D3 50000 today, but she did not know they were out of Refresh Tears. She said she was responsible for the storeroom, but nurses should let her know when they used the last of a over the counter medication. <BR/>Interview on 11/09/22 at 11:15 a.m., with LVN M was attempted and unsuccessful. Two attempts to contact were made.<BR/>During an interview on 11/09/22 at 11:38 a.m., the DON said Metoclopramide should be given 30 minutes before a meal. She said the medication was important because it coated the stomach to prevent an upset stomach from certain foods. She said giving the medication after eating is not as effective. She said it could cause stomach cramps, ingestion, vomiting, or diarrhea. She said after an inhaler puff, a resident should rinse and spit with water. She said not doing it affects the oral mucous and teeth. She said it could cause infection in the mouth and dental issues causing eating difficulties and weight loss. She said Medical Records Staff Member was responsible for medical supplies and over the counter medications. She said Resident #8 not getting her Vitamin D3 and Refresh tears could lead to fractures, decrease bone health, dry eyes, or blurred vision. She said she was going to start a list nurses had to fill out when they took the last of a medication. She said she was going to monitor the list to make sure staff were filling it out. She said a nurse should have noticed the incorrect medication list on Resident #8's MAR for constipation. She said she called the doctor, and the orders should have always said MiraLAX not Glymax. She said Physicians did monthly medication reviews, but this was never caught. She said thankfully the Resident #8 was getting MiraLAX instead of the Glymax, she said it could have caused digestive issues. She said expected the nurses to verify medications which was 1 of the 6 Rights of Medication Administration for all medications. <BR/>During an interview on 11/09/22 at 12:20 p.m., the Administrator said she expected the nurses to follow the physician orders. <BR/>Record review of a facility General Guidelines for Medical Administration policy, dated 08/20, revealed .medications are administered as prescribed in accordance with good nursing principles and practice .at a minimum, the 5 rights .right drug .should be applied to all medications administration .select the medication, check the label, container, and contents for integrity, and compare the medication against the medication administration record .prior to the administration of any medications, the medication and dosage scheduled on the resident's MAR are compared with the medication label .medications are administered in accordance with written orders of the prescriber .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 15 residents (Resident #14) and 1 of 1 treatment carts reviewed for drug storage. <BR/>The facility failed to securely store over the counter medication Neosporin for Resident #14.<BR/>LVN D failed to securely lock the wound treatment cart.<BR/>These failures could place residents at risk for adverse reactions. <BR/>Findings included:<BR/>1. Record review of the face sheet 1/8/2024 indicated Resident #14 was [AGE] years old and was admitted on [DATE] with diagnoses including Ataxia (poor muscle control), Functional urinary incontinence (involuntary leakage of urine due to environment or physical barriers to toileting), History of falling, lack of coordination, and diabetes.<BR/>Record review of the MDS dated [DATE] indicated Resident # 14 was usually understood and understood by others. Resident #14 indicated a BIMS score of 5 indicating Resident #14 was cognitively impaired. Resident #14 MDS indicated moderate hearing loss that required hearing appliance and for the speaker to increase volume and speak distinctly.<BR/>Record review of Order Summary Report dated 1/10/2024 for Resident #14 did not indicate an order for Neosporin. Record review of a Medication Administration Record (MAR) for January 2024 indicated Resident #14 did not indicate an intervention or order for Neosporin.<BR/>During an observation and interview on 1/10/2024 at 10:23 a.m., Resident #14 was sitting in recliner. There were 2 - tubes of Neosporin on bedside table. The Neosporin tubes was yellow and white. There was no label identifying orders or resident identifying information. The Neosporin did not have a resident identifying label. The resident said she kept the two ointments at her bedside table, so she uses the ointment on her arms and face as needed for an itch. The resident did not have a roommate at time of interview or observation. Resident #14 said she had the ointment since she was admitted on [DATE].<BR/>During Interview on 1/10/2024 at 11:18 a.m. LVN B said she was not aware Resident #14 had Neosporin on her bedside table. She said the Neosporin should be stored in the medication cart and would require an order. LVN said if medication is identified in a resident's room, staff should remove the medication and explain to resident the importance of notifying staff of any medication brought in facility. During an interview on 1/10/2024 at 11:27 a.m. CNA A who has worked Resident #14's hall said she never seen ointment sitting on Resident #14's bedside table. She said that residents are not supposed to have medications in their room and if identified by staff, it should be removed and given to the charge nurse or her boss.<BR/>During Interview on 1/10/2024 at 11:39 a.m. the DON said normally residents are not supposed to have medications in room unless they have order for self-administering medication. The DON said medication is supposed to be stored on the wound care cart and expects aids to report to nurse, then the nurse is to go in the room and identify if the resident is supposed to have the medication. The DON said she expects the nurses to check the orders, call the family to identify where the medication came from or if ordered. The DON said the resident can have medications in room if determined they are able to self-administer. DON said the physician is the one who makes the determination if a resident can self-administer. The DON said having medications in room without staff knowledge could cause harm such as an adverse reaction or allergic breakout.<BR/>During Interview on 1/10/2024 at 12:30 pm Administrator _ SP said she expects the nurse to notify charge nurse if a resident has medication that is not prescribed in room. She said normally the medications are stored on treatment cart or medication cart unless the resident has an order to have the medication in the room. She said the physician is the one who makes the determination if a resident can self-medicate, and we would need to know about it to provide the best care.<BR/>2. During an observation on 01/09/24 at 11:20 a.m., the wound treatment cart was sitting in the hall outside of room [ROOM NUMBER]. The cart was unlocked with a ring of keys laying on top of the cart. There were no staff members present. The door to room [ROOM NUMBER] was closed. There were no residents in the hall. There were rooms across the hall and near 309 that were occupied by residents. In drawer # 1 there was a tube of Santyl 250 units (a medication used to remove damaged tissue from chronic skin ulcers and severely burned areas), Nystatin cream (a medicated cream or ointment that treats fungal or yeast infections in your skin), 1 tube of Triamcinolone Acetonide Cream 0.1 % (medication used to help relieve redness, itching, swelling, or other discomfort caused by skin condition), 2 bottles Nyamyc 100,000 units per gram (a medicated cream or ointment that treats fungal or yeast infections in your skin), 6 boxes of BPCO Ointment (a medication used as a wound dressing for topical use used to manage chronic and acute wounds, and dermal ulcers), 1 box of Hydrocortisone Cream (a topical medication skin conditions that cause swelling, redness, itching and rashes), Therahoney gel (a medication used to treat wounds and other skin conditions), 2 boxes of hemorrhoidal cream (a cream used to treat swollen veins in your lower rectum) . Drawer 2 had 2 boxes Nyamyc 100,000 usp units per gram, 2 bottles of Betadine (a topical antiseptic that provides infection protection against a variety of germs for minor cuts, scrapes, and burns), Drawer 3 contained various supplies and wound dressings, the 4th drawer had one spray bottle of wound cleanser, 1 bottle of Dakin's solution (a dilute sodium hypochlorite (NaClO) solution commonly known as bleach), and various wound care supplies, and the 5th drawer contained H-chlor 0.125 solution (the same as Dakin's solution) along with various dressing and wound care supplies.<BR/>During an interview on 01/09/24 at 11:25 a.m., RN L said she had been in room [ROOM NUMBER] providing wound care. She said during wound care she found another place on the resident that required a bandage. She said she had to come out of the room during care to get the supplies from the cart. She said she was just in a hurry. She said leaving the cart unlocked could cause problems if a resident got a hold of something in the cart.<BR/>During an interview on 01/10/24 at 11:57 a.m., the DON said all carts should be locked when the nurses were not present, and the nurse should take the keys with them. She said the cart should be locked any time a nurse walks away from the cart. She said any cart being left unlocked could make it to where anyone could take or misplace anything that was in the cart.<BR/>During an interview on 01/10/24 at 12:38 p.m., the Administrator said if a nurse was not using a medication cart or treatment cart then the cart should be locked. She said a resident could get something out of an unlocked cart they should not have. <BR/>Review of a Bedside Medication Storage facility policy # 4.3 Effective date 09-2018 and revised date 08-2020 indicated, .Bedside medication storage is permitted for residents who wish to self-administer medications, upon written order of the prescriber and once self-administration skills have been assessed and deemed .<BR/>Review of a Storage of Medications facility policy dated 09/2018 indicated, .Medications and biologicals are stored safely, securely and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 1 of 13 residents reviewed for call lights. (Resident #30)<BR/>The facility failed to ensure Resident #30's emergency call light, in the bathroom, was not wrapped around the support bar.<BR/>This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.<BR/>Findings include:<BR/>Record review of Resident #30's face sheet, dated 11/07/22, revealed Resident #30 was an 81- year-old female who was admitted to the facility on [DATE] with diagnoses which included muscle wasting and atrophy (shortening), difficulty in walking, lack of coordination, fracture of neck of right femur, fall on same level, reduced mobility, need for assistance with personal care, unsteadiness on feet, history of falls and muscle weakness.<BR/>Record review of Resident #30's quarterly MDS, dated [DATE], revealed she was understood and understood others. Resident #30 had a BIMS score of 03, which indicated severe cognitive impairment. Resident #30 required extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. Resident #30 was not steady, only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfers. Resident #30 had lower extremity limited range of motion on one side.<BR/>Record review of Resident #30's care plan, problem date initiated 10/04/21 and revision on 02/18/22, revealed ADL self-care performance deficit related to decreased mobility related to pain. Interventions included resident could transfer herself she had pain.<BR/>Record review of Resident #30's fall scale, dated 05/03/22, revealed high risk for falling due to history of falling, more than one diagnosis, none/bedrest/wheelchair/nurse assist ambulatory aid, weak gait, and overestimates or forgets limits.<BR/>Record review of Resident #30's fall scale, dated 08/03/22, revealed high risk for falling due to history of falling, more than one diagnosis, none/bedrest/wheelchair/nurse assist ambulatory aid, impaired gait, and overestimates or forgets limits.<BR/>Record review of Resident #30's fall scale, dated 10/06/22, revealed high risk for falling due to history of falling, more than one diagnosis, none/bedrest/wheelchair/nurse assist ambulatory aid, weak gait, and overestimates or forgets limits. <BR/>During an observation and interview on 11/07/22 at 1:12 p.m., Resident #30 was in her room, in her wheelchair. Resident #30's bathroom door in her room was open. In Resident #30's bathroom, the emergency call light was wrapped around the support bar on the wall several times with only a small portion hanging out. Resident #30 said she did use the bathroom and sometimes self-transferred herself without assistance. <BR/>During an observation on 11/08/22 at 10:25 a.m., in Resident #30's bathroom, the emergency call light was wrapped around the support bar on the wall several times with only a small portion hanging out. When the small portion of the emergency call light hanging below the safety bar was pulled the call light did not activate. <BR/>During an interview on 11/08/22 at 10:29 a.m., CNA E said she had been employed at the facility since January 2012. She said Resident #30 did self-transfer. She said the facility did encourage her to call for assistance before she transferred herself. She said the emergency call light in the bathroom should not be wrapped around the support bar. She said the call light would probably not activate or the resident would have to pull hard to make it activate. She said the call light being wrapped around the safety bar prevented Resident #30 from calling for help. She said it could cause her to lay on the floor in pain until someone made rounds to check on her. She said anyone who noticed the call light wrapped around the safety bar should have corrected the issue. <BR/>During an interview on 11/09/22 at 10:30 a.m., LVN D said Resident #30 did self-transfer herself. She said she did not have a history of falls, so she felt it was okay for Resident #30 to self-transfer. She said Resident #30 also did not always call for assistance. She said Resident #30 was a fall risk and was prescribed medications which could affect her balance. She said Resident #30's emergency call light should not be wrapped around the side bar. She said with the call light being wrapped around the side bar she would not be able to reach it if she was on the floor or it could not activate when pulled. She said she would not be able to get assistance or call for help. She said CNAs should be checking all call lights when they made rounds. <BR/>During an interview on 11/09/22 at 11:38 a.m., the DON said Resident #30's emergency call light should not be wrapped around anything that would impede it from being activated. She said if the string was too long, she could have shortened the cord. She said the cord wrapped around the safety bar could cause Resident #30 to not be able to get assistance or help in an emergency. She said this risk was a delay in help or addressing injuries. She said everyone was responsible for making sure call lights were accessible. <BR/>During an interview on 11/09/22 at 12:20 p.m., the ADM N said the emergency call light in the bathroom should not be wrapped around the safety hand bar. She said the call light being wrapped around the bar impended the light from being activated which could delay help. She said anyone who made rounds in the resident's room should ensure all call light were within reach and able to be activated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 1 of 15 residents reviewed for dignity. (Resident #19)<BR/>The facility failed to provide Resident #19 with a type of clothing protector (designed to protect clothing from mealtime mishaps) to ensure she did not have food on gown after eating.<BR/>The facility failed to ensure Resident #19 was cleaned up promptly after meals. <BR/>These failures placed residents at risk for diminished quality of life, loss of dignity and self-worth.<BR/>Findings included:<BR/>Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including abnormal posture, dysphagia (difficulty swallowing), hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side, and muscle weakness. <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required partial/moderate assistance for eating. <BR/>Record review of Resident #19's care plan dated 04/10/23 indicated Resident #19 had psychosocial well-being problem related to disease process. Intervention included encourage participation from resident who depends on others to make own decisions. <BR/>Record review of Resident #19's care plan dated 04/10/23 indicated resident [Resident #19] is at risk for nutritional impairment related to above ideal body weight, received regular diet. Intervention OT to screen and provide adaptive equipment for feeding as needed. <BR/>During an observation and interview on 01/08/24 at 1:04 p.m., revealed Resident #19 was in her bed and was wearing a hospital gown on. On Resident #19's hospital gown and right hand were small amounts of food particles. Resident #19 said she fed herself and did not use a towel or clothing protector. <BR/>During an observation and interview on 01/09/24 at 1:15 p.m., revealed Resident #19 was in her bed and was wearing a hospital gown. On Resident #19's hospital gown and face were moderate amounts of food particles. Resident #19 said she fed herself and was not offered a towel or clothing protector. Resident #19 said she did not want food on herself. <BR/>During an interview on 01/10/24 at 12:22 p.m., RCP O said Resident #19 sometimes made a mess when she ate. She said when she worked with Resident #19, she offered her a towel to cover herself. She said it was the RCP's and LVN's responsibility to make sure the resident had a clothing protector or was cleaned up after a resident ate. She said Resident #19 having food particles on their body, and unable to clean it probably did not make her feel good. She said it could also make the resident feel like they were bothering staff. <BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said Resident #19 was able to feed herself finger food better than other types of food. She said staff were supposed to encourage and assist her if needed during mealtimes. She said Resident #19 spilled food when she ate. She said it was the RCP's and LVN's responsibility to offer a clothing protector with meals or clean her up afterwards. She said it was important for Resident #19's dignity and appearance. <BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said Resident #19 could feed herself. She said it was the RCP's responsibility to provide and offer a resident a clothing protector and clean a resident up, who was unable to do it themselves. She said she expected the staff to clean the residents up right away and change into dry clothes. She said Resident #19 having food particle on herself was a dignity issue. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said she expected the staff to offer all residents a clothing protector. She said she expected the staff to clean the food from a resident. A resident's rights policy was requested at this time and was not received before or after exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment to those residents who eat their meals in one of one dinning rooms. <BR/>The facility failed to identify and rectify foul smells in the dining room. <BR/>This failure could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth.<BR/>Findings included:<BR/>During an observation on 01/08/2024 at 10:30 a.m., it was observed that the dining room had a foul smell similar to the smell of sewage. <BR/>During an interview and observation on 01/08/2024 at 11:00 a.m., Director of Plant Operations J stated that there were no drains that were backing up sewage in the facility. He said in the kitchen there was a drain cleaning solution that was pumped into a pipe while dishes were being washed. He said that was to ensure that the drainage pipe was cleaned and to prevent a smell from occurring. He said at the end of November 2023 and early December 2023 they ran out of the cleaning solution, but it was back in stock by mid December 2023. He said that there were no sewage backups in the facility, and he did not know where the smell in the dining room was coming from. It was observed that the smell identified in the dining room was not coming from the kitchen. The kitchen was clean and had no offensive odors. <BR/>During an interview on 01/08/2024 at 11:05 a.m., Dietary Manager K said that there was no overflow of sewage in the kitchen nor were there any foul smells as a result of any pipes or other sources from the kitchen. She said the kitchen was very clean and there were no sewage backups visible. <BR/>During an interview on 01/08/2024 11:14 a.m., the Administrator said there was no sewage backup that she is aware of in the facility. She said sometimes there was an off smell in the building, but it isn't identified. She said there have not been any plumbers that have come to the facility to resolve an overflow sewage issue. She said there were some issues with pipes that were corrected but it was due to flushable wipes being flushed into the toilets. <BR/>Record review of requested plumbing invoices for the last year (2023) revealed no indication of sewage backups. Record review of statements reflected that the facility contacted plumbing services on 01/08/2024 to request an appointment, Focused care at [NAME] is scheduled for an appointment January 17, 2024 to check sewage smell.<BR/>During an interview on 01/09/2024 at 08:21 a.m., Resident #16 stated that the smell in the dining room was like sewage. Resident #16 said that the smell in the dining room bothered her. She said she did not know where the smell came from, but it was only in the dining room. She said that the Director of Plant Operations J was going to spray into the ceiling vents when it smelled really bad to help reduce how bad it could smell.<BR/>During an interview on 01/09/2024 at 08:45 a.m., a Community Member said there was a very strong smell in the dining room the Sunday they went to have church services on 12/03/2023. She said they were told the sewer leak was in the kitchen or maybe the dining area. She said she was unable to remember who said this. She said the smell was bad enough for them to not want to provide church services that weekend. She said they were there this past Sunday, 01/07/2024, and the smell was not nearly as bad as on 12/03/2023 but it was still noticeable. She said she didn't hear anyone mention about the smell, but they didn't ask either. <BR/>During an interview on 01/10/2024 at 10:54 a.m., with the Administrator she said she didn't have an answer on why there was a smell inside the dining room. She said they called plumbers to come and investigate. She said she didn't remember when the smell started. She said she had smelled it intermittently. She said they used a chemical in the kitchen to try and keep the pipes clean in an effort to reduce the smell. She said residents have the right to have a homelike environment. She said that a resident could be dissuaded from eating in the dining room due to the foul smell. <BR/>Record review of the Maintenance Work Request Log dated from June 2023 to December 2023 did not reveal an issue reported regarding the smell in the dining room. Maintenance requests for clogged toilets in residents' rooms were logged however none of them were in proximity of the dining area.<BR/>Review of a Quality of Life - Homelike Environment facility policy dated May 2017 indicated, Residents are provided with a safe, clean, comfortable, homelike environment .staff shall provide person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences .the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include clean, sanitary, and orderly environment . pleasant neutral scents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for one (Resident #192) of six residents reviewed for care plan completion.<BR/>The facility failed to complete Resident #192's baseline care plan within the required 48-hour timeframe of admission.<BR/>This failure could place residents who were admitted within the last 30 days at risk for not receiving necessary care and services or having important care needs identified.<BR/>Findings included : <BR/>Review of Resident #192's face sheet dated 12/29/2023 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including Senile Degeneration of the Brain (the mental deterioration or loss of intellectual ability), Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems), and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). <BR/>Review of Resident #192's Baseline Care Plan revealed a date of admission of 12/29/23 and an implementation date of 12/31/23. The Baseline Care Plan reflected Ten days overdue . on 01/08/2023. No baseline care plan was available to use as it was marked incomplete. <BR/>During an interview on 01/09/2024 at 1:50 p.m., the DON said it was nursing services who were responsible to ensure that baseline care plans are completed. She said Resident #192's baseline care plan was not completed. She said staff were unable to view the baseline care plan as a section were not marked complete until 01/09/2024 (after the survey began). She said residents' baseline care plans could not be accessed by staff to view during this time. <BR/>During an interview on 01/10/2024 at 10:54 a.m., the Administrator said the nurse that admits the resident was responsible for developing a resident's baseline care plan. She said multiple people develop the care plan including nurses and social services. She said they are required to enter a baseline care plan within 48 hours. She said the purpose of a baseline care plan was so that staff can understand the care and needs of a resident within the first 48 hours after admission. She said residents can be placed at risk for staff not knowing the care needs of the resident if the baseline care plan was not completed. She said it could lead to a resident not receiving the care that they require.<BR/>Review of facility's policy Baseline Care Plan dated November 1st, 2019, reflected, . A baseline care plan is required to be completed within 48 hours of admission .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for one (Resident #192) of six residents reviewed for care plan completion.<BR/>The facility failed to complete Resident #192's baseline care plan within the required 48-hour timeframe of admission.<BR/>This failure could place residents who were admitted within the last 30 days at risk for not receiving necessary care and services or having important care needs identified.<BR/>Findings included : <BR/>Review of Resident #192's face sheet dated 12/29/2023 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including Senile Degeneration of the Brain (the mental deterioration or loss of intellectual ability), Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems), and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). <BR/>Review of Resident #192's Baseline Care Plan revealed a date of admission of 12/29/23 and an implementation date of 12/31/23. The Baseline Care Plan reflected Ten days overdue . on 01/08/2023. No baseline care plan was available to use as it was marked incomplete. <BR/>During an interview on 01/09/2024 at 1:50 p.m., the DON said it was nursing services who were responsible to ensure that baseline care plans are completed. She said Resident #192's baseline care plan was not completed. She said staff were unable to view the baseline care plan as a section were not marked complete until 01/09/2024 (after the survey began). She said residents' baseline care plans could not be accessed by staff to view during this time. <BR/>During an interview on 01/10/2024 at 10:54 a.m., the Administrator said the nurse that admits the resident was responsible for developing a resident's baseline care plan. She said multiple people develop the care plan including nurses and social services. She said they are required to enter a baseline care plan within 48 hours. She said the purpose of a baseline care plan was so that staff can understand the care and needs of a resident within the first 48 hours after admission. She said residents can be placed at risk for staff not knowing the care needs of the resident if the baseline care plan was not completed. She said it could lead to a resident not receiving the care that they require.<BR/>Review of facility's policy Baseline Care Plan dated November 1st, 2019, reflected, . A baseline care plan is required to be completed within 48 hours of admission .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 of 5 residents (Resident #19, Resident #25, and Resident #29) reviewed for unnecessary psychotropic medications (are medications that affect the mind, emotions, and behavior).<BR/>The facility failed to ensure Resident #19 had behavior monitoring for her prescribed antianxiety (treats anxiety disorders), anticonvulsant (are prescription medications that help treat and prevent seizures), and antipsychotic (are the main class of drugs used to treat people with schizophrenia) medications. <BR/>The facility failed to ensure Resident #19 had side effect monitoring for her prescribed antianxiety, anticonvulsant, and antipsychotic medications. <BR/>The facility failed to ensure Resident #25 had an appropriate diagnosis for his prescribed Quetiapine (Seroquel; is an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and depression) 50 mg. <BR/>The facility failed to ensure Resident #25 had an anxiety diagnosis for his prescribed antianxiety medication. <BR/>The facility failed to ensure Resident #25's prn Lorazepam (is used to treat anxiety) was ordered for 14 days.<BR/>The facility failed to ensure Resident #25 had behavior monitoring for his prescribed psychotropic medications. <BR/>The facility failed to ensure Resident #25 had side effect monitoring for his prescribed psychotropic medications.<BR/>The facility failed to ensure Resident #29 had a documented diagnosis for the use of his prescribed Seroquel (Quetiapine) 25 mg.<BR/>These failures could put residents at risk of receiving unnecessary psychotropic medications.<BR/>Findings included:<BR/>1. Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including Schizoaffective Disorder (is a mental illness that can affect your thoughts, mood and behavior), Bipolar type, Bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), mild depressed, recurrent depressive disorder (a depressed mood or loss of pleasure or interest in activities for long periods of time), generalized anxiety (you are worrying constantly and can't control the worrying), insomnia (is a common sleep disorder), and conversion disorder with seizures or convulsions (is a condition in which a person experiences physical and sensory problems, such as paralysis, numbness, blindness, deafness or seizures, with no underlying neurologic pathology). The face sheet did not indicate a diagnosis of anxiety. <BR/>Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 received antipsychotic, antianxiety, and antidepressant during the last 7 days of the assessment period. <BR/>Record review of Resident #19's care plan dated 03/21/23, revised 04/10/23 indicated Resident #19 was at risk for adverse consequence related to receiving psychotropic medications. Interventions included monitor side effects of anti-depressant (a type of medicine used to treat clinical depression) and antipsychotic. Monitor/document/report prn adverse reactions to antidepressant and psychotropic, monitor/record occurrence for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, verbal/aggression towards staff/others, etc.,) and document per facility protocol. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine (is used to treat certain types of seizures and bipolar disorder) 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Gabapentin (works in the brain to prevent seizures and relieve pain for certain conditions in the nervous system) 600 mg, give 1 tablet by mouth one time a day for neuropathy (happens when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged). <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Zyprexa (is an antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder), give 20 mg by mouth at bedtime for increased mood, decreased anxiety, and agitation, start date 08/11/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated Buspirone (is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety) 10 mg, give 1 tablet by mouth three times a day for antianxiety, start date 08/19/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 indicated monitor resident for side effect of muscle rigidity, change in appetite, sleep disturbance, tardive dyskinesia (is an uncommon side effect of certain medicines), seizures, cardiac changes every shift, start date 03/18/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated monitor resident for behaviors including but not limited to crying, withdrawn, and unrealistic fears every shift for depression, start date 03/19/23.<BR/>Record review of Resident #19's order summary dated 01/09/24 indicated monitor resident for behavior of unrealistic fears, yelling/screaming, hallucinations every shift: see diagnosis, start date 08/28/23. <BR/>Record review of Resident #19's order summary dated 01/09/24 did not indicate behavioral monitoring for Buspirone (antianxiety), Carbamazepine (anticonvulsant), Gabapentin (anticonvulsant), Zyprexa (antipsychotic). <BR/>Record review of Resident #19's order summary dated 01/09/24 did not indicate side effect monitoring for Buspirone (antianxiety), Carbamazepine (anticonvulsant), Gabapentin (anticonvulsant), Zyprexa (antipsychotic). <BR/>2. Record review of Resident#25's face sheet printed on 01/09/24 indicated Resident #25 was an [AGE] year-old male and was admitted on [DATE] with diagnoses including Parkinson's disease (is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) with dyskinesia, Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), moderate, with other behavioral disturbance, and Alzheimer's disease (is a type of dementia that affects memory, thinking and behavior). <BR/>Record review of Resident #25's quarterly MDS assessment dated [DATE] indicated Resident #25 was usually understood and usually had the ability to understand others. The MDS indicated Resident #25 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #25 did not have display behaviors. The MDS indicated Resident #25 was dependent for walking and substantial/maximal assistance for toilet transfer, chair/bed to chair transfer, and sit to stand. The MDS indicated Resident #25 received an antipsychotic during the last 7 days of the assessment period. <BR/>Record review of Resident #25's care plan dated 12/27/23 indicated Resident #25 was at risk for adverse consequence related to receiving psychotropic medication. I [Resident #25] am currently taking psychotropic medication with diagnosis of anxiety and dementia with behaviors. Intervention administers psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift. <BR/>Record review of Resident #25's order summary dated 01/09/24 indicated Lorazepam 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxiety/sundowners, start date 12/13/23. <BR/>Record review of Resident #25 order summary dated 01/09/24 indicated Quetiapine 50mg, give 1 tablet by mouth at bedtime for behaviors, start date 12/27/23. <BR/>Record review of Resident #25 order summary dated 01/09/24 did not indicate behavior monitoring for psychotropic medications.<BR/>Record review of Resident #25 order summary dated 01/09/24 did not indicate side effect monitoring for psychotropic medications.<BR/>Record review of Resident #25's MAR dated 01/01/24-01/31/24 indicated Lorazepam 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxiety/sundowners. Dose given 01/01/24, 01/02/24, 01/04/24, 01/05/24, 01/06/24, 01/07/24, 01/09/24, 01/10/24. <BR/>3. Record review of Resident #29's face sheet dated printed 01/09/24 indicated Resident #29 was an [AGE] year-old male and admitted on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mild, with agitation, delusional disorder (is a type of psychotic disorder), and psychosis (is when people lose some contact with reality). The face sheet did not indicate schizoaffective disorder (is a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). The face sheet indicated MD S was Resident #29's primary physician. <BR/>Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated Resident #29 was understood and sometimes had the ability to understand others. The MDS indicated Resident #29 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS did not indicate Resident #29 had psychosis or behavioral symptoms. The MDS indicated Resident #29 required partial/moderate assistance for toilet hygiene and shower/bath self, supervision for personal hygiene, and independent for oral hygiene and eating. The MDS indicated Resident #29 received an antipsychotic during the last 7 days of the assessment period. <BR/>Record review of Resident #29's care plan dated 01/09/23 indicated Resident #29 was at risk for adverse consequence related to receiving psychotropic medication. I [Resident #29] am currently taking psychotropic medication with diagnosis of depression and psychotic/psychosis. Intervention administers psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift. <BR/>Record review of Resident #29's order summary dated 01/09/24 indicated Seroquel 25 mg, give 1 tablet by mouth at bedtime for schizoaffective, start date 09/30/23. <BR/>During an interview on 01/10/24 at 12:47 p.m., LVN P said she used diagnoses list in the chart to add to orders she received. She said sometimes MD and NP sent order with diagnoses already added. She said nurses were responsible for ordering and doing behavior and side effect monitoring. She said the behavior and side effect monitoring should be done by drug classification. She said it was important to do behavior and side effect monitoring for each drug class because each classification had different side effects monitor and behaviors it treated. She said prn psychotropic meds could be ordered for 14 days for hospice residents. She said she was not sure about other residents. She said she did not know why prn psychotropic meds needed 14 days stop dates. She said the MDS coordinator (CRS), NP, and MD made sure residents had appropriate diagnosis for antipsychotic meds and would let the staff know if it was not appropriate. She said antipsychotic meds should have appropriate diagnoses to make sure the resident gets the right medication and know if the black box warnings applied to the resident. <BR/>During an interview on 01/10/24 at 1:20 p.m., the CRS said if she found an inappropriate diagnoses while reviewing the chart, she notified staff of the issue. She said Resident #25 diagnosis of dementia with behaviors was not an appropriate diagnosis for Seroquel. She said the Resident #29 did not have Schizoaffective as a listed diagnosis on his chart.<BR/>On 01/10/24 at 2:23 p.m., attempted to contact MD S by phone, no return call before or after exit. <BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said nurse were responsible for doing behavior and side effect monitoring. She said the nurse who received the order should make sure to add behavior and side effect monitoring. She said behavioral and side effect monitoring should be for each drug classification. She said it was important to have side effect monitoring to have information to relay to the doctor. She said it was important to have behavioral monitoring to know if a medication worked or needed. She said an antianxiety prn medication should have 14 days stop date. She said the nurse who received the prn order and before administration of the antianxiety med should make sure it had a stop day. She said she monitored prn orders and 14 days stop dates. She said she must have missed Resident #25's Lorazepam order. She said 14 days stop date were important to reassess the need of the medication. She said it could risk the resident getting a medication they did not need. She said the CRS looked at orders for appropriate diagnoses. She said appropriate diagnoses and medications were important to treat the actual diagnosis. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said if the resident was care planned for side effect and behavior monitoring, it should be done. She said monitoring should be documented in notes and followed up on. She said monitoring should be done by drug class. She said it was the nurse responsibility for monitoring of psychotropic medications. She said nursing management should be ensuring nurses were doing the monitoring. She said nursing management should be doing chart audits and if issues found, do in-services with the staff. She said prn meds should be 14 days so they could be reassessed for the need of it. She said diagnosis added to the resident chart should come from the physician. <BR/>Record review of a facility's Psychotropic Medication Review policy dated 04/20 indicated .careful assessment as to whether the medication is necessary and pharmacologically appropriate .comply with state and federal regulations related to the use .to include regular review for continued need, appropriate dosage, side effects, risk and/or benefits .monitors psychotropic drug use noting and adverse effects .reviews of the use of the medication with IDT on monthly basis .

Based on interviews and record review the facility failed to complete a performance review of each Resident Care Provider (RCP) at least once every 12 months, for 5 of 5 (RCP L, RCP O, RCP U, RCP V, and RCP W) reviewed for annual competency evaluations.<BR/>The facility failed to complete annual RCP (facility titles CNA as RCP) competency evaluations for RCP L, RCP O, RCP U, RCP V, and RCP W based on the personnel file review results.<BR/>This failure could affect residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs.<BR/>Findings included:<BR/>Record review of the Personnel File Review completed on 02/12/25, indicated RCP L, RCP O, RCP U, RCP V, and RCP W did not have a competency evaluation on file. The Personnel File Review indicated RCP L's date of hire was 01/07/25, RCP O 12/5/24, RCP U 12/5/24, RCP V 10/17/24, and RCP W 11/21/24. <BR/>During an interview on 02/12/25 at 1:44 p.m., the Director of Nurses said that she did not know if the RCP (CNA) competencies had been completed. She said she could not find them. She said that the previous Director of Nurses did not file them or indicate where she placed them if she completed them. She said it was important for Resident Care Providers to have their annual competencies evaluated to ensure they were proficient in the areas of care they provide. <BR/>During an interview on 02/12/25 at 5:09 p.m., the Administrator said she did not know if the RCP competencies were completed or not. She said she believed they were completed but they did not have documented proof to provide at the time the interview was conducted . <BR/>Record review of the facility policy titles Competency of Nursing Staff dated 04/2020, indicated All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will participate in a facility-specific, competency-based staff development and training program demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.

**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 status for 1 of 15 resident reviewed for assessments. (Resident #25)<BR/>The facility failed to code Resident #25's fall on his MDS.<BR/>This failure could place residents at risk of not having individual needs met.<BR/>Findings included:<BR/>Record review of Resident#25's face sheet printed on 01/09/24 indicated Resident #25 was an [AGE] year-old male and was admitted on [DATE] with diagnoses including Parkinson's, Dementia, moderate, with other behavioral disturbance and fall on same level from slipping, tripping, and stumbling with subsequent striking against other objects.<BR/>Record review of Resident #25's quarterly MDS assessment dated [DATE] indicated Resident #25 was usually understood and usually had the ability to understand others. The MDS indicated Resident #25 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #25 was dependent for walking and substantial/maximal assistance for toilet transfer, chair/bed to chair transfer, and sit to stand. The MDS did not indicate Resident #25 had any falls in the last month, since admission, or prior assessment. <BR/>Record review of Resident #25's care plan dated 12/08/23, revised on 12/29/23 indicated Resident #25 had an actual fall with serious injury, poor balance, fall on same level from slipping, tripping, and stumbling with subsequent striking against other object, and periprosthetic fracture (are fractures that occur in association with an orthopedic implant) around internal prosthetic left knee joint (is a surgery to replace a knee joint with a man-made artificial joint. The artificial joint is called a prosthesis). Fall: 12/12/23, 12/13/23, 12/18/23, and 12/28/23. Interventions included 12/12/23: incontinent care frequently, 12/13/23: staff to assist to bathroom, and 12/18/23: encourage resident to use call light. <BR/>Record review of the facility's incident report date range 07/08/23-01/08/24 indicated Resident #25 had unwitnessed falls on 12/13/23, 12/18/23, and 12/28/23. <BR/>During an interview on 01/10/24 at 1:20 p.m., the CRS said she was responsible for MDSs and care plans. She said she only worked part time at the facility. She said Resident #25's fall should have been coded on his MDS. She said it was important to have an accurate MDS to notify the state, and it affected the facility's quality measures and statistics. She said the corporate MDS performed audits every 3 months to check the accuracy of the MDSs completed. <BR/>During an interview on 01/10/24 at 2:29 p.m., the DCO said the CRS was responsible for MDSs. She said she knew MDSs needed to be accurate for the resident information to be correct and billing purposes. She said Resident #25's MDS should be correct and show his falls. <BR/>During an interview on 01/10/24 at 3:57 p.m., the ADM said the CRS was responsible for accuracy of the resident's MDS. She said the MDS should be correct because it reflected the condition of each resident. <BR/>Record review of a facility's MDS Completion Accuracy and Timeliness policy revised 11/15/23 indicated .the purpose of this policy is to ensure accuracy .