REUNION PLAZA SENIOR CARE AND REHABILITATION CENTE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #14) of 6 residents reviewed for quality of care. <BR/>The facility failed to ensure Resident #14 had supervision that prevented him from going outside and falling causing a hematoma and abrasion to his head.<BR/>This failure could result in residents experiencing accident, injuries, and diminished quality of life. <BR/>Findings included:<BR/>1. Record review of an undated face sheet reflected Resident #14 was a [AGE] year-old male that admitted to the facility on [DATE] with the diagnosis of dementia, atrial fibrillation (irregular heartbeat), and diabetes mellitus type II and discharged [DATE].<BR/>Record review of Resident #14's admission MDS dated [DATE] reflected he had a BIMS of 01 which indicated severe cognitive impairment. The MDS also indicated Resident #14 had some physically aggressive behavior and he required partial to moderate assistance with ADLs.<BR/>Record review of Resident #14's care plan dated 05/07/2024 reflected a care plan titled Behavioral Changes with the problem of high elopement risk. The goal was to keep the resident safe within the facility. <BR/>Record review of admission assessment dated [DATE] indicated Resident #14 was a high elopement risk scoring a 22 out of 25 points scored for elopement.<BR/>Record review of an incident report dated 06/22/2024 revealed Resident #14 exited the front of the building and fell from his wheelchair onto the ground outside the front entrance of the building. Resident #14 sustained an abrasion to his forehead and a hematoma.<BR/>During an interview on 08/14/2024 at 10:02 a.m., RN P stated Resident #14 attempted to find an exit all day every day since the day he was admitted . She stated he was hard to redirect about 50% of the time. She stated she learned to redirect him with food and sitting in the dining room and that worked most of the time. She stated he would push right past you if you were standing in the way of him and where he was attempting to go. She stated she had not felt he was being mean, she stated he just had not registered that someone was in front of him.<BR/>During an interview on 08/14/2024 at 2:20 p.m., LVN Q stated on 06/22/2024 at lunch time Resident #14 went outside the front door of the facility and fell from his wheelchair onto his right side striking his head on the ground causing a hematoma and abrasion to his right forehead. She stated she was alerted by a family member of his presence outside because the staff was busy serving lunch, and no one saw him go outside. She stated she was aware he was an elopement risk, and they were doing frequent checks on him every 15-20 minutes and keeping him in eyesight if he were out of this room. LVN Q stated all the staff pitched in and tried to keep an eye on Resident #14, but it was not always possible to watch him. She stated he just slipped out because all hands are on deck when it was meal service time. She stated he was exit seeking every day because of his dementia. She stated he had gotten outside once before but the staff saw him before the door even closed behind him and redirected him back into the facility. LVN Q stated she had not believed he would have fallen that time if he had not been outside because it appeared to her the wheel on his wheelchair went off the sidewalk and dumped him out onto the ground. She stated the next day he discharged to a secured unit on 06/23/2024.<BR/>During an interview on 08/15/2024 at 2:00 p.m., the DON stated she was aware Resident #14 was an elopement risk and she understood there were other facilities that could take better care of his needs, but his family insisted he stay at the facility. She stated the family was devastated when we informed them that he could no longer stay at our facility, and we needed to find him a safe place to live immediately. The DON stated Resident #14 had 4-5 falls while he was here from the wandering up and down the hall all day and night. She stated the fall he had on 06/22/2024 could have been prevented had Resident #14 not been exit seeking and found his way outside, where the sidewalk caused him to be dumped from his wheelchair.<BR/>During an interview on 08/15/2024 at 3:15 p.m., the ADM stated she was aware Resident #14 was an elopement risk and the facility was trying different things to see if an adjustment period might calm that behavior down. She stated unfortunately it was not a successful match for him to remain in the facility because all the resident's must be safe that stay at the facility.<BR/>Review of facility's fall prevention policy titled Fall Evaluation and Prevention, dated revised August 2020, reflected The facility will evaluate residents for their fall risk and develop interventions for prevention . Upon Admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 3 of 22 residents (Resident #6, Resident #7 and Resident #4) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #6 and Resident #7's oxygen tubing and humidifier bottles were dated per the facility's policy.<BR/>The facility failed to change Resident #6's oxygen tubing and humidifier bottle every Wednesday per the physician's orders. <BR/>The facility failed to change Resident #6 and Resident #7's nebulizer mask and tubing per the facility's policy.<BR/>The facility failed to ensure Resident #6 and Resident #7's nebulizer, mask and tubing were dated per the facility's policy.<BR/>The facility did not ensure Resident #4's suction canister was emptied when it was &frac34; full.<BR/>The facility failed to ensure Resident #4's suction device, tubing, and suction canister were not dated.<BR/>These failures could place residents at risk for of respiratory infections.<BR/>Findings included:<BR/>1.Record review of Resident #6's face sheet dated 2/8/23 revealed Resident #6 was an [AGE] year-old female, and was admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease- constriction of the airways and difficulty breathing), atrial fibrillation (irregular and often rapid heart rate that causes poor blood flow), orthostatic hypotension (type of low blood pressure that occurs when standing up from sitting of lying down), and pain. <BR/>Record review of Resident #6's quarterly MDS dated [DATE] revealed Resident #6 had a BIMS of 12, which indicated she was cognitively intact. Resident #6 required limited to extensive assistance of 1 person for most ADL's. Resident #6 required oxygen therapy.<BR/>Record review of the Resident #6's order summary report dated 2/08/23 revealed an order for oxygen at 2 LPM by a nasal cannula; albuterol sulfate 0.63 mg (milligrams) in 3 mL (milliliters) of solution for nebulization inhalation every four hours as needed for shortness of breath; and ipratropium 0.5 mg with 3 mg in 3 mL of solution for nebulization inhalation every six hours. Resident #6's orders revealed an order for oxygen canister/tubing change every Wednesday evening and date humidifier water and oxygen tubing weekly on Wednesday.<BR/>Record review of Resident #6's eTAR dated 2/08/23 revealed the oxygen/tubing change every Wednesday evening and change & date humidifier water and oxygen tubing weekly on Wednesday was not documented as completed on Wednesday 2/01/23. There was not a task on the eTAR related to changing Resident #6's nebulizer tubing or nebulizer mask.<BR/>Record review of Resident #6's nurses' notes with date range of 10/08/22-2/08/23 revealed there was no documentation the nurses changed Resident #6's oxygen tubing on 2/01/23 or her nebulizer tubing, or nebulizer mask every 48 hours per the facility's policy.<BR/>During an observation and interview on 2/08/23 at 2:00 PM with Resident #6 revealed she had a nebulizer machine (changes liquid medication to a mist) with nebulizer tubing and a mask attached and the tubing nor the mask were dated. The nebulizer with tubing and mask was stored in a bag that reflected the bag was issued 6/22/22. The resident said she received breathing treatments with the nebulizer machine and mask every six hours. Resident #6 was wearing her oxygen at the time of the observation. The oxygen tubing nor the humidifier bottle were dated. Resident #6 said when she left the room in her wheelchair, she had oxygen bottles and she stored her oxygen tubing and cannula in the bag hanging on the oxygen concentrator at her bedside. The bag did not have a date. Resident #6 said she thought the nurses changed her oxygen tubing and nebulizer mask and tubing every month. She did not know when her oxygen tubing and nebulizer mask and tubing were changed last.<BR/>2. Record review of Resident #7's face sheet dated 2/8/23 revealed Resident #7 was a [AGE] year-old female, and was admitted to the facility on [DATE] with diagnoses of heart failure, atrial fibrillation, cerebral atherosclerosis (arteries in the brain become hard, thick, and narrow due to the buildup of plaque or fatty deposits inside the artery walls, which decreases the blow to areas of the brain), kidney failure (kidneys lose the ability to remove waste and balance fluids in the body), spondylosis (age-related wear and tear of the spinal disks), and pain. <BR/>Record review of Resident #7's annual MDS dated [DATE] revealed Resident #7 had a BIMS of 9, which indicated she was moderately cognitively impaired. Resident #7 required supervision to limited assistance of 1 person for most ADL's. Resident #7 required oxygen therapy.<BR/>Record review of Resident #7's order summary report dated 2/08/23 revealed an order for oxygen at 2 LPM by a nasal cannula and ipratropium 0.5 mg with 3 mg in 3 mL of solution for nebulization inhalation three times daily. Resident #7's orders revealed an order to change and date the nebulizer mask/mouthpiece & tubing weekly on Wednesday's night shift. There was not an order related to changing the oxygen tubing.<BR/>Record review of Resident #7's eTAR dated 2/08/23 revealed the change of the nebulizer mask/mouthpiece, & tubing was not documented as completed on Wednesday 2/01/23.<BR/>During an observation and interview on 2/08/23 at 11:49 AM, revealed Resident #7 had oxygen tubing with a nasal cannula attached to a humidifier bottle and they were not dated. The nasal cannula was stored in a bag hanging on the oxygen concentrator and the bag reflected it was issued 6/22/22. Resident #7 said she used her oxygen at night and sometimes during the day when she was short of breath. Resident #7's nebulizer and mask were in a bag, but they were not dated. Resident #7 said she could not remember when her oxygen tubing or nebulizer tubing and mask had last been changed. <BR/>During an interview on 2/08/23 at 3:55 PM with the DON, she said it was a constant struggle trying to get the night shift to do what they were supposed to do. She said she had gone down and visited with Resident #6 and Resident #7 after she knew the surveyor had visited with them and she saw for herself that the oxygen tubing/humidifier bottles and nebulizer/mask were not dated. She said if the tubing/humidifier bottles and nebulizer/masks were not dated, along with no documentation of when they were changed, then they would not be able to determine how long the resident had had the equipment and it could lead to the residents developing respiratory infections. The DON said she was ultimately responsible to ensure the night shift was changing and dating the respiratory equipment per the physician's orders and the facility's policies.<BR/>During an interview on 2/08/23 at 4:13 PM with RN A, she said the night shift nurses were responsible for changing the oxygen tubing and nebulizers/masks on Wednesday nights. She said the oxygen tubing and nebulizer masks should be dated when changed and documented in the resident's chart. She said if the oxygen tubing and nebulizers/masks were not changed regularly they would become nasty and dirty and could cause the resident to develop a respiratory infection. She said she did not specifically check the respiratory equipment (oxygen tubing, nebulizer tubing & masks/mouthpieces) for dates, because night shift was responsible for changing and dating the equipment. She said she would change any respiratory equipment herself and date the equipment if she noticed anything did not look sanitary. <BR/>During an interview on 2/08/23 at 4:25 PM with the Administrator, who was also one of the Infection Preventionists, revealed she expected the oxygen tubing/humidifier bottles and nebulizer/masks to be labeled/dated and it should be documented in the eTAR per the physician's orders. She said she the oxygen tubing/humidifier bottles and nebulizer/masks should be changed per the facility's policies.<BR/>3. Record review of Resident #4's consolidated physician orders dated 2/10/23 indicated he was [AGE] years old and readmitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), colostomy (surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) status, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) status, dysphagia (difficulty swallowing), and shortness of breath. <BR/>Record review of Resident #4's MDS dated [DATE], indicated Resident #4 sometimes made himself understood and usually understood others. The MDS indicated Resident #4 had short-term and long-term memory problems. The MDS indicated Resident #4 had moderately impaired cognitive decision-making skills. The MDS indicated Resident had no behavior of rejecting care. <BR/>Record review of Resident #4's care plan revised on 1/20/23 indicated Resident #4 had increased secretions and an increased risk of aspiration. The care plan interventions included assess for the presence of dyspnea (difficult or labored breathing) and suction as needed. <BR/>During an observation on 2/8/23 at 11:00 a.m. revealed Resident #4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an observation on 2/8/23 at 1:00 p.m. revealed Resident # 4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an observation on 2/8/23 at 3:00 p.m. revealed Resident #4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an interview on 2/9/23 at 9:30 a.m., LVN B said she took care of Resident #4 regularly on the 6:00 a.m. to 6:00 p.m. shift. LVN B said she changed the suction canister and tubing yesterday (2/8/23) evening at approximately 5:00 p.m. when Resident #4's family member pointed out the suction canister was full. LVN B said she had not noticed that the canister was full yesterday during the morning or afternoon. LVN B said it was ultimately the nurse's responsibility but would expect CNAs to notify her if they (CNAs) noted the canister was full. LVN B said the canister and tubing should be dated and initialed. LVN B said the suction canister and tubing should be changed at least every week and as needed. LVN B clarified if the suction device was dropped on the floor the tubing and suction device would be changed. LVN B further clarified if the suction canister was &frac12; way full the canister should be changed. LVN B said the suction equipment will not suction properly if the canister is full. LVN B said she did not suction Resident #4 yesterday prior to 5:00 p.m. LVN B said if he (Resident #4) had needed to be suctioned, and the canister was full, she would have had to retrieve a suction canister before he could have been suctioned. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said suction tubing and suction canisters should be dated to ensure they (suction tubing and suction canisters) are changed weekly. RN C said suction canisters should be emptied before they are full because when full they will not work properly. RN C said a full suction canister could delay a resident receiving suction for a minute or two while staff retrieved another canister. <BR/>During an interview on 2/9/23 at 11:45 a.m., CNA D said she took care of Resident #4 regularly on the day shift. CNA D said nurses handled anything related to suction equipment. CNA D said she did not report the canister was full to the nurse on 2/8/23 because she did not notice it was full. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected staff to ensure suction equipment was dated and suction canisters were changed when the canister was &frac34; full. The DON said she expected nurses to check the level of the canister at least once a shift and when they were in the room providing other care tasks to ensure the canister would be ready for use if suction was needed with no delay in care. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected nurses to follow policy and procedure regarding suction equipment. <BR/>Record review of the facility policy and procedure titled, Respiratory Equipment Change Schedule, reviewed by facility administration on 01/12/22 reflected, Standard of Practice: The community will provide a schedule for changing disposable equipment at regular intervals as determined by manufacturer recommendations and local community standards. Procedures: . provide a schedule for changing disposable equipment at regular intervals as determined by manufacturer recommendations and local community standards . aerosol tubing and aerosol nebulizer to be changed every forty-eight hours . small volume medication nebulizers, place in clean paper bag, labeled with resident's name and leave a resident's bedside . (8) Suction Canister: .(b) Change or empty canister or collection when &frac34; full. (9) Suction tubing .(b) Change or empty canister or collection when &frac34; full .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 9 residents (Residents #2 and Resident #3) reviewed for infection control practices.1. The facility failed to ensure CNA A and CNA B did not contaminate Resident #2's clothing, draw pad, bedding, pillows, and feeding tube pole after performing incontinent care.2. The facility failed to ensure CNA A and CNA B donned (put on) a gown while performing incontinent care on Resident #2, who was on Enhanced Barrier Precautions (EBP).3. The facility failed to ensure LVN C donned a gown while disconnecting Resident #3's feeding tube, assessing feeding tube placement, and attempting to flush the feeding tube, and the resident was on Enhanced Barrier Precautions.These failures could place residents at risk for cross contamination, at an increased risk of infection, and the spread of infection.Findings included:1. Record review of Resident #2's face sheet dated 7/14/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #2 had diagnoses which included quadriplegia (inability to move upper or lower body), shortness of breath, and lack of coordination.Record review of Resident #2's quarterly MDS assessment dated [DATE], indicated he was unable to complete the BIMS score, which indicated he had cognitive impairment. The MDS indicated Resident #2 was dependent on staff for all ADLs. The MDS indicated Resident #2 had a feeding tube.Record review of Resident #2's Care Plan dated 7/14/25 indicated he had a care area/problem of infection control with intervention of Enhanced Barrier Precautions, gown and glove use during high-contact resident care activities, which included providing hygiene, changing briefs, and assisting with toileting.Record review of Resident #2's Physician Orders did not reflect an order for Enhanced Barrier Precautions.During an observation on 7/14/25 at 11:45 AM, Resident #2 was lying in bed with head of bed elevated with tube feeding being infused by an infusion device. There was a blue name tag on the outside of his room, a PPE cart and EBP sign just to the inside of his door in his room.During an observation on 7/14/25 beginning at 1:30 PM, CNA A and CNA B entered Resident #2's room and washed their hands and put on gloves. CNA A and CNA B positioned themselves on opposite sides of Resident #2's bed to perform incontinent care on Resident #2. CNA A pulled a male incontinent pad from between Resident #2's legs and placed it in the trash bag. CNA B was on the window side of Resident #2 and rolled resident toward her and held him on his side while CNA A cleansed the head of his penis with a wipe, then used another wipe to cleanse the shaft of the penis, then another 2 wipes to cleanse down each side of his inner thighs. CNA A then used the same gloves to reposition the resident's pillow, moved his feeding tube pole, placed one hand on his shoulder and one on his thigh and pulled him toward her without changing her gloves. CNA B then cleansed Resident #2's bottom with 3 wipes and went between his legs, there was no bowel movement present. Then CNA B and CNA A still wearing the same gloves used during incontinent care, repositioned Resident #2, stuffed a 3-sided body pillow all around Resident #2, used the draw pad under him to pull Resident #2 up in bed, pulled his gown down and then removed their gloves. Neither CNA A nor CNA B wore a gown during Resident #2's incontinent care. Resident #2 had a blue name tag outside his door, an EBP sign posted on the wall just inside his door along with a PPE cart with EBP supplies. During an interview on 7/14/25 at 1:50 PM, CNA A said she had worked at the facility since 2019 and normally worked the 6 AM to 2 PM shift. CNA A said staff should change gloves during incontinent care more times than she did on Resident #2. CNA A said she should have changed her gloves after cleaning Resident #2's front perineal (private) area and before touching multiple surfaces in his room. CNA A said it was a hygiene thing and cross-contamination and could give Resident #2 an infection. CNA A said it was an infection control issue and could cause skin irritation too. CNA A said she would know someone was on EBP if there was a bucket and a sign outside the resident's door. CNA A said staff had to suit up with gown, gloves, and mask if a resident was on EBP. CNA A said residents on EBP were the residents with something in their urine or bowel. CNA A said Resident #2 probably should be on EBP because he had a feeding tube. CNA A said she did not see the EBP sign or the bucket just inside Resident #2's room and did not know what EBP was. CNA A said she did not know why Resident #2 had a EBP sign and cart, because they did not use it. CNA A said she had been on Resident #2's hall since April 2025 and had not ever used a gown during Resident #2's care.During an interview on 7/14/25 at 1:56 PM, CNA B said she had worked at the facility since May of 2025 and normally worked the 2 PM -10 PM shift but picked up a 6 AM -2 PM on 7/14/25. CNA B said she should have changed her gloves after performing incontinent care on Resident #2 and before touching multiple surfaces in his room. CNA B said it was cross-contamination and could cause him an infection. CNA B said they should have worn gowns while performing incontinent care on Resident #2 because he had a feeding tube. CNA B said EBP was to protect the staff and the resident from cross-contamination. CNA B said not wearing a gown during incontinent care could spread infection. CNA B said she did not see the EBP cart or EBP sign that was just inside Resident #2's room.Record review of the facility's Nursing Services-Competency Evaluation for Skill/Procedure: Perineal Care without catheter of CNA A dated 5/21/25 had a check mark in the met column which indicated CNA A had performed the procedure of perineal care and met the performance criteria, which included discarding used supplies, removed gloves, and performed hand hygiene and applied new gloves and placed new brief and changed lines as needed and positioned resident comfortably, and gave table and call light. Record review of the facility's Nursing Services-Competency Evaluation for Skill/Procedure: Perineal Care without catheter of CNA B dated 5/30/25 had a check mark in the met column which indicated CNA B had performed the procedure of perineal care and met the performance criteria, which included discarding used supplies, removed gloves, and performed hand hygiene and applied new gloves and placed new brief and changed lines as needed and positioned resident comfortably, and gave table and call light. 2. Record review of Resident #3's face sheet dated 7/15/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #3 had diagnoses which included myotonic muscular dystrophy (genetic condition characterized by progressive muscle weakness and wasting), diabetes (high blood sugar), and gastrostomy (feeding tube).Record review of Resident #3's quarterly MDS assessment dated [DATE], indicated she had a BIMS of 10, which indicated she had moderate cognitive impairment. The MDS indicated Resident #3 required moderate to dependent on staff for most ADLs. The MDS indicated Resident #3 had a feeding tube.Record review of Resident #3's Care Plan dated 7/15/25 indicated she had a care area/problem of altered nutritional status: enteral feeding monitor. Resident #3 also had a care area/problem of Infection control with intervention of Enhanced Barrier Precautions, gown and glove use during high-contact resident care activities.Record review of Resident #3's Physician Orders dated 7/01/25 - 7/31/25 did not reveal an order for Enhanced Barrier Precautions.Record review of Resident #3's Medication Record dated 6/23/25 - 7/15/25 indicated Enhanced Barrier Precautions every shift.During an observation and interview on 7/15/25 at 9:53 AM, Resident #3 was lying in bed and had a feeding tube infusion device connected to her feeding tube and the alarm was going off that it had completed. Resident #3 said staff wear gloves when administering her feedings and medications through her feeding tube and when providing incontinent care, but the staff never wear gowns during her care. There was a blue name tag outside her door, a PPE cart just inside Resident #3's door, but there was no EBP sign posted.During an observation and interview on 7/15/25 beginning at 10:04 AM, LVN C entered Resident #3's room and put on gloves. LVN C then pulled back the Resident #3's covers to expose her feeding tube. LVN C unhooked the feeding tube, then placed her stethoscope on the resident's abdomen, and checked placement of the feeding tube with 60 cc of air. LVN C then attempted to flush the feeding tube with water and then begun rolling the feeding tube between her fingers as she was leaned against the resident's bed/bedding. LVN C did not wear a gown as part of EBP. LVN C said they often had difficulty flushing the resident's feeding tube. LVN C said she was going to have someone else come try to flush it. During an interview on 7/15/25 at 10:35 AM, LVN C said she had worked at the facility for approximately twelve years and normally worked on the day shift. LVN C said she would know a resident was on EBP because they should have a PPE box in their room. LVN C said the EBP was for residents that had urinary catheters, wounds, feeding tubes, or any openings that could introduce infection. LVN C said residents on EBP should also have a sign posted indicating they were on EBP. LVN C said if staff were in direct contact with the resident, they should suit up and I did not do it on Resident #3. LVN C said she should have also worn a gown with her gloves during Resident #3's care. LVN C said it was important to follow EBP due to the at-risk residents had ports of entry for infection and EBP protected both the resident and staff. LVN C said EBPs was so staff did not carry anything from one resident to another resident. LVN C said if staff did not follow the EBP, it could place the residents at a higher risk of infection.During an interview on 7/15/25 at 2:17 PM, the ADON said he was also the Infection Preventionist. The ADON said staff should change their gloves during incontinent care any time they were doing different tasks. The ADON said the staff should have changed their gloves and performed hand hygiene after cleaning the Resident #2's front perineal area and prior to touching any other surfaces in the resident's room. The ADON said then staff should have changed gloves and performed hand hygiene after cleaning the resident's back perineal area and prior to touching any other of the resident's surfaces to prevent cross-contamination. The ADON said it was important to perform hand hygiene and change gloves appropriately to prevent cross-contamination and prevent the spread of infection. The ADON said all staff were responsible for ensuring staff were following the infection control policy and procedures. The ADON said residents who were on EBP was indicated by the blue name tags outside the resident's door and a PPE cart inside the resident's room. The ADON said they do not use the EBP signs, but staff had been educated that the blue name tags were indicative of the resident being on EBP. The ADON said any resident who had an invasive device, such as urinary catheter, a feeding tube, dialysis access, wounds or anything that would increase the risk of infections from an outside source would be on EBP. The ADON said the purpose of EBP was to protect the resident from an outside source of infection from direct care contact. The ADON said the resident, who was on EBP, was at an increased risk of infection if staff did not wear gown and gloves during direct care. The ADON said staff could spread infection from one resident to another resident if they were not wearing a gown during direct care. During an interview on 7/15/25 at 2:45 PM, the DON said staff should know a resident was on EBP from the blue name tags outside the resident's door and a PPE cart inside the resident's room. The DON said they do not use the EBP signs and only used the blue name tags outside the resident's room. The DON said the reasons a resident would be on EBP would be anyone with a feeding tube, urinary catheter, wounds, and any other indwelling device. The DON said the purpose of EBP was almost a reversed precaution, to protect the resident from getting something from the staff due to the resident was at a higher risk of infection and cross-contamination. The DON said staff should have changed their gloves when going from a dirty surface to a clean surface. The DON said staff should wash or sanitize their hands prior to and post incontinent care. The DON said the Infection Preventionist and herself would be responsible for ensuring staff were following the infection control policy and procedures. The DON said staff could transfer any bad bugs anywhere they touched with their contaminated gloves. The DON said the resident had the potential of infection if staff were not following EBP and transferred germs or bacteria from one resident to another resident. During an interview on 7/15/25 at 4:10 PM, the ADM said he would expect staff to follow the facility's infection control policy and procedures and change gloves and perform hand hygiene per their policies. The ADM said he would expect the EBP to be followed to protect the residents from anything staff may have come in to contact with. The ADM said not changing gloves, performing hand hygiene, following the EBP could be a potential infection control issue.Requested an Infection Control policy on 7/15/25 at 5:00 PM from the facility's Regional Nurse and was provided a policy titled Infection Prevention, Control & Surveillance, which did not contain pertinent information. Record review of the facility's policy titled Perineal Care dated revised April 10, 2023 indicated . staff would provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection . procedure . perform hand hygiene. Apply clean gloves . 5. Perineal care for a male resident . d. wash tip of penis . f. cleanse the shaft of the penis . 6. observe perineal area . 8. Turn resident to clean all areas of buttocks . 9. Dispose of gloves and used supplies and perform hand hygiene . 10. Apply new gloves and place new brief . 11. Position resident comfortably . Record review of the facility's policy titled Hand Hygiene for Staff and Residents dated revised February 2025 indicated . purpose . to reduce the spread of infection with proper hand hygiene . hand hygiene was the most important component for preventing the spread of infection . hand hygiene was done . before . before resident contact . after . contact with soiled or contaminated articles, such as articles that were contaminated with body fluids . resident contact . contact with contaminated object or source where there was a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds . toileting or assisting others with toileting .Record review of the facility's policy titled Enhanced Barrier Precautions dated revised March 2025 indicated . many residents in nursing homes were at increased risk of becoming colonized and developing infections with multi-drug-resistant organisms (MDROs) . facility utilized Enhanced Barrier Precautions (EBP) as a strategy to decrease transmission of CDC-targeted and epidemiologically important MDROs when Contact Precautions do not apply . indications . wounds and/or indwelling medical devices . indwelling medical devices include central lines . urinary catheters, feeding tubes . high contact resident care activities . providing hygiene . changing briefs or assisting with toileting . device care or use . feeding tube . communication . indicate the residents who were on EBP by subtle means, such as an alternate color of the resident's name badge on door .

**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 11 of 22 residents (Residents #19, #60, #33, #61, #93, #97, #54, #8, #70, #23, and #76) reviewed for reasonable accommodations.<BR/>-The facility failed to ensure Residents #19, #60, #33, #61, #93, #97, #70, and #54 call lights were accessible. <BR/>-The facility failed to replace Resident #93's toilet with a taller, more accessible toilet.<BR/>- The facility failed to respond to Resident #8, Resident #70, Resident #23, and Resident #76 in a timely manner.<BR/>This failure could place residents at risk of injuries, health complications and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of Resident 19's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), glaucoma (a group of eye conditions that damage the optic nerve, the health of which is vital for good vision), and hypertension (blood pressure that is higher than normal).<BR/>Record review of Resident #19's quarterly MDS, dated [DATE], reflected she had a BIMS score of 11, which indicated a minimal impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. <BR/>Record review of Resident #19's care plan dated 06/24/2022 titled self-care deficit revealed Resident #19 required extensive assistance with bed mobility, transfer, ambulation, and toileting. <BR/>During an observation on 09/12/2022 at 10:02 am Resident #19 was looking for her call light and could not find her call light. The call light was noted to be on the floor underneath the bed.<BR/>During an observation and interview on 09/13/2022 at 11:18am Resident #19 was looking for her call light and could not find her call light. The call light was on the floor bedside the bed. Resident #19 was unable to reach the call light. Resident #19 stated she had no way of getting help if she could not use her call light. She stated her call light was not within reach at least once daily. She stated no one can hear you if you scream and she was not able to get out of bed to look for the call light on her own.<BR/>2. Record review of Resident 60's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: dementia (A group of thinking and social symptoms that interferes with daily functioning.), anemia (a condition in which the number of red blood cells is below normal), and major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).<BR/>Record review of Resident # 60's MDS, dated [DATE], reflected he had a BIMS score of 05, which indicated moderately impaired cognitive status. His functional status reflected he required extensive assistance with bed mobility, toilet use and personal hygiene. She required supervision only for eating. <BR/>Record review of Resident #60's care plan dated 07/06/2022, reflected Resident #60 required extensive assistance with bed mobility, transfer, toileting, and personal hygiene. The fall care plan dated 07/06/2022 reflected Resident #60 was a fall risk with multiple falls and call light was to be in reach at all times.<BR/>During an observation and interview on 09/12/2022 at 9:45 am, Resident #60 was lying in bed and stated he could not find his call light. The call light for Resident #60 was noted on the floor beside the bed. Resident #60 stated he had fallen the previous night because he was unable to reach his call light and get help out of the bed.<BR/>During an observation and interview on 09/13/2022 at 4:40 pm, Resident #60 was sitting up on the side of his bed attempting to get out of bed. Resident #60 stated he had to get to the organ to play music. Resident #60's call light was on the floor behind the headboard.<BR/>3. Record review of the face sheet dated 9/14/2022 indicated Resident #33 was [AGE] years old and was admitted on [DATE] with diagnoses including liver cell carcinoma (liver cancer), stroke, and heart disease. <BR/>Record review of a care plan dated 9/3/2022 indicated Resident #33 had a history of anxiety and was prescribed an anti-anxiety medication. Resident #33 had impaired physical mobility and required assistance with self-care. <BR/>Record review of the MDS dated [DATE] indicated Resident #33 was understood and usually understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 8 which indicated Resident #33 was moderately cognitively impaired. Resident #31 required extensive to total assistance from staff with ADLs. <BR/>During an observation on 9/12/2022 at 11:00 a.m., revealed Resident #33 in her bed. The cord to her call light was draped over the rail and the call light was near the floor. The call light was out of reach of the resident. <BR/>During an observation on 09/14/22 at 8:32 a.m., revealed Resident #33 was in her bed. Her call light was on the floor on the right side of bed, out of reach of the resident.<BR/>4. Record review of a face sheet dated 9/14/2022 revealed Resident #61 was [AGE] years old and was initially admitted on [DATE] with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone, or posture), paranoid schizophrenia (a mental disorder characterized by continuous or relapsing episode of psychosis), and moderate intellectual disabilities. <BR/>Record review of a care plan dated 7/19/2022 indicated Resident #61 had a history of cerebral palsy and required extensive assistance with bed mobility and transfers. The care plan indicated Resident #61 was immobile.<BR/>Record review of the most recent MDS dated [DATE] indicated Resident #61 was sometimes understood and sometimes understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) of 8. This score indicated moderate cognitive impairment for Resident #61. The MDS also indicated Resident #61 required limited to extensive assistance from staff for ADLs. <BR/>During an observation on 9/12/22 at 10:21 a.m., Resident #61 was in bed and her call light was on the floor on the right side of her bed and was under a trash can. The call light was out of reach of Resident #61.<BR/>During an observation on 9/12/22 at 12:08 p.m., Resident #61 was in bed and her call light was on the floor on the right side of her bed and was under a trash can. The call light was out of reach of Resident #61.<BR/>During an observation on 9/12/22 at 2:38 p.m., incontinent care was provided for Resident #61. Resident #61's call light was on floor on the right side of her bed and was under the trash can at bedside. The call light was out of Resident #61's reach. <BR/>During an observation on 9/13/22 at 8:55 a.m., Resident #61 was asleep in bed. The resident's call light was on the floor on the right side of her bed and was under the trash can. <BR/>During an interview on 9/15/22 at 10:10 a.m., LVN E said she did see call lights off to the side and out of reach of residents. She said the morning of 9/15/2022, Resident #61's call light was on her bedside table. She said it would probably be better with a clip on the cord. She said if a resident cannot reach their call light, they would not be able to call for help .<BR/>5. Record review of a face sheet dated 9/14/2022 indicated Resident #93 was [AGE] years old and was initially admitted on [DATE] with diagnoses of presence of right artificial shoulder joint, diabetes, and abnormality gait and mobility. <BR/>Record review of consolidated physician orders dated 9/14/2022 for Resident #93 indicated an order dated 8/22/2022 for a sling ever am shift, monitor sling to right arm QD (every day). <BR/>Record review of a care plan with dated 6/16/2022 indicated Resident #93 had decrease ROM (range of motion) to right shoulder, right elbow, and right wrist. <BR/>Record review of the MDS dated [DATE] indicated Resident #93 was understood and understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 13 indicating Resident #93 was cognitively intact. The MDS indicated Resident #93 required supervision only during toilet use. The MDS indicated Resident #93 had mood disorders of anxiety and depression. <BR/>During an observation and interview on 9/12/2022 at 3:17 p.m., Resident #93 said his toilet is too low and he has trouble getting off the toilet and back into his wheelchair. The resident had amputations to both lower extremities. There was a motorized wheelchair at bedside. The resident said he can transfer himself. The bathroom was observed. The toilet did appear low and other than a bar on the far wall there was not adaptive equipment. <BR/>During an interview on 9/14/2022 at 11:01 a.m., Resident #93 said he had resided in his current room since February 2022. He said he had complained to Maintenance Supervisor several times about his toilet being too low. He said he remembers reporting this to the Maintenance Supervisor in February 2022. He said at one point they did bring him an over the commode seat, but it did not help him. He said he complained to the administrator at least twice. He said on 9/13/2022 the administrator told him that she thought the toilet had already been replaced. He said since February he has had trouble getting on and off the toilet from his electric wheelchair. He said it had been worse the last 3 weeks because his right arm had been in a sling.<BR/>During an observation and interview on 9/14/2022 at 11:22 a.m., Maintenance Supervisor said the procedure for maintenance issues was for staff to fill out a work order and place it in his box. He said Resident #93 had complained to him weeks ago about his toilet being too low for him. He said he could not remember exactly how long it had been. He said the issue was never reported to him in writing and he said he had carried him a taller over the commode toilet seat, but he could not use it because it kept moving on him. He said there was a delay in getting the toilet replaced because the taller toilet was on backorder. He said he had a new toilet in the back of his truck. He said he went to a hardware store on 9/13/2022 and bought a new taller toilet. The Maintenance Supervision measured the lower toilet in Resident #93 bathroom. The toilet measured 15 inches from the floor to the toilet seat. The Maintenance Supervisor measured Resident #93's electric wheelchair. The wheelchair measured 25 inches from the floor to the top of seat. <BR/>During an interview on 09/14/2022 at 3:23 p.m., CNA C said it had been at least 6 months since she had provided care to Resident #93. She said at that time he reported to her that his toilet was too low. She said he had told her he might need help because it was too low. She said she reported the issue to the nurses and to the Maintenance Supervisor at that time.<BR/>6. Record review of a face sheet dated 9/14/2022 revealed Resident #97 was [AGE] years old and was initially admitted on [DATE] with diagnoses including urinary tract infection, pressure ulcer, and chronic pain syndrome. <BR/>Record review of a care plan dated 9/12/2022 indicated Resident #97 had impaired physical mobility and required assistance from staff. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #97 was usually understood and understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) of 9 which indicated Resident #97 was moderately cognitively impaired. The MDS indicated Resident #97 required extensive assistance with ADLs.<BR/>During an interview on 9/14/2022 at 11:45 a.m., Resident #97 said her mattress was changed on 9/13/2022. While her mattress was being changed, her call light was draped over the end table beside her bed. She said afterwards she was uncomfortable in the bed but could not use the call light to call for help. She said she had to yell out for help until someone came to her room to help her reposition in the bed. <BR/>During an interview on 9/14/2022 at 3:34 p.m., CNA D said every shift she comes in for her shift, call lights are in the floor and out of reach of resident. She said call lights should be in reach of each resident. <BR/>7. Record review of the face sheet dated 09/14/22 revealed Resident #54 was [AGE] years old, female, and admitted on [DATE] with diagnosis including cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and heart failure (heart doesn't pump enough blood for your body's needs). <BR/>Record review of the MDS dated [DATE] revealed Resident #54 was usually understood and usually understood others. The MDS revealed Resident #54 had clear speech and impaired vision with corrective lenses. The MDS revealed Resident #54 had a BIMS of 08 which indicated mild cognitive impairment and required total dependence for all ADLs except eating. <BR/>Record review of the care plan dated 08/17/22 revealed Resident #54 was a fall risk related to history of heart failure and peripheral vascular disease and high fall risk as evidence by right and left lower extremity weakness and cognitive status: mildly/moderately impaired. Interventions include keep call light and most frequently used personal items within reach. <BR/>During an interview and observation on 09/12/22 at 2:59 p.m., Resident #54 was lying in bed visibly upset and crying. She said she had been needing help, but no one came. She said it happens all the time. She said she could not find her call light. The call light was at the head of the bed out of reach.<BR/>8.Record review of the face sheet dated 09/14/22 revealed Resident # 8 was [AGE] years old, female and admitted on [DATE] with diagnosis including cerebral ischemia (acute brain injury that results from impaired blood flow to the brain), unsteadiness on feet, abnormal posture, lack of coordination, muscle weakness, and muscle wasting and atrophy(shortening). <BR/>Record review of the MDS dated [DATE] revealed Resident #8 was understood and usually understood others. The MDS revealed Resident #8 had clear speech and highly impaired vision with corrective lenses. The MDS revealed Resident #8 had a BIMS score of 12 which indicated mild cognitive impairment and required limited assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing.<BR/>Record review of the care plan dated 05/26/22 revealed Resident #8 was a fall risk related to history of stroke, heart failure, hypertension, and high fall risk assessment as evidence by joint mobility interferes with balance, generalized weakness, and extensive assist for transfer. Interventions included assist resident with ADLs as needed and keep call light and most frequently used items within reach. <BR/>During an observation on 09/12/22 at 9:42 a.m., Resident #8 was hollering out and mumbling to herself. Resident #8 was standing up in front of her recliner with her brief off. Resident #8 told a CNA, I tried to wait for help, but no one came.<BR/>During an interview on 09/12/22 at 10:47 a.m., Resident #8 said staff take a long time to answer the call and did not think she needed assistance with being changed. She said sometimes she must take matters in her own hands and change herself, like this morning. <BR/>During an observation on 09/13/22 at 11:40 a.m., Resident #8 call light was going off. CNA V answered the call light at 12:14 p.m. Resident #8 told CNA V she needed to be changed.<BR/>9. Record review of the face sheet dated 09/14/22 revealed Resident #70 was [AGE] years old female and admitted on [DATE] with diagnoses including acquired absence of right leg above the knee, age related debility (physical weakness), and cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). <BR/>Record review of the MDS dated [DATE] revealed Resident #70 was understood and understood others. The MDS revealed Resident had clear speech and adequate vision with corrective lenses. The MDS revealed Resident #70 had a BIMS of 14 which indicated intact cognition and required extensive assistance for toilet use and total dependence for transfers, dressing, personal hygiene, and bathing. <BR/>Record review of the care plan dated 08/04/22 revealed Resident #70 was a fall risk related to high fall risk assessment as evidence by amputation, joint mobility interferes with balance, and cognitive status. Interventions included keep call light and most frequently used personal items within reach. <BR/>During an interview on 09/12/22 at 3:27 p.m., Resident #70 said there was a delay in the call light response time, from 30 to 45 minutes. <BR/>During an interview on 09/13/22 at 9:25 a.m., Resident #70 said she could not find her call light in the middle of the morning. She said she needed to call the nurse for some pain medication because she was in pain. Resident #70 said when she could not find her call light in the middle of the morning, it was attached to her body pillow that fell on the floor. She said someone came in and picked up the pillow but not her call light.<BR/>During an interview and observation on 09/13/22 at 4:24 p.m., Resident #70's call light was on the floor, and she said she needed to be changed. <BR/>10. Record review of the face sheet dated 09/15/22 revealed Resident # 23 was [AGE] years old, male, and admitted on [DATE] with diagnosis including transient ischemic attack (is a stroke that lasts only a few minutes) and cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). <BR/>Record review of the MDS dated [DATE] revealed Resident #23 was understood and understood others. The MDS revealed Resident #23 had a BIMS score of 12 which indicated mild cognitive impairment and required limited assistance with transfers and dressing but extensive assistance with toilet use and bathing. <BR/>Record review of the care plan dated 06/29/22 revealed Resident #23 was a fall risk related to fall evidence by generalized weakness and cognitive status: mildly/moderately impaired. Interventions included keep call light and most frequently used personal items within reach. <BR/>During an interview on 09/12/22 at 11:38 a.m., Resident #23 said staff did not answer the call light timely. He said sometimes it takes them 1-2 hours for staff to answer the light. He said it happened on all the shifts.<BR/>11. Record review of the face sheet dated 09/14/22 revealed Resident #76 was [AGE] years old, male, and admitted on [DATE] with diagnoses including cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), heart failure (heart doesn't pump enough blood for your body's needs), and obesity. <BR/>Record review of the MDS dated [DATE] revealed Resident #76 was understood and understood others. The MDS revealed Resident #76 had clear speech, moderate difficulty hearing, and impaired vision with corrective lenses. The MDS revealed Resident #76 had a BIMS score of 09 which indicated mild cognitive impairment and required extensive assistance for bed mobility, dressing, personal hygiene and total dependence for transfers, toilet use and bathing. <BR/>Record review of the care plan dated 05/04/22 had fall risk related to fall, history of heart failure, and high fall risk assessment as evidence by generalized weakness and cognitive status. Interventions included keep call light and most frequently used personal items within reach.<BR/>During an interview on 09/12/22 at 11:24 a.m., Resident #76 said the CNAs take forever to answer the call light.<BR/>During an interview on 09/14/22 at 1:27 p.m., CNA V said she had worked at the facility 2 years ago and returned 2 days ago. She said call lights should be answered within 2 minutes. She said 2 CNAs are normally on the halls. She said no residents had complained to her about call light response time. She said the day Resident #8's call light was unanswered for an extended period was because she and the other CNA were off the floor. She said they both were in the dining room helping with lunch. She said both CNAs are not both supposed to leave the floor and she did not inform the ADON. She said call lights being within reach and answered timely prevented falls and accidents for continent residents. She said resident probably felt frustrated when the call lights were not answered or could not find it to get help. <BR/>During an interview on 09/14/22 at 2:52 p.m., LVN W said she had previously worked at the facility 5 years ago and returned last week. She said call lights should be answered asap because you do not know if the issues were minor or major. She said any staff member can answer call lights and ensure they are within reach. She said call lights are mostly answered timely. She said properly placed call light and timely response could prevent falls and the resident could be calling about chest pain, shortness of breath, or incontinent care. <BR/>During an interview on 09/14/22 at 3:25 p.m., CNA X said she was the CNA coordinator but had been working the floor. She said call lights should be answered asap and the facility trained CNAs to follow the same guidelines. She said call lights should be hooked out something within reach and eyesight. She said she had not heard any residents complain but she did not work the 100-hall often. She said proper placed call light and timely response could prevent falls and residents could be calling for help because they were having a stroke or heart attacked. She said call lights not being answered timely and within reach could make the resident feel neglected. She said it was the CNAs responsibility for timely call lights response and placing them within reach. <BR/>During an interview on 09/15/22 at 11:07 a.m., CNA Y said she had worked at the facility since August 2019. She said she worked 2pm-10pm shift and worked the 100-hall frequently. She said call lights should be answered within 2-3 minutes and attached to the bed remote control or bed sheets. She said call lights were important because it was the resident's line of communication and could prevent falls. She said it was the CNAs responsibility for timely call lights response and placing them within reach.<BR/>During an interview on 9/14/22 at 4:59 p.m., the DON said she expected the nurses and CNAs to put the call lights within reach of the residents even if they could not use it. The DON said call lights being in reach was important for the resident to be able to have access to call out for assistance and comforting in knowing the call light was there to call out for help. The DON said not having call lights in reach could result in a fall and a need unnoticed until a routine check. She said it was her responsibility to ensure all direct care staff placed the call lights within reach of each resident. The DON said daily routine rounds were made by the ADON to ensure call lights were in reach. The DON said it was her understanding that rounds were made, and call lights were in reach. <BR/>A policy dated 02/12/2022 titled Call Light Answering revealed: Standards of Practice: The staff will provide an environment that helps meet the residents needs by answering call lights appropriately. Respond to patients/resident's call lights and emergency lights in a timely manner .when leaving room, be sure the call light is placed within the resident's reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed 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 one out of one resident (Resident #2) reviewed for PASRR.<BR/>The facility failed to submit NFSS forms timely for Resident #2. <BR/>These failures 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 include:<BR/>1. Record review of a face sheet dated10/03/2023 revealed Resident #2 was a [AGE] year-old female that admitted to the facility on [DATE] with the diagnoses of cerebral palsy (caused by abnormal brain development or damage to the developing brain that affects a person's ability to control his or her muscles), paranoid schizophrenia (stems from delusions-firmly held beliefs that persist despite evidence to the contrary-and hallucinations-seeing or hearing things that others do not), and muscle weakness.<BR/>Record review of Resident #2's quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 99, which indicated Resident #2 was cognitively impaired. Resident # 2 required extensive assistance for locomotion, bed mobility, bathing, and dressing. The MDS indicated Resident #2 was usually understood and usually understood others.<BR/>Record review of Resident #2's care plan dated 07/15/2023 stated Resident #2 was PASRR positive for the diagnosis of cerebral palsy and paranoid schizophrenia. Resident #2's ADL care plan indicated Resident #2 would have PT/OT evaluate and treat as needed to maintain or improve physical function.<BR/>Record review of the habilitation service plan (HSP) dated 06/12/2023, revealed Resident #2 was recommended to receive occupational therapy 5 times per week for 6 months to increase Resident #2's independence and safety with dressing and bathing.<BR/>The sign in sheet for the HSP, also dated 06/12/2023 indicated Resident #2, the PASRR Habilitation Coordinator, the social worker, the MDS Coordinator, and the Physical Therapy Assistant were present during the meeting and agreed on the recommendation.<BR/>Record review on an email correspondence dated 08/15/2023 between the PASRR Unit Program Specialist and the Administrator revealed the facility was informed and instructed in writing to submit a NFSS Request by a specific deadline but failed to do so. Also, the NFSS Request submittal by the NF was denied and there was not a follow up submittal to ensure the request was approved to provide specialized services for PASRR for the resident. The instructions included the following : Be sure your facility checks the status of the requests daily to ensure they are approved. Prompt attention should be given to the request if it has a pending denial status once it is submitted. This is a time sensitive status and can result in system generated denial if not followed up on by date noted by the reviewer in the request.<BR/>Review of Simple LTC portal (portal used to submit PASRR service requests) for Resident #2's OT Assessment reflected a note, dated 08/11/2023, NFSS form for OT was not submitted within 30 calendar days of the IDT meeting and it was form was not accepted.<BR/>During an interview on 10/04/2023 at 11:10 a.m., with the PASRR Habilitation Coordinator revealed the meeting on 06/11/2023 was the quarterly PASRR meeting mandated by the state. The PASRR Habilitation Coordinator stated it was decided in the meeting that Resident #2 would benefit from occupational therapy (OT) services and the process was initiated for Resident #2 to be evaluated and the paperwork to be submitted by the facility for approval for funding by the PASRR service group for the therapy. She stated the team present in the meeting decided it would be beneficial for her to have a reason to get out of bed every day and have therapy to look forward to. The PASRR Habilitation Coordinator stated after the meeting took place and she put her notes into the system it was up to the facility to complete the process.<BR/>During an interview on 10/04/2023 at 11:55 a.m., the PASRR Unit Program Specialist, stated her emails to the facility were self-explanatory and the facility failed to comply with the emails she sent. She stated it was important to file the NFSS form within 30 days after the IDT meeting and failure to do so may result in a resident not receiving needed rehabilitative services and could contribute to a decline in functional status. <BR/>During an interview with the MDS nurse 10/04/2023 at 2:00 pm, stated that she started she was unsure why the Simple LTC portal had not been checked daily to ensure Resident #2's OT request was followed up on. The MDS nurse stated it was important for the NFSS form to be completed 30 days after the IDT meeting. The MDS nurse stated that failure to submit the NFSS form within the timeframe may lead to residents not receiving services at the facility. <BR/>During an interview with the DON on 10/05/2023 at 12:20 p.m., stated she was unfamiliar with the process of PASRR and left it to the corporate MDS nurse to assist in those matters. <BR/>During an interview with the Administrator on 10/05/2023 at 1:40 p.m., stated she had received the emails from the PASRR specialist and a phone call. The Administrator stated the PASRR specialist called and said follow the instructions on the email and added no assistance with the process. The Administrator stated it was the right of Resident #2 to receive OT, but the Administrator did not feel Resident #2 had suffered any ill affect from having not received the services. <BR/>Policy related to PASRR services was requested 10/05/2023 at 10:00 a.m. and 1:00 p.m. by the Administrator and no policy was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good grooming and personal hygiene for a resident who is unable to carry out activities of daily living were provided for 2 of 4 residents reviewed for activities daily living (Resident #2 and Resident #5)<BR/>The facility did not clean or trim the nails of Resident #2 and Resident #5. <BR/>The facility failed to promptly respond to Resident #2 and Resident #5's call lights who were ADL dependent.<BR/>These failures could place dependent residents at risk of poor hygiene, infections, injuries and unmet needs. <BR/>Findings included: <BR/>Record review of Resident #2 's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including respiratory failure, colon cancer, diabetes, and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred). <BR/>Record review of Resident #2's MDS dated [DATE] indicated Resident #2 made himself understood and usually understood others. The MDS indicated Resident #2 had moderately impaired cognitive function (BIMS of 10). The MDS indicated he had no behavior of rejecting care. The MDS indicated he required limited assistance with locomotion in his wheelchair, supervision only with toilet use and eating. The MDS indicated he required extensive assistance with dressing, personal hygiene and bathing. The MDS indicated bed mobility had only occurred once or twice during the 7 days look back period. The MDS indicated transfers and walking had not occurred during the 7 days look back period. <BR/>Record review of Resident #2's care plan dated 12/7/22 indicated his ADL dependency was not specifically addressed. <BR/>During an observation on 2/8/23 at 11:15 a.m. revealed Resident #2 laid in his bed. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/>During an interview and observation on 2/8/23 at 2:44 p.m. revealed Resident #2 sat in his bed. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/> Resident #2 said he had been at the facility approximately 2 months. He said no one had offered to trim and clean his nails since he had been at the facility.<BR/>During an observation and interview on 2/9/23 at 9:05 a.m. revealed Resident #2 sat in his wheelchair. His nails were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under several of the nails. CNA F was making his bed. CNA F said nail care was usually done on shower days by the CNAs. CNA F indicated she had just administered a shower to Resident #2. CNA F said nurses trimmed the nails of diabetic residents. <BR/>During an observation on 2/9/23 at 11:17 a.m. revealed Resident #2 was in therapy sitting in his wheelchair. CNA F stood at his side viewing his nails. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/>During an interview on 2/9/23 at 11:18 a.m., CNA F said she did not know if Resident #2 was a diabetic. CNA F said she cleaned Resident #2's nails in the shower by washing over the top of his hands but indicated she did not clean under his nails. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said she worked the hall on which Resident #2 resided on 2/8/23. RN C said there was no set schedule for diabetic nail care and nurses just performed the care as it needed to be done. RN C said no CNAs had reported to her that any diabetic resident needed nail care yesterday (2/8/23). RN C said Resident #2's nails were very thick and would have to be soaked before they could be cut. RN C said that might be why the nail care had not been performed. RN C said it was important to ensure nail care was completed to prevent infection. <BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she regularly worked the hall that Resident #2 resided on. CNA E said CNAs and nurses were responsible to ensure residents nails were cleaned and trimmed. CNA E said nurses performed nail care for diabetic residents. CNA E said there was no set schedule for CNAs to perform nail care and indicated she performed nail care when she saw it needed to be done. CNA E said if she saw nail care was needed for a diabetic resident, she would notify the nurse. CNA E said she could not remember if she notified RN C that nail care was needed for Resident #2. CNA E said it was important to ensure nail care was completed to maintain resident hygiene.<BR/>2. Record review of Resident #5's consolidated physician orders dated 2/10/23 indicated he was [AGE] years old admitted to facility on 1/16/23 with diagnoses including atherosclerotic heart disease (heart disease caused by the buildup of fats, cholesterol and other substances in and on the artery walls), and rheumatoid arthritis (chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility) and dementia. <BR/>Record review of Resident #5's MDS dated [DATE] indicated Resident #5 usually understood and usually made himself understood. The MDS indicated he had moderately impaired cognitive function (BIMS of 9). The MDS indicated he had no behavior of rejecting care. The MDs indicated transfers had only occurred once or twice during the 7 days look back period. The MDS indicated locomotion in his wheelchair had not occurred during the 7 days look back period. The MDS indicated he required limited assistance with walking in his room and eating. The MDS indicated he required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and bathing. <BR/>Record review of Resident #5's care plan revised on 2/1/23 indicated his ADL dependency was not specifically addressed.<BR/>During an observation and interview on 2/8/23 at 3:45 p.m. revealed Resident #5 laid in his bed. His nails were long (approximately 1/2 centimeter past the end of his fingers). There was a dark brown substance under several (more than 2 nails on each hand but less than 5 nails of each hand) nails to each hand. Resident #5 said he wanted his nails to be cleaned and trimmed. Resident #5 said he did not know when his nails were last cleaned and trimmed. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said she worked the hall on which Resident #5 resided on 2/8/23. RN C said CNAs were responsible to perform nail care for non-diabetic residents. RN C said there was no set schedule for CNAs to perform nail care and indicated CNAs were to perform the nail care as needed. RN C said it was important to ensure nail care was completed to prevent infection.<BR/>During an observation on 2/10/23 at 9:32 a.m. revealed Resident #5 laid in his bed. His nails were long (approximately 1/2 centimeter past the end of his fingers). There was a dark brown substance under several (more than 2 nails on each hand but less than 5 nails of each hand) nails to each hand. <BR/>During an interview on 2/10/23 at 10:28 a.m., CNA G said residents were to have their nails cleaned and trimmed on shower days by CNAs. CNA G said resident nails were to be cleaned and trimmed as needed in between shower days. CNA G said it was important to ensure nail care was done to avoid infection and unintentional injury (scratches and skin tears).<BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she regularly worked the hall that Resident #5 resided on. CNA E said CNAs and nurses were responsible to ensure residents nails were cleaned and trimmed. CNA E said nurses performed nail care for diabetic residents and CNAs performed nail care for non-diabetic residents. CNA E said there was no set schedule for CNAs to perform nail care and indicated she performed nail care when she saw it needed to be done. CNA E said she did not recall performing nail care for Resident #5 but indicated she would have cleaned and trimmed his nails if she noticed they were long and dirty. CNA E said it was important to ensure nail care was completed to maintain resident hygiene. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected CNAs to ensure nail care was completed for non-diabetic residents as it was needed. The DON said she expected nurses to perform nail care for diabetic residents as it was needed. The DON said it was important to ensure nail care was done to prevent unintentional injuries (such as scratches) and prevent infections. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected staff to ensure resident's nails were cleaned and trimmed. <BR/>Record review of the facility policy and procedure titled Bathing revised on 02/12/20 reflected, .Tasks commonly completed during the bathing process .Report abnormal findings to the nurse in charge .needs shall be discussed with the resident and responsible party during care plan meetings with the interdisciplinary team in order to identify and implement proper hygiene habits and promote resident rights and dignity The policy and procedure did not specifically address nail care. A policy and procedure for nail care was requested but not received. <BR/>3. During an observation on 2/8/23 at 2:44 p.m. revealed Resident #5 could be heard across the hall yelling Somebody come help me. <BR/>During an observation on 2/8/23 at 2:47 p.m. revealed Resident #2 pushed his call light in order to obtain assistance to get up.<BR/>During a continuous observation on 2/8/23 from 2:47 p.m. to 3:15 p.m. revealed Resident #5's call light dome remained lit up and the call light alarm was audible until 3:12 p.m. Resident #5 continued to yell intermittently for help from 2:47 p.m. to 3:15 p.m. Resident #2's call light dome remained lit up and the call light alarm was audible until 3:15 p.m. Resident #5's room was directly adjacent to Resident #2's room. <BR/>During an observation on 2/8/23 at 2:51 p.m., revealed Receptionist I walked by both Resident #2 and Resident #5's rooms as Resident #5 yelled out. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:52 p.m. revealed LVN J walked by both Resident #2 and Resident #5's rooms pushing a treatment cart. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:55 p.m. revealed Admissions Director K walked by both Resident #2 and Resident #5's rooms as Resident #5 yelled out Help. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:57 p.m. revealed an unidentified staff member in a khaki-colored polo pushed a red hand truck/ appliance dolly (tool to move heavy items) by both Resident #2 and Resident #5's rooms. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:58 p.m. revealed Housekeeper L stood in the hallway, 2 rooms down from Resident #2 and Resident #5's rooms. Housekeeper L stood in front of his housekeeping cart with his back toward the surveyor. His head was bent down as if he were looking at something in front of him. <BR/>During an observation on 2/8/23 at 3:02 p.m. revealed CNA H walked by both Resident #2 and Resident #5's rooms. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 3:12 p.m. revealed Maintenance Personnel M answered Resident # 5's call light. <BR/>During an observation on 2/8/23 at 3:15 p.m. revealed CNA H answered Resident #2's call light.<BR/>During an interview on 2/8/23 at 3:16 p.m., maintenance personnel M said answering call lights was everyone's (all staff's) responsibility. Maintenance Personnel M said he may not be able to get/do exactly what the resident requested/needed. Maintenance Personnel M said he could ensure there was not an emergency and notify the nurse of the resident request/need. Maintenance Personnel M said Resident #5 said he just wanted to go home. <BR/>During an interview on 2/8/23 at 3:17 p.m., CNA H said anyone could answer a call light. CNA H said even if the staff were not clinical, they can and should respond to a call light. CNA H said non-clinical staff should check on call lights because there could be an emergency, or the resident might have a simple request. CNA H said she did not immediately check on the call lights because she had just came onto her shift. CNA H said she should have checked on the call lights the first time she went by and notified the residents she would be right back. CNA H said Resident #2 needed help to get up. <BR/>During an interview on 2/8/23 at 3:18 p.m., Housekeeper L said he had worked at the facility since November 2022. Housekeeper L said he noticed the call lights going off but had not been given any instructions regarding call lights. Housekeeper L said he was not sure if he was supposed to answer call lights. <BR/>During an interview on 2/8/23 at 3:29 p.m., Admissions Director K said she had worked at the facility for approximately 3 years. Admissions Director K said any staff could check on a call light, but some residents call out or yell out like every 10 minutes. Admissions Director K said even for the residents that frequently call out she would still check on them. Admissions Director K said she was not sure if Resident #2 and Resident #5 were residents that called out frequently. Admissions Director K said staff had to respond to call lights because the resident might actually need help. Admissions Director K said she did see Resident #2 and Resident #5's call lights when she walked by. Admissions Director K said she did hear Resident #5 yell as she walked by his room. When asked why she did not respond to the call lights or Resident #5's yell for help Admissions Director K said I want to say in my heart of hearts it's because I didn't think they needed Admissions Director K stopped mid-sentence and then said but I can't say that. Admissions Director K then said there was no excuse for not having stopped and checked on Resident #2 and Resident #5's call lights. <BR/>During an interview on 2/8/23 at 3:35 p.m., LVN J said she did not remember walking by Resident #2 and Resident #5's rooms with her cart. LVN J said she certainly would have stopped and checked on the call lights had she noticed they were going off. LVN J said we (all staff) were responsible for answering call lights. <BR/>During an interview on 2/9/23 at 10:19 a.m., Receptionist I said she use to be a CNA and had worked at the facility for 2 &frac12; years. Receptionist I said all staff members were responsible for answering call lights. Receptionist I said it was important to respond to call lights because it could be an emergency. Receptionist I said if the request were something simple, non-clinical staff can assist them or notify the nurse. Receptionist I said she did not remember walking past Resident #2 and Resident #5's call lights yesterday (2/8/23). Receptionist I said she did not remember Resident #5 yelling out for help. Receptionist I said she would have answered the call lights had she noticed them going off. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said all staff clinical or not, were responsible for responding to resident call lights. The DON indicated it was unacceptable that call lights remained unanswered for over 20 minutes while multiple staff members walked by. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected all staff to respond to resident call lights in order to ensure resident needs were met. <BR/>Record review of the facility policy and procedure titled, Call Lights-Answering, revised on 02/12/20 reflected, Standard of Practice: The staff will provide an environment that helps meet the resident's needs by answering call lights appropriately. Procedures: (1) Respond to patients/resident's call lights and emergency lights in a timely manner . (5) If unable to complete the request, do not turn off the call light; the call light will remain on until the service is completed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 6 residents (Resident #27 and Resident #361) reviewed for pressure injury.<BR/>The facility failed to ensure Resident #27 low air loss mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings.<BR/>The facility failed to ensure Resident #27 had dressing on his back wounds. <BR/>The facility failed to ensure the WCN loosening Resident #27's dressing, before removing, from his heel wound to prevent bleeding. <BR/>The facility failed to ensure Resident #27 was turned and repositioned every 2 hours.<BR/>The facility failed to ensure Resident #27 was positioned correctly when using his positioning aides.<BR/>The facility failed to treat Resident #361's unstageable (the base of the wound was covered by a layer of dead tissue that was yellow, grey, green, brown, or black and unable to determine the stage of the wound) sacral pressure ulcer for 3 days after admission.<BR/>These failures could place residents at risk for deterioration of wound. <BR/>Findings included:<BR/>1. Record review of Resident #27's face sheet dated 10/30/23 indicated Resident #27 was a [AGE] year-old male and admitted on [DATE] with diagnoses including cerebral infarction ((also known as a stroke) refers to damage to tissues in the brain due to a loss of oxygen to the area), pressure ulcer of buttock (also known as bedsores, are an injury that breaks down the skin and underlying tissue), stage 3, skin changes and pain.<BR/>Record review of Resident #27's annual MDS assessment dated [DATE] indicated Resident #27 was usually understood and usually understood others. The MDS indicated Resident #27 had a BIMS score of 09 which indicated moderately impaired cognition and required limited assistance with dressing, extensive assistance with bed mobility, toilet use, personal hygiene, and bathing. The MDS indicated Resident #27 had 2 Stage 4 pressure ulcers and were present upon admission/entry or reentry. The MDS indicated Resident #27 had skin and ulcer/injury treatments of pressure reducing device for bed, nutrition or hydration intervention, pressure ulcer/injury care, application of ointments/medications other than to feet, and application of dressing to feet. The MDS indicated Resident #27 received an anticoagulant (are medicines that help prevent blood clots) for 3 days during the 7 days assessment period. <BR/>Record review of Resident #27's care plan dated 09/21/23 indicated anticoagulant/antiplatelet (medications that prevent blood clots from forming) related to diagnosis of atrial fibrillation (is an irregular and often very rapid heart rhythm) and history of cerebrovascular accident (stroke) as evidence by Apixaban (is used to prevent serious blood clots from forming due to a certain irregular heartbeat) 5mg tablet 1 tablet by mouth 2 times a day. Interventions included handle resident carefully when turning, positioning, or transferring and maintain pressure on skin tears, blood draws sites, and IV sites for at least five minutes. <BR/>Record review of Resident #27's care plan dated 10/24/23 indicated Resident #27 was at risk for/actual of skin breakdown related to skin failure and history of pressure injury as evidence by pressure reducing/redistribution mattress (redistribute a patient's weight so as to relieve pressure points), pressure ulcer risk: high score 10-12, confined to bed most of time, wound (pressure, diabetic or stasis), open lesions. Interventions assist resident to turn and reposition frequently, report refusals, off load heels, position resident properly; use pressure reducing or pressure relieving devices if indicated, and treatments and dressings as ordered per physician. <BR/>Record review of Resident #27's Consolidated Physician Orders dated 04/06/23 Pressure reducing/redistributing mattress, night shift. <BR/>Record review of Resident #27's Consolidated Physician Orders dated 06/02/23 Air Mattress to bed, every 2 shifts. Check every shift for function. <BR/>Record review of Resident #27's Consolidated Physician Orders dated 10/12/23 indicated cleanse wound on day shift, cleanse wound to left upper back with normal saline, pat dry, apply calcium alginate with silver (Assist with infection reduction. Primary dressing for wounds with moderate to heavy exudate (drainage)), cover with silicone bordered dressing (is highly conformable with a thin, low-profile edge to help minimize the rolling and lifting that can impact adhesion) daily.<BR/>Record review of Resident #27's Consolidated Physician Orders dated 10/27/23 indicated cleanse wound on day shift, right back with normal saline, pat dry, apply alginate calcium when blister breaks and cover with silicone foam bordered dressing daily.<BR/>Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated Pressure reducing/redistributing mattress, night shift. Diagnosis: Benign Prostate Hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty) with lower urinary tract symptoms. Start date: 04/06/23. Documentation noted every day, night shifts.<BR/>Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated Air Mattress to bed, every 2 shifts. Check every shift for function. Diagnosis: skin changes. Start date: 06/02/23. Documentation noted every day, 2 shifts. <BR/>Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated cleanse wound on day shift, cleanse wound to left upper back with normal saline, pat dry, apply calcium alginate with silver, cover with silicone bordered dressing daily. Diagnosis: skin changes. Start date: 10/12/23. Documentation noted 10/12/23-10/31/23 on day shift. <BR/>Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated cleanse wound on day shift, right back with normal saline, pat dry, apply alginate calcium when blister breaks and cover with silicone foam bordered dressing daily. Diagnosis: skin changes. Start dated: 10/27/23. Documentation noted 10/27/23-10/31/23 on day shift.<BR/>Record review of Resident #27's wound evaluation and management summary dated 10/25/23 indicated .wounds on his sacrum .left first finger .right lateral (outside of your foot) heel .right upper lateral foot .left upper back .left back .right back .stage 4 pressure wound (There is full-thickness skin loss extending through the fascia with considerable tissue loss) of the right, upper, lateral foot full thickness .2.4cmx1.8cmx0.2cm (Lx W x D) .at goal for wound progress .stage 4 pressure wound of the right, lateral heel, full thickness .3.4cm.3.4cmx0.1cm .stage 4 pressure wound sacrum full thickness .6.8cmx10cmx2cm .at goal .recommendation off-load wound .reposition per facility protocol .group-2 mattress .stage 3 pressure wound of the left upper back full thickness .1.2cmx0.9cmx0.1cm .improved evidence by decreased surface area .non-pressure wound of the left back partial thickness .9cmx2.5cmx0.1cm .abrasion/sheer .non-pressure wound of the right back .6cmx1.5cmxnot measurable cm .blister fluid filled .<BR/>Record review of Resident #27's wound evaluation and management summary dated 11/01/23 indicated .wounds on his right lateral heel .left upper back .sacrum .right upper lateral foot .left back .right back .left first finger . stage 4 pressure wound the right, upper, lateral foot full thickness .8cmx10cmx0.2cm .objective palliation .wound progress at goal . stage 4 pressure wound of the right, lateral heel, full thickness .3.5cmx4.0cmx0.1cm .wound progress at goal . stage 4 pressure wound sacrum full thickness .9cmx12.5cmx2.0cm .wound progress at goal . stage 3 pressure wound of the left upper back full thickness .19cmx12.5cmx0.1cm .wound progress at goal .unavoidable due to generalized decline .non-pressure wound of the left back .signoff-wounds has merged with another site on 11/01/23 . non-pressure wound of the right back .signoff-wounds has merged with another site on 11/01/23<BR/>Record review of the facility's weight log dated 10/04/23 indicated Resident #27 was 6'3 and 215.6 pounds. <BR/>During an interview and observation on 10/30/23 at 11:24 a.m., Resident #27 was on a bariatric (a person is classified as having obesity), low air loss mattress, lying on his back. Resident #27 feet were covered but appeared to be elevated. Resident #27 low air loss mattress setting was 50 pounds. Resident #27 said he had wounds on his right foot and bottom. He said he came to the facility with the wounds. Resident #27 said he did not feel like the staff turned him enough. <BR/>During an observation on 10/30/23 at 3:41 p.m., Resident #27 was lying on his back with head of his bed elevated. <BR/>During an observation on 10/31/23 at 9:46 a.m., Resident #27 was lying on his right side with an elongated, balloon shaped pillow in front of him. He said he did not know what the pillow was used for, and it had not been used before. Resident #27's low air loss mattress setting was on 50 pounds. <BR/>During an observation on 10/31/23 at 11:37 a.m., Resident #27 was lying on his right side with an elongated, balloon shaped pillow in front of him.<BR/>During an observation on 10/31/23 at 2:08 p.m., Resident #27 was lying on his left side and the low air loss mattress setting was on 50 pounds.<BR/>During an observation and interview on 10/31/23 at 3:02 p.m., Resident #27 was lying on his left side with triangular shaped positioning aide behind his back. When WCN NN removed the covers from Resident #27's legs, 2 small rectangular shaped positioning wedges were beneath his heels, but no pillow or wedge observed underneath the knees and Resident #27's calf was laying on the edge of the rectangular wedges which caused an indentation to his calf. During wound care provided by WCN NN, WCN NN removed a dressing from Resident #27's left heel. The dressing from Resident #27's left heel was slightly stuck to the skin and when removed, small amounts of frank blood dripped onto the positioning wedges. When Resident #27 was turned on his left side, one dressing was noted to the left side of his back but two other wounds were noted to the back without dressing. Resident #27's low air loss mattress setting was on 50 pounds. Resident #27 said he was 6'3 and 380 lbs. <BR/>During an observation on 11/01/23 at 3:08 p.m., Resident #27's low air loss mattress setting was on 300 pounds. <BR/>During an interview on 11/02/23 at 10:26 a.m., WCN NN said she started as the wound care nurse August 2023. She said everyone was responsible for checking the low air loss mattress settings. She said Resident #27's low air low mattress setting was on 50 pounds. She said when she went to do wound care with the wound care doctor today (11/02/23), they noticed the mattress looked low. She said she did not know how to unlock the bed settings, so the wound care doctor fixed the settings on Resident #27's bed. She said she thought the wound care doctor set the bed to 180 pounds. She said she only looked at the machine lights to make sure they were green, after the wound care doctor set the settings. She said she did not know why the wound care doctor set the low air loss mattress settings at 180 pounds because Resident #27 weighed more than 180 pounds. She said she normally tried to glance at the low air loss mattress machine when she did his daily dressings changes. She said she because there was no specific order on what weight to set the mattress settings on, she would look up the resident's weight to determine the settings. She said the floor nurses should check the mattress setting every shift to make sure it was working and on the right settings. She said the nurse's charted on the TAR every shift, they checked the mattress. She said correct inputted weight on the low air loss mattress was important to prevent wounds from happening and current wounds from getting worse. She said the wrong settings negatively affected the resident by worsening the wounds and be in pain. She said that could cause the need for pain medication and contributed to the slow healing of Resident #27's sacrum wounds. The WCN NN said CNAs were responsible for turning and repositioning residents every 2 hours when they made rounds. She said the hall nurse should ensure the CNAs were turning and repositioning residents every 2 hours. She said she did not know how the hall nurse monitored if every 2-hour turning happened. She said she looked into resident's rooms when she walked the halls to monitor turning and repositioning. She said turning and repositioning every 2 hours prevents further deterioration of wounds, removed pressure to prevent wounds, and reduced pressure on bony areas. She said she had not noticed Resident #27 not been tuned and repositioned every 2 hours. The WCN NN said she was responsible for dressing changes and wound care Monday-Friday and floor nurse did dressing changes on the weekend. She said the nurses were responsible for the resident's dressing staying on and changing the dressing when soiled. She said when she did Resident #27's wound care on Monday (10/30/23), he had 3 dressing to his back. She said no one notified her two of the dressing had fallen off on Tuesday (10/31/23) prior to the observed dressing change. She said the CNAs are supposed to let the nurses know when a dressing comes off. She said the wounds needed dressing to stop bacteria from getting in and help with healing. She said if no dressing is on the wounds, it could get infected and deteriorate. She said this would cause Resident #27 to need antibiotics and different treatment orders. She said she did not know if the CNAs had been instructed or in-serviced to notify nursing staff when wound dressing come off. The WCN NN said she did not know if CNAs had training on how to use and place positioning aides. She said she did not know if the positioning wedges came in different size and lengths since Resident #27 was tall and bariatric. She said she did not remember on Tuesday (10/31/23) during the dressing change if Resident #27 had a pillow underneath his knees. She said but Resident #27 should have a pillow underneath his knees to prevent pressure and give knee support. She said no knee support could cause blisters, wounds, and decreased range of motion. She said the facility was in the process of starting training on turning and repositioning. The WCN NN said Resident #27 was on a blood thinner and the Xeroform gauze dried out and stuck to the wound. She said she could have moistened the dressing to help prevent the wound from bleeding. She said Resident #27 being on a blood thinner cause him to bleed easier than other residents. <BR/>During an interview on 11/02/23 at 11:35 a.m., CNA H said she had been a CNA for 20 years but started back working at the facility around August 2023. She said she worked 6am-2pm shift on the 100-hall. She said she worked with Resident #27. She said resident were supposed to be turned every 2 hours to prevent skin break down and pressure sores. She said she knew how to correctly position resident using position aides and knew why it was important. She said pillows or position aides were important because they kept the skin from touching, prevented skin breakdown, and relieved pressure areas. She said she always found Resident #27 with a pillow underneath his knees. She said she let nurses know when wound dressing came off. She said Resident #27's back dressing normally stayed on, but his butt dressing came loose often. She said the wounds needed dressings because they were pressure sores, and they needed the dressing to heal. <BR/>During an interview on 11/02/23 at 2:06 p.m., LVN N said she had worked at the facility for 4 years and worked the 6am-6pm shift. She said she primarily worked the 300-hall and 400-hall but also worked the others hall too. She said residents should be turned. She said the resident should be turned and repositioned every 2 hours by the aides. She said LVN should check what position the resident are in throughout the day. She said if residents refused to be turned and repositioned, the aides needed to notify the nurse so it could be charted. She said turning and repositioning ensured resident did not develop wounds. LVN N said it was the nurse's responsibility to make sure the low air loss mattress was working every time you entered the room. She said all nurses should make sure the setting was on the correct weight by checking the weight in the computer system. She said the correct settings helped distribute the correct amount for the wounds and if the mattress is flat, it could cause more wounds or make current wounds worse. LVN N said all nurses should make sure dressings stayed on. She said if the wounds are left open, bacteria could be introduced and cause an infection. She said the infection could cause the resident to need antibiotics, develop sepsis (is a serious condition in which the body responds improperly to an infection) and c-diff ((also known as Clostridioides difficile or C. difficile) is a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon)), and death. <BR/>During an interview on 11/02/23 at 3:04 p.m., the DON said the CNAs should be turning and repositioning residents every 2 hours and as needed. She said LVNs and the DON should ensure it happened by making rounds. She said the facility used to have a system in place to have residents face a certain way a specific time of the day. She said that process did not work. She said she picked a different hall a week and monitored turning and repositioning. She said turning and repositioning was important to prevent skin breakdown. She said it was always uncomfortable to the resident to stay in the same position. The DON said the WCN was responsible for making sure low air loss mattress were on the right settings or weight. She said the WCN should at least be checking weekly, if not every time she was in the room doing dressing changes. She said unfortunately, CNAs can accidently change the setting and family members. She said the wrong setting could cause pressure and effect the resident's skin integrity. She said she did not know if the low air loss mattress being on the incorrect weight could cause pressure ulcer delayed healing. She said the floor nurse were responsible to make sure the low air loss mattress was working and on the ordered type of mattress. The DON said the WCN did dressing changes and the aides should notify the LVN when the dressing came off. She said the aides know to notify the nurses when a dressing comes off. She said wounds without ordered dressing risked infection and delayed healing. She said wound dressing were important for adequate healing. The DON said she did not know if all the aides knew how the use positioning aide/wedges. She said the facility had a large turnover in aides and was in the process of training the staff. She said pillow or wedge should be between or under the knees to provide support. She said correct use of positioning aides was important for comfort, proper body alignment, and reduced pressure wounds. <BR/>During an interview on 11/02/23 at 4:30 p.m., the WC MD said Resident #27 was under his care for several wounds. He said Resident #27 had recently been placed on hospice and his wound care was palliation, so not directly trying to heal the wounds. He said he had also clustered some wounds after his last visit (11/01/23) to decrease the amount of treatment needing to be performed. He said he vaguely remembered Resident #27 mattress setting being on the wrong weight. He said the low air loss mattress should be close the resident's weight and if tolerated, alternating every 15 minutes. He said Resident #27 was about 250 pounds so 50 pounds was far from what he needed. He said Resident #27 had a decline in health, decreasing the healing of his wounds. He said Resident #27 being on 50 pounds settings instead of about 250 pounds could feasibly have contributed to the increased size of the pressure and non-pressure wounds. He said he did not know the facility's policy on how often the low air loss mattress setting should be checked but they should be checked when wound care was provided. <BR/>2. Record review of Resident #361's face sheet dated 10/30/23 revealed Resident #361 was admitted to the facility initially on 2/17/17 and readmitted on [DATE] with diagnoses including lymphedema (swelling in an arm or leg caused by a blockage in the lymphatic system, part of the immune and circulatory systems), pneumonia (infection in lungs), weakness, abnormalities of gait and mobility, heart failure, and diabetes (high sugar levels in blood).<BR/>Record review of Resident #361's admission MDS dated [DATE] indicated Resident #361 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated Resident #361 was cognitively intact. Resident #361 required extensive assistance of 2 persons for most ADLs. Resident #361 was always incontinent of urine and frequently incontinent of bowel. The MDS said Resident #361 did not have pressure ulcers.<BR/>Record review of Resident #361's undated care plan revealed he was at risk for/actual skin breakdown with onset date of 8/07/23.<BR/>Record review of hospital records dated 8/3/23 revealed Resident #361 had a sacral decubital ulcer (wound caused from pressure to the lower back at the bottom of the spine) and was being treated with Santyl (ointment used to remove damaged tissue from skin ulcers).<BR/>Record review of Resident #361 's admission assessment revealed there was no documentation of an admission assessment upon admission.<BR/>Record review of Resident #361 's initial skin assessment revealed there was no documentation of an initial skin assessment completed.<BR/>Record review of Resident #361 's nurses' notes revealed there was no documentation until 8/18/23 and it did not address Resident #361 's pressure ulcer to his sacrum/coccyx.<BR/>Record review of Resident #361 's order summary report dated 10/31/23 revealed there was no orders to treat Resident #361 's pressure ulcer to his sacrum/coccyx until 8/07/23, however, the order did not match what APRN QQ had documented in his 8/07/23 note. The 8/07/23 order was to cleanse the coccyx wound every other day with wound cleanser, pat dry, apply medihoney, wet/dry dressing, and cover with mepilex.<BR/>Record review of Resident #361 's physician visit note dated 8/07/23 completed by APRN QQ revealed during the visit Resident #361 complained of pain to his coccyx. APRN QQ documented Resident #361 to have an unstageable sacral wound that covered his sacrum and his left and right buttocks. APRN QQ documented the wound to have slough and eschar to the wound base with serous drainage present. APRN QQ ordered wound care to cleanse the wound with wound cleanser, pat dry, apply Santyl to moist fluffed gauzes covering the entire wound, cover with dry gauze and secure with a silicone foam dressing every other day.<BR/>During an interview on 11/01/23 at 10:31 AM, APRN QQ said he did not recall being notified about Resident #361 's wound to his bottom upon his admission. APRN QQ said he would have expected the admitting nurse to notify him with abnormal findings for orders. APRN QQ said Resident #361 admitted on Friday 8/04/23 and he saw Resident #361 on Monday 8/07/23. APRN QQ said he remembered there was little mention of the pressure ulcer to Resident #361 's bottom in the hospital records during his review. APRN QQ said the wound was covered with slough (wet dead tissue) and eschar (dried out dead tissue) and he was unable to stage the pressure injury. APRN QQ said it was a pretty bad wound and he gave orders for wound care, and he made a referral for the wound care physician to see him that usually came to the facility on Wednesdays. APRN QQ said after the wound care physician saw Resident #361 and debrided the wound (cut away dead tissue), then they were able to see the extent of the wound. APRN QQ said the resident had osteomyelitis (bone infection) in his foot and he suspected that it could have come through the bone and settled in the sacrum/coccyx. APPRN QQ said he did an x-ray of the sacral area, and it was suspicious of osteomyelitis, then they decided it was best to send him to the hospital for further treatment. APRN QQ said depending on how the wound looked upon admission on [DATE], he most likely would have given the same orders and made a referral to wound care. APRN QQ said it was possible the wound could have deteriorated without appropriate care from 8/04/23 until 8/07/23, but unlikely that it would have deteriorated to the point of needing emergent intervention in that time frame.<BR/>During an interview on 11/01/23 at 11:18 AM, LVN KK had worked at the facility for six months and normally worked on 600 hall on the 6am-6pm shift. LVN KK said the nurse on the floor was primarily responsible for completing the admission assessment, obtaining and entering orders, initial skin assessments upon the resident's arrival/admission. LVN KK said the first nurse to lay eyes on resident was responsible for all the admission stuff. LVN KK said if a resident was admitted during the week, he preferred to have the wound care nurse go with him and do the skin assessment with him. LVN KK said by completing the admission assessment that included the skin assessment, it would find a pressure wound and it was important to find pressure wounds on admission, so it would show it was acquired at hospital and not at the facility. He would document LVN KK said if he found any new wounds during his skin assessment, he would notify the physician for orders, and he let wound care nurse and the DON know. LVN KK said the nurses were responsible for doing the wound care on the weekends if there was no treatment nurse on the weekend. LVN KK reviewed Resident 361's chart at surveyor request and he none of Resident #361's admission assessments, including the skin assessment was not completed upon admission and still did not show to be completed. LVN KK said it appeared there was no orders to treat the pressure ulcer to Resident #361's bottom until 8/07/23. LVN KK said he could not tell what nurse had admitted Resident #361 due to there was no notes documented.<BR/>During an interview on 11/01/23 at 11:49 AM, MD RR said he remembered Resident #361 and he had a really nasty coccyx wound. MD RR said he saw Resident #361 on 8/16/23 and that was the only time he saw him in August. MD RR said he debrided the wound and then staged it as a stage 4 pressure ulcer (extends to muscle, tendon, and bone). MD RR said he believed he received the referral to see Resident #361 on 8/16/23 and remembered APRN QQ asking him to see Resident #361. MD RR said any wound that did not receive the appropriate care over three days would most likely deteriorate. <BR/>During an interview on 11/01/23 at 11:57 AM, LVN NN said she began working at the facility sometime in August 2023. LVN NN said she did not recall seeing Resident #361 for wound care because he may have admitted before she began working at the facility as the wound care nurse. LVN NN said the nurses were responsible for completing the admission skin assessments and if she was at the facility, she would do them with the admitting nurse. <BR/>During an interview on 11/01/23 at 6/02 PM LVN O said she had worked at the facility for five years and normally worked the 600 hall on 6pm-6am shift. LVN O said on new resident admissions, the nurse had to complete a head-to-toe assessment to include weight, vital signs, assess lungs, heart, feet, and look at everywhere on their skin. LVN O said findings during the assessment should be documented in the admission assessment and skin assessment questionnaire. LVN O said if she found a pressure wound and did not have orders to treat it, then she would notify the physician for orders for treatment immediately. LVN O said Resident #361 did not admit to 600 hall, he was on the 100 hall when he came back from the hospital in August after his amputation. LVN O said she thought an agency nurse admitted him. LVN O said if a pressure ulcer did not receive appropriate care for three days, then the wound could get worse.<BR/>During an interview on 11/02/23 at 8:36 AM, ADON P said she had worked at the facility since 7/26/23. ADON P said she was responsible for reviewing the 24-hour reports, reviewing nurses' notes, making sure labs were done, along with making sure the nurses were doing what they were supposed to do and helping the DON and ADM. ADON P said she also reviewed new admissions to ensure all the medications were reconciled correctly and available. ADON P said the admitting nurse was responsible for completing the admission assessments and skin assessments as soon as possible, but within 24 hours. ADON P said there was no admission assessment documented on Resident #361 and there were only two nurses' notes on Resident #361. ADON P said if the admission assessment, skin assessments, nurse's notes or anything were not documented, it affected Resident #361's care. ADON P said if it was not documented, then it was not done. ADON P said not receiving needed care to Resident #361's pressure ulcer for three days could have negatively affected the healing of his wound.<BR/>During an interview on 11/02/23 at 10:05 AM, the DON said the admission assessment, skin assessment, medication review, orders, bed rail evaluation, consents, and baseline care plans should be completed by the admitting nurse. The DON said the admission assessments should be completed by the admitting nurse within 24 hours of admission. The DON said the documentation on Resident #361 was terrible and just awful due to there was no admission assessment with skin assessment and only two nurses' notes during Resident #361's 8/04/23-8/18/23 stay. The DON said she could not determine who the admitting nurse was that did not complete the admission and skin assessments on Resident #361, but she said she believed it had to be an agency nurse. The DON said she was responsible for making sure the nurses were completing the admission assessments. The DON said they had an admission audit form that was started by ADON P, and the DON was the second check. The DON said at time of Resident #361's admission, she did not have an ADON to help her and was having to work the floor frequently and at night and was not able to follow on things like she needed to. The DON said due to the admission assessments not being completed and Resident #361's pressure to his sacrum/coccyx was not discovered on admission, then his needed care was delayed and that was not good. The DON said not receiving care to Resident #361's sacrum/coccyx pressure ulcer could have negatively impacted the healing of the pressure ulcer, however, since it was not documented on his admission assessment, there was no way of determining how much or if any deterioration occurred to his pressure ulcer. <BR/>During an interview on 11/02/23 at 10:52 AM, the ADM said the receiving nurse would be responsible for completing an admission assessment and the DON or her designee checks over it. The ADM said if the admission assessment was not completed, then they could miss resident care needs. The ADM said a complete admission assessment should be completed to identify any resident issues and provide interventions to prevent decline. The ADM said she would have expected Resident #361 to have been provided care to his pressure ulcer to his coccyx to prevent further breakdown. <BR/>Record review of the facility's policy titled Prevention of Pressure Ulcers/Injuries dated July 2018 indicated . residents would receive care to maintain skin integrity and prevent pressure ulcers/injuries . residents will be repositioned on a routine basis based on the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 7 residents (Resident #27) reviewed for appropriate treatment and services to prevent urinary tract infections (an infection in any part of the urinary system, the kidneys, bladder, or urethra (is a hollow tube that lets urine leave your body)). <BR/>The facility failed to ensure Resident #27's indwelling catheter (drains urine from your bladder into a bag outside your body) remained free of dependent loops (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag) and had a leg strap to anchor catheter to his leg. <BR/>This failure could place residents at risk for urinary tract infections.<BR/>Findings included:<BR/>Record review of Resident #27's face sheet dated 10/30/23 indicated Resident #27 was a [AGE] year-old male and admitted on [DATE] and 04/06/23 with diagnoses including cerebral infarction ((also known as a stroke) refers to damage to tissues in the brain due to a loss of oxygen to the area), pressure ulcer of buttock (also known as bedsores, are an injury that breaks down the skin and underlying tissue), stage 3, and pain. <BR/>Record review of Resident #27's annual MDS assessment dated [DATE] indicated Resident #27 was usually understood and usually understood others. The MDS indicated Resident #27 had a BIMS score of 09 which indicated moderately impaired cognition and required limited assistance with dressing, extensive assistance with bed mobility, toilet use, personal hygiene, and bathing. The MDS indicated Resident #27 had an indwelling catheter and always had bowel incontinence.<BR/>Record review of Resident #27's care plan dated 09/21/23 indicated Resident #27 was at risk for problem with elimination related to Foley catheter placement, history of urinary tract infection as evidence by diagnosis of obstructive uropathy (is a disorder of the urinary tract that occurs due to obstructed urinary flow). Intervention catheter care every shift and as needed and monitor for signs and symptoms of urinary tract infection. <BR/>Record review of Resident #27's consolidated physician order dated 08/07/23 indicated Foley Catheter 16 fr, night shift to continuous gravity drainage and catheter care. Bulb size 10 mL. ***Privacy bag checked, and placement of leg strap verified every shift**** The consolidated physician order indicated Resident #27 had an diagnosis of urinary tract infection. <BR/>Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated Foley Catheter 16 fr, night shift to continuous gravity drainage and catheter care. Bulb size 10 mL. ***Privacy bag checked, and placement of leg strap verified every shift**** Dx: Obstructive (is a disorder of the urinary tract that occurs due to obstructed urinary flow) and reflux (is kidney scarring caused by urine flowing backward from the bladder into a ureter and toward a kidney) uropathy. Start date: 08/07/23. The TAR indicated documentation of verification 10/01/23-10/31/23. <BR/>During an interview and observation on 10/30/24 at 11:24 a.m., Resident #27 was lying in bed on his back. Resident #27 looked confused and said he did not know about a strap around his leg to hold the catheter. <BR/>During an observation on 10/31/23 at 3:02 p.m., Resident #27 got wound care performed by WCN NN and no leg strap to hold his indwelling catheter was noted. Resident #27's indwelling catheter tubing was looped through the brief tabs forming a dependent loop. <BR/>During an interview om 11/02/23 at 10:26 a.m., WCN NN said she did not recall seeing a leg strap on Resident #27's leg for his indwelling catheter during his dressing changes. She said leg strap was important to prevent pulling. She said no leg strap and dependent loops placed residents at risk for infection and damage to the urethra. She said the nurses should be checking for a leg strap and no dependent loops. <BR/>On 11/02/23 at 11:20 a.m., an indwelling catheter policy was requested from the ADM. The policy was not provided prior or after exit.<BR/>During an interview on 11/02/23 at 12:47p.m., an anonymous staff member said Resident #27 currently did not have leg strap and never had a leg strap for his catheter. They said a leg strap helped the catheter not move. They said they normally looped the tubing in his brief to prevent it from pulling. They said not having a leg strap could cause a tear in Resident #27 genital and leakage. They said they had not been instructed to not loop catheter tubing. <BR/>During an interview on 11/02/23 at 2:06 p.m., LVN N said all residents with an indwelling catheter should have a leg strap. She said the LVNs were responsible for making sure residents had a leg strap. She said the leg strapped helped the catheter from pulling. She said not having a leg strap could cause pain and trauma to the urethra. She said those issues could cause problem with urinations. <BR/>During an interview on 11/02/23 at 2:52 p.m., RN TT said this was her 3rd shift working at the facility. She said she did not know if Resident #27 had a leg strap on. She said the CNAs should tell the nurses if a resident did not have one. She said Resident #27 should have a leg strap on to secure his catheter. She said the leg strap prevented pulling and from the catheter coming out. She said pulling of the catheter could cause a tear and damage the urethra or split the penis. She said the damage of the urethra could cause bleeding and pain during urination. She said dependent loops cause increased risk of infection. <BR/>During an interview on 11/02/23 at 3:04 p.m., the DON said Resident #27 should have a leg strap for his indwelling catheter. She said it was the nurse's responsibility to make sure resident had a leg strap. She said the leg strap kept the catheter in place and prevented dislodgement. She said pulling placed resident at risk for bleeding, irritation, and damaged to the urethra. She said loops through the resident's brief was not recommended due to the increased risk of infection. <BR/>Record review of a facility's .<BR/>The article from the Journal of Community Nursing December 12, 2014 titled The importance of fixation and securing devices in supporting indwelling catheters accessed at the Magonline Library website on 11/08/23 https://levityproducts.com/wp-content/uploads/2020/09/The-importance-of-fixation-and-securing-indwelling-catheters-2013.pdf stated, .catheter securing devices are vital part of catheter management .the catheter and attached drainage system should be well supported in a comfortable position for individual at catheter insertion to prevent complications .possible complications when not using adequate securing devices included .if the catheter migrates or is removed accidently, it can lead to urethral trauma, infection, patient discomfort and/or urinary retention .damage to the bladder neck can occur .lead to cleaving, causing discomfort and irritation .high potential risk for urinary tract infection .inflammation can lead to infection, tissue necrosis, blockage of urethra, bladder irritability, spasms and bypassing .high incidence of unplanned catheter changes .<BR/>The article from the Journal of wound Ostomy Continence Nursing May/June 2015 titled Prevalence of Dependent Loops in Urine Drainage Systems accessed at the National Library of Medicine website on 11/08/23 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4423413/ stated, . A dependent loop is formed by excess drainage tubing in a urine drainage system where urine or liquid can accumulate. Dependent loops trap drained urine and are suspected of impeding bladder drainage and increasing the residual volume of retained urine in the bladder. Dependent loops have been associated with an odds ratio of 2.1 for developing catheter-associated urinary tract infection (CAUTI) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 2 of 3 resident (Resident #3, Resident #6) reviewed for hydration. <BR/>The facility failed to ensure Resident #3 and Resident #6 hydration was within reach.<BR/>This failure could place residents at risk for dehydration (occurs when your body loses more fluid than you take in), electrolyte imbalance (occurs when certain mineral levels in your blood get too high or too low), and infections. <BR/>Findings included:<BR/>1. Record review of Resident #3's face sheet dated 11/02/23 indicated Resident #3 was 91-years-old male and admitted on [DATE] with diagnosis including dementia (a group of thinking and social symptoms that interferes with daily functioning), malignant neoplasm of prostate (is a disease in which malignant (cancer) cells form in the tissues of the prostate) and muscle weakness.<BR/>Record review of Resident #3's significant change in status MDS assessment dated [DATE] indicated Resident #3 was usually understood and sometimes had the ability to understand others. The MDS indicated Resident #3 had a BIMS score of 04 which indicated severely impaired cognitive impairment and required extensive assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and total dependence for bathing.<BR/>Record review of Resident #3's care plan dated 09/21/22 indicated Resident #3 received a diuretic (medicines that help reduce fluid buildup in the body). Intervention included monitor for blood potassium level, hypotension (low blood pressure), and signs/symptoms of dehydration. <BR/>Record review of Resident #3's care plan dated 09/07/23 indicated Resident #3 had an altered nutritional status related to risk of malnutrition as evidence by thin liquid consistency. Intervention included monitor oral intake of food and fluid. <BR/>Record review of Resident #3's, October 2023-November 2023 ADL report, category: eating, fluid intake in ml indicated:<BR/>*10/27/23 no documentation of fluid intake <BR/>*10/28/23 no documentation of fluid intake<BR/>*10/29/23 at 11:56 a.m. 0 ml fluid intake (CNA MM), no documentation for 2pm-10pm or 10pm-6am shift<BR/>*10/30/23 at 7:30 a.m. 25 ml (CNA H), 11:30 a.m. 25 ml (CNA H), 4:30 p.m. 600 ml (CNA OO)<BR/>*10/31/23 at 7:30 a.m. 25 ml (CNA H), 11:30 a.m. 25 ml (CNA H), 4:30 p.m. 360 ml (CNA PP)<BR/>*11/01/23 at 7:30 a.m. 25 ml (CNA H), 11:30 a.m. 25ml (CNA H), 4:4:30 p.m. 360 ml (CNA PP)<BR/>Record review of Resident #3's Comprehensive Metabolic (is a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working) lab work dated 08/14/23 did not show electrolyte imbalance related to dehydration. No recent lab work drawn. <BR/>During an observation on 10/31/23 at 9:52 a.m., Resident #3's water pitcher was on his bedside table against the wall, not within reach. <BR/>During an observation on 10/31/23 at 2:10 p.m., Resident #3's water pitcher was on his bedside table against the wall, not within reach.<BR/>2. Record review of Resident #6's face sheet dated 10/30/23 indicated Resident #6 was a [AGE] year-old female and admitted on [DATE] and 09/07/20 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), paraplegia (is a specific pattern of paralysis (which is when you can't deliberately control or move your muscles) that affects your legs), and chronic kidney disease (means your kidneys are damaged and can't filter blood the way they should). <BR/>Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was sometimes understood and sometimes had the ability to understand others. Resident #6 had unclear speech. The MDS indicated Resident #6 was unable to complete BIMS and had short-and-long term memory problem recall. The MDS indicated Resident #6 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #6 required limited assistance for eating and dressing, extensive assistance for bed mobility and bathing, and total dependence for toilet use. <BR/>Record review of Resident #6's care plan dated 09/29/22 indicated Resident #6 had altered nutritional status related to use of diuretics, laxative and/or cardiovascular as evidence by resident has inadequate fluid intake. Intervention included monitor oral intake of food and fluid. <BR/>Record review of Resident #6's, October 2023 -November 2023 ADL report, category: eating, fluid intake in ml indicated:<BR/>*10/27/23 no documentation of fluid intake <BR/>*10/28/23 no documentation of fluid intake<BR/>*10/29/23 at 7:30 a.m. 360 ml (CNA MM), at 11:30 a.m. 360 ml (CNA MM)<BR/>*10/30/23 at 7:30 a.m. 50 ml (CNA H), at 11:30 a.m. 50 ml (CNA H), at 4:30 p.m. 600 ml (CNA OO)<BR/>*10/31/23 at 7:30 a.m. 25 ml (CNA H), at 11:30 a.m. 50 ml (CNA H), at 4:30 p.m. 600 ml (CNA OO)<BR/>*11/01/23 at 7:30 a.m. 50 ml (CNA H), at 11:30 a.m. 50 ml (CNA H), at 4:30 p.m. 600 ml (CNA OO)<BR/>Record review of Resident #6's lab work, provided by the facility, indicated no electrolyte lab work had been drawn since 09/09/20.<BR/>During an interview on 10/30/23 at 2:16 p.m., family member C said one of her main concerns was her family member's water was never within reach when she visited. Family member C said her family member also did not have the strength to lift the water pitcher and she brought smaller cups for her to use. Family member C said she had to fill her family members pitcher herself and sometimes other residents too. <BR/>During an observation on 10/30/23 at 3:43 p.m. Resident #6's clear water pitcher with ml marking on the side, was full of water with no ice and on the bedside tray not within reach. <BR/>During an observation on 10/31/23 at 9:26 a.m. Resident #6's clear water pitcher was filled between the 600ml-700ml marking with no ice. The water pitcher was on the bedside tray not within reach.<BR/>During an observation on 10/31/23 at 9:42 a.m., CNA H started passing out ice water on the 100-hall.<BR/>During an observation on 10/31/23 at 11:35 a.m., Resident #6 had fresh ice water filled to 700 ml but was on the bedside tray not within reach.<BR/>During an observation on 10/31/23 at 2:05 p.m., Resident #6's water pitcher was still at 700 ml of water with no ice and on the bedside tray not within reach.<BR/>During an observation on 10/31/23 at 4:00 p.m., Resident #6's water pitcher was still at 700 ml of water with no ice and on the bedside tray not within reach.<BR/>During an interview on 11/02/23 at 12:47 a.m., an anonymous staff member said they passed out ice water at the start of each shift and after dinner. They said CNAs should make sure resident's water was within reach. They said they filled up the water pitcher to about 700 ml and counted down from there how much the resident drank. They said they had arrived on their shift and a resident water pitcher was filled to top with no ice. They said they had arrived on their shift and Resident #3 and Resident #6 bedside tray holding the water pitcher would be pushed out of reach. They said Resident #6 needed her water poured in smaller cups with a straw to help her drink. They said drinking adequate water helped prevent dehydration and dry skin. They said not having enough water could hurt the kidneys. <BR/>During an interview on 11/02/23 at 2:06 p.m., LVN N said anybody could pass water out. She said anybody could make sure it was within reach. She said the LVNs should ensure the aides are passing and offering hydration and keeping it within reach. She said she monitored hydration by asking resident if they had water during med pass and offered water to resident who need encouragement. She said hydration should be passed every shift and when asked by the resident. She said aides should offer hydration to resident every time they went into their rooms. She said adequate hydration prevented dehydration which could result in death. <BR/>During an interview on 11/02/23 at 3:04 p.m., the DON said hydration should be passed out on each shift and as needed. The DON said anyone could pass out hydration, but the aides were initially responsible. She said the LVNs should ensure hydration was passed out as needed and offered to resident frequently. She said when she did morning rounds, she monitored hydration. She said hydration was important to prevent dehydration and skin issues. She said dehydration could cause imbalances and decrease fluid volume which can affect vital signs. <BR/>Record review of a facility's Hydration policy revised 04/07 indicated .the staff will provide supportive measures such as providing fluids .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview 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 1 of 5 residents (Resident #29) reviewed for unnecessary medications in that: <BR/>The facility failed to ensure Resident #29 had appropriate diagnoses for the use of Acetaminophen (is used to treat many conditions such as headache, muscle aches, arthritis, backache, toothaches, colds and fevers), Albuterol (is used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways)), Boost (a nutrient-packed high protein nutritional drink for muscle health and immune support), House shake (Fortified Nutritional Shakes provides a convenient way to supplement calories and protein), bedtime snack, Linezolid (is used to treat infections, including pneumonia, and infections of the skin), Magnesium (is used as a dietary supplement for individuals who are deficient in magnesium), and Tussin (is used to relieve coughs caused by the common cold, bronchitis, and other breathing illnesses). <BR/>This failure 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/>Record review of Resident #29's face sheet dated 10/30/23 indicated Resident #29 was 91-years-old male and admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), acute respiratory failure (happens when not enough oxygen passes from your lungs to your blood), Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), vitamin deficiency (a deficiency of one or more essential vitamins), pain, abnormal weight loss<BR/>Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated Resident #29 was usually understood and usually understood others. The MDS indicated Resident #29's BIMS score was 10 which indicated moderate cognitive impairment and required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and bathing.<BR/>Record review of Resident #29's care plan dated 11/11/22 indicated Resident#29 had pain related to severe cognitive impairment as evidence by acetaminophen 325 mg 2 tablet by mouth. Intervention included administer pain medication as ordered. <BR/>Record review of Resident #29's care plan dated 11/11/22 indicated Resident#29 had altered nutritional status related to increase needs for wound care and admission status: recent weight loss as evidence by increase nutrients needs, pressure ulcer, and significant weight loss. Intervention included provide vitamins. <BR/>Record review of Resident #29's care plan dated 09/25/23 indicated antibiotic as evidence by Zyvox (Linezolid) 600 mg 1 tablet by mouth 2 times a day for 10 days (09/25/23). Intervention included observe for possible side effects, please review medication information listed on electronic healthcare record for specific antibiotic side effects. <BR/>Record review of Resident #29's consolidated physician order dated:<BR/>*05/03/22 HS snack daily at bedtime (ordered as a snack food or beverage items to be given at the hour of sleep for diabetics)<BR/>*05/03/22 Magnesium 200mg 2 tablets by mouth 1 time per day<BR/>*07/08/22 House Shake 1 can by mouth 3 times per day<BR/>* 12/12/22 Acetaminophen 325mg tablet 2 tablets by mouth 2 times per day<BR/>*06/21/23 Boost Plus 0.06 gram-1.5 kcal/ml oral liquid (Lactose-reduced food) 1 bottle by mouth 1 time per day at lunch<BR/>*06/30/23 Tussin DM Clear 10mg-100mg/5ml oral syrup 10 ml by mouth 2 times per day<BR/>*09/25/23 Linezolid 600mg tablet 1 tablet by mouth 2 times per day 10 days<BR/>*10/19/23 Albuterol sulfate 2.5mg/3ml solution for nebulization 1 solution for nebulization inhalation 4 times per day as needed for shortness of breath nebulization<BR/>Record review of Resident #29's MAR dated 10/01/23-10/31/23 indicated:<BR/>* HS snack daily at bedtime. Dx: Acute respiratory failure. Start date: 05/30/22. Acute respiratory failure was related to the lungs not snacks at bedtime for diabetics.<BR/>* Magnesium 200mg 2 tablets by mouth 1 time per day. Dx: diabetes mellitus without complication. Start date: 06/28/23. Diabetes was related to the glucose level not Magnesium vitamin deficiency. <BR/>* House Shake 1 can by mouth 3 times per day. Dx: Cellulitis of left lower limb. Modification date: 06/28/23. Cellulitis was a deep infection of the skin caused by bacteria not related to fortified shake for nutrition.<BR/>* Acetaminophen 325mg tablet 2 tablets by mouth 2 times per day. Dx: Type 1 diabetes mellitus (is a condition in which your immune system destroys insulin-making cells in your pancreas) with diabetic neuropathy (a type of nerve damage that can occur with diabetes). Modification date: 04/14/23. Acetaminophen was used to treat fever or pain not blood glucose levels. <BR/>*Boost Plus 0.06 gram-1.5 kcal/ml oral liquid (Lactose-reduced food) 1 bottle by mouth 1 time per day at lunch. Dx: Dementia. Start date: 06/21/23. Boost was used for weight loss management not used to Dementia.<BR/>* Tussin DM Clear 10mg-100mg/5ml oral syrup 10 ml by mouth 2 times per day. Dx: Dementia. Start dated: 06/30/23.Tusssin DM was a cough medicine not used to treat Dementia.<BR/>*Linezolid 600 mg 1 tablet by mouth 2 times per day 10 days ESBL in urine Dx: Chronic kidney disease (means your kidneys are damaged and can't filter blood the way they should). Modification date: 09/25/23. End date: 10/05/23. Linezolid was an antibiotic and should be used to treat a diagnosis of infection. <BR/>* Albuterol sulfate 2.5mg/3ml solution for nebulization 1 solution for nebulization inhalation 4 times per day as needed for shortness of breath nebulization. Dx: dementia. Modification date: 07/23/23. End date: 10/19/23. Albuterol sulfate was used to treat difficulty breathing not Dementia. <BR/>During an interview on 11/02/23 at 2:06 p.m., LVN N said she had been working at the facility for 4 years. She said the nurse who put the medication order in should make sure the right diagnosis is selected for the medication. She said other LVNs who administered the medication and the ADON should also monitor appropriate diagnoses with medications. She said the appropriate diagnosis was important to understand why a medication was given, know if the resident received the right medication for the prescribed diagnosis, and for billing purposes. She said it could negatively affect the resident if a wrong medication was given for the wrong diagnosis which could harm the resident. She said Acetaminophen was normally given for pain and/or fever (elevated body temperature) and Linezolid was an antibiotic. She said Albuterol was normally prescribed for resident with COPD or upper respiratory infections. She said Tussin DM was normally ordered for coughing or respiratory issues so Dementia was not an appropriate diagnosis. She said Boost and House shakes were normally ordered for resident with weight loss. She said Magnesium was used for resident with vitamin deficiencies. <BR/>During an interview on 11/02/23 at 3:04 p.m., the DON said all nursing staff was responsible for appropriate diagnoses with medications. She said on admission the orders should be inputted correctly with the appropriate diagnoses by the nurse. She said the MDS coordinator and DON tried to review orders for appropriate diagnoses, but the facility received a lot of admission. She said most nursing staff when inputting medication orders, select the first diagnoses listed. She said the resident's orders got behind because each order had to be manually fixed and she was only one person. She said the responsibility untimely fell on her to ensure medications had appropriate diagnoses. She said appropriate diagnosis was important to understand why a medication was be given and was the treatment effective. <BR/>During an interview on 11/02/23 at 4:07 p.m., the ADM said she expected nursing administration to handle appropriate diagnoses with medication for the residents. <BR/>Record review of a facility's Medication Ordering and Receiving from Pharmacy Providers policy revised 01/12/20 indicated .staff will order and receive medication from pharmacy providers in accordance with standard practice guideline .<BR/>Review of Nursing Process: Patient Safety during drug therapy (2024), https://www.nursingcenter.com/clinical-resources/nursing-drug-handbook/ndh-toolkit/nursing-process was accessed on 11/08/2023 indicated .drug therapy is a complex process that can easily lead to adverse patients events .applying the nursing process .assessment, nursing diagnosis .during drug therapy enables the nurse to systemically identify the drug therapy needs of each patient .administer medication utilizing the eight rights .right drug .right reason .

**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 2 of 5 residents (Resident #5, Resident #6) reviewed for unnecessary psychotropic medications.<BR/>The facility failed to limit Resident #5's Lorazepam (anti-anxiety) prn medications to 14 days and the prescribing practitioner did not provide a rationale for extended use.<BR/>The facility failed to have an appropriate diagnosis or indication of use for Resident #5's Lorazepam. <BR/>The facility failed to document Resident #5's behaviors to justify administration of Lorazepam and effectiveness of administration.<BR/>The facility failed to have an appropriate diagnosis or indication of use for Resident #6's Seroquel (Quetiapine Fumarate; antipsychotic).<BR/>The facility failed to have an appropriate diagnosis or indication of use for Resident #6's Clonazepam (anti-anxiety; is used to treat seizures, panic attacks, and anxiety). <BR/>The facility failed to document behavior monitoring for Resident #6's antipsychotic use.<BR/>These failures could put residents at risk of receiving unnecessary psychotropic medications. <BR/>Findings included:<BR/>1. Record review of Resident #5's face sheet dated 10/30/23 indicated Resident #5 was a [AGE] year-old female and admitted on [DATE] with diagnosis including psychosis (a mental disorder characterized by a disconnection from reality), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), personality disorder (are conditions where an individual differs significantly from an average person), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). <BR/>Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated Resident #5 was usually understood and usually had the ability to understand others. The MDS indicated Resident #5 had a BIMS score of 13 which indicated intact cognition and required supervision for transfer, limited assistance for bathing, and extensive assistance for bed mobility, dressing, toilet use, personal hygiene. The MDS indicated Resident #5 received 1 days of an antianxiety medication in the 7-day assessment period.<BR/>Record review of Resident #5's care plan dated 06/21/23 indicated Resident #5 received an antianxiety medication as evidence by Lorazepam 0.5mg tablet 1 tablet by mouth 2 times per day as needed for anxiety. Interventions included monitor behaviors every shift and ask physician to review medication for possible dose reduction every 3 months. <BR/>Record review of Resident #5's consolidated physician order dated 06/29/22 indicated Lorazepam 0.5mg 1 tablet by mouth 2 times per day as needed for Anxiety.<BR/>Record review of Resident #5's MAR dated 10/01/23-10/31/23 indicated Lorazepam 0.5mg 1 tablet by mouth 2 times per day as needed for Anxiety. Dx: Bipolar disorder, current manic without psychotic features. Start date: 06/29/22. No end date noted. Resident #5 received as needed doses on 10/03/23 at 10:01 p.m. (LVN FF), 10/04/23 at 4:17 a.m. (LVN FF), 10/04/23 at 10:13 p.m. (RN RR), 10/07/23 at 3:55 a.m. (LVN QQ), 10/19/23 at 12:10 p.m. (ADON P), 10/22/23 at 6:57 p.m. (LVN FF), 10/23/23 at 5:40 p.m. (ADON P), 10/26/23 at 8:12 p.m. (LVN FF). <BR/>Record review of Resident #5's Behavior Monitoring report dated 10/01/23-11/01/23 indicated no episodes of restlessness or interventions related to use of Lorazepam 0.5mg. <BR/>Record review of Resident #5's Medication Review Record dated 06/29/23 indicated .prn psychotropic orders need a 14 day stop date .at the time physician will need to reevaluate need for the following . Lorazepam 0.5mg PO BID PRN .duration greater than 14 days will need physician rationale .<BR/>On 11/01/23 at 3:36 p.m., attempted to contact LVN FF by phone. No return call prior or after exit.<BR/>2. Record review of Resident #6's face sheet dated 10/30/23 indicated Resident #6 was a [AGE] year-old female and admitted on [DATE] and 09/07/20 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance (sleep challenges, psychosis, agitation, and mood swings), psychotic disturbance (a mental disorder characterized by a disconnection from reality), mood disturbance (disorders are described by marked disruptions in emotions (severe lows called depression or highs called hypomania or mania)), and anxiety (is a feeling of unease, such as worry or fear, that can be mild or severe) major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder, delusional disorder (is characterized by one or more firmly held false beliefs that persist for at least 1 month), and histrionic personality disorder (is a mental condition in which people act in a very emotional and dramatic way that draws attention to themselves). <BR/>Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was sometimes understood and sometimes had the ability to understand others. Resident #6 had unclear speech. The MDS indicated Resident #6 was unable to complete BIMS and had short-and-long term memory problem recall. The MDS indicated Resident #6 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #6 required limited assistance for eating and dressing, extensive assistance for bed mobility and bathing, and total dependence for toilet use. The MDS indicated Resident #6 received 3 days of an antipsychotic and antianxiety medications in the 7-day assessment period. The MDS indicated Resident #6 received an antipsychotic medication on a routine basis only. <BR/>Record review of Resident #6's care plan dated 09/21/23 indicated Resident #6 received anti-anxiety related to diagnosis and yells out with history of combative behaviors as evidence by clonazepam 0.5 mg tablet 1 tablet by mouth 3 times per day. Intervention monitor behaviors every shift. <BR/>Record review of Resident #6's care plan dated 09/21/23 indicated Resident #6 received psychotropic drug use related to diagnosis and history of hallucinations, delusions as evidence by Seroquel 25mg tablet (Quetiapine Fumarate) 1 tablet by mouth at bedtime. Intervention included monitor behavior every shift and document. <BR/>Record review of Resident #6's consolidated physician order dated 08/02/23 Quetiapine Fumarate 25mg 1 tablet by mouth at bedtime.<BR/>Record review of Resident #6's consolidated physician order dated 08/08/23 Clonazepam 0.5 mg tablet 1 tablet by mouth 3 times per day. <BR/>Record review of Resident #6's MAR dated 10/01/23-10/31/23 indicated Quetiapine Fumarate 25mg 1 tablet by mouth at bedtime. Dx: dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Modification date: 08/04/23.<BR/>Record review of Resident #6's MAR dated 10/01/23-10/31/23 indicated Clonazepam 0.5 mg tablet 1 tablet by mouth 3 times per day. Dx: dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Start date: 08/08/23. <BR/>On 11/01/23 at 4:07 p.m., Resident #6's behavioral monitoring on the facility's EHR was assessed and no information was noted. On 11/02/23 at 3:04 p.m., the DON assessed Resident #6's behavioral monitoring on the facility's EHR and no information was noted. <BR/>During an interview on 11/02/23 at 2:06 p.m., LVN N said she had been working at the facility for 4 years. She said Dementia was not an appropriate diagnosis for Seroquel. She said the nurse who received the ordered, should have clarified with the ordering provider an appropriate diagnosis. She said Clonazepam was anti-anxiety medication and the diagnosis for use should not be dementia. She said the facility had behavior monitor on the computer system. She said behaviors and interventions should be charted every shift or when a prn medication was given. She said prn psychotropic medication should be ordered for only 14 days then reevaluate for use. She said the nurse who entered the prn order should make sure it was only for 14-day intervals. She said giving an inappropriate psychotropic medication could hurt a resident if not given for the right reason. She said before psychotropic prn medications were given, other things should have been tried. She said it was important not to over sedate the resident. <BR/>During an interview on 11/02/23 at 3:04 p.m. the DON said Dementia was not an approved diagnosis for Seroquel or Clonazepam. She said Lorazepam was an antianxiety medication and if it was ordered prn then it needed to be for 14 days. She said nursing staff should document behaviors at least every shift that correlated with the medication. She said nursing staff should document why a prn medication was given and if it was effective. She said the LVN should do review the diagnosis, make sure prn orders are 14 days, and chart behaviors prior to administering antipsychotic medications. She said she should be monitoring this process and antipsychotic medications were discussed during morning standard of care meetings. <BR/>Record review of a facility's Psychotropic Drugs-Use policy revised 07/27/20 indicated .assess the patient/resident for the use of .antipsychotics .only appropriate for the following acceptable diagnosis (es) .schizophrenia .Huntington's disease .Tourette's syndrome .non-pharmacological approaches must be attempted and documented instead of using psychotropic medications .careful evaluate of the resident's records should be reviewed for appropriate diagnosis for medication use .antianxiety .need supporting diagnosis and documentation .staff will complete and sign the monitoring/behavior form each shift .menu .EMR .Nurse .Monitoring .to identify and document number of episodes, interventions, and outcomes of targeted behaviors .documentation will include that staff ruled out .medical causes and unmet needs .residents do not receive PRN psychotropic medications unless necessary to treat a diagnosed specific condition which must be documented in the record .prn orders for psychotropic medications which are not antipsychotic medication are limited to 14 days .the attending physician/prescriber may extend the order .the medical record must contain a documented rationale and determined duration .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 12 residents reviewed for medications. (Resident #32)<BR/>The facility failed to ensure Resident #32's IV antibiotic (meropenem) was initiated per MD orders to begin on 06/07/2024. <BR/>These failures could cause prolonged illness and increased recovery time for residents.<BR/>Findings included:<BR/>Record review of an undated face sheet indicated Resident #32 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of PVD (peripheral vascular disease- poor circulation), sepsis (severe infection), and diabetes mellitus type II.<BR/>Record review of Resident #32's 5-day MDS 06/12/2024 assessment indicated she had a BIMS of 15 and required substantial to maximum assistance for toileting, transfer and hygiene. The MDS indicated Resident #32 received dialysis during her stay. No behaviors were noted on the MDS.<BR/>Record review of Resident #32's EHR revealed no care plans for IV antibiotics.<BR/>Record review of Resident #32's discharge orders from the acute hospital on [DATE] revealed the following discharge instructions:<BR/>Additional instructions- She will need to continue vancomycin and meropenem until 06/18/2024.<BR/>Record review of Resident #32's dialysis MAR dated 06/07/2024 indicated Vancomycin 750 mg IV once daily on Monday- Wednesday and Friday were administered every Monday, Wednesday and Friday from 06/07/2024 to 06/18/2024.<BR/>Record review of Resident #32's facility MAR dated June 2024 indicated meropenem 1 gram daily was not started until 06/10/2024. <BR/>During an interview on 08/14/2024 at 7:00 p.m., LVN N stated she was the nurse that admitted Resident #32 on 06/06/2024. LVN N stated she saw on the discharge order sheet that the resident was to continue her vancomycin that she was receiving at dialysis and meropenem until 06/18/2024. The meropenem had no dose or frequency so I put on the 24-hour report that clarification was needed on her [Resident #32's] antibiotic. She stated she was off the next couple of days and never thought about it after that.<BR/>During an interview on 08/15/2024 at 2:15 p.m., the DON stated Resident #32's meropenem was not started on 06/07/2024 because it was overlooked on the discharge orders, and it was not until a chart audit was done on 06/10/2024 that a clarification order was received that it was okay to start the meropenem 1 gram on 06/10/2024 and continue it for 14 days. The resident and her family were informed, as well as the wound care specialist that ordered the antibiotic. No increased white blood cells, no change in the wound drainage was noted. The DON stated Resident #32 was still getting the vancomycin with her dialysis treatment three times per week. She stated she assessed Resident #32, and no acute issues were found.<BR/>During an interview on 08/15/2024 at 2:30 p.m., NP O stated he was called and was informed the facility missed 3 doses of IV meropenem for Resident #32. NP O stated in his medical opinion that since the resident was receiving the other antibiotics, it was only 3 missed doses, and there were no physical signs of decline, and no harm was done to the resident by postponing the treatment. He stated if Resident #32 had developed a temperature or pain to the affected area he would have had cause for concern, but she had not so he just began the IV and continued it for the same duration originally ordered. He stated he gave a clarification order to start the meropenem when it was available from the pharmacy and continue it for the original 14 days ordered.<BR/>During an interview on 08/15/2024 at 3:20 p.m., the ADM stated she was made aware of the 3 missed doses of meropenem by the DON on 06/10/2024 when it was noticed and a staff in-service on clarification of medication orders was conducted. The ADM stated it was the DON's responsibility to check behind the nurses and make sure all medications were ordered per the discharge instructions. The mistake was noticed during that reconciliation. The ADM stated not receiving ordered antibiotics could lead to prolonged infections, recurrent infections, or sepsis.<BR/>Record review of policy dated April 2019 was documented Administering Medications, Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observations, interviews, and record review, the facility failed to ensure the menus met the nutritional needs of residents and were followed for 2 of 2 meals (the lunch meals on 12/2/24 and 12/3/24) reviewed for nutritional adequacy. <BR/>The facility did not serve the posted lunch menu of breadstick and iced cinnamon raisin bars on 12/02/24. <BR/>Cook Q did not follow the recipe for cheesy rice by using sliced cheese instead of shredded cheese per the recipe on 12/03/24. <BR/>The facility did not follow the soup recipe on 12/03/24 by serving canned mushroom soup instead of homemade soup. <BR/>The facility failed to use the appropriate size serving scooper for the pureed chicken, tomatoes and okra and potatoes and ground chicken for the lunch meal service on 12/03/24. <BR/>The facility failed to ensure [NAME] Q scooped full serving sizes during the lunch meal on 12/03/24.<BR/>These failures could affect all residents in the facility, who eat from the kitchen, by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. <BR/>Findings included:<BR/>Record review of a grievance filed by a family member of Resident #63, dated 10/23/24, indicated the menu was not being followed during mealtimes. <BR/>Record review of the Week at a Glance Current Menu provided on 12/02/24, indicated:<BR/>*Monday (12/02/24) Lunch: Spaghetti with Meat Sauce, Italian Tossed Salad, Iced Cinnamon Raisin Bars, Breadstick, Coffee or Tea, and Water.<BR/>*Tuesday (12/03/24) Lunch: Baked Chicken Thigh, Cheesy Rice, Okra and Tomatoes, Spiced Peaches, Dinner roll, Coffee or Tea, and Water. <BR/>Record review of the facility's Baked Chicken Thigh recipe provided on 12/03/24, indicated portion size 3oz.<BR/>Record review of the facility's Okra and Tomatoes recipe provided on 12/03/24, indicated portion size 4oz spoodle (a unique cross between a serving spoon and a ladle). <BR/>Record review of the facility's Cheesy Rice recipe provided on 12/03/24, indicated portion size #8 dip (4oz). The recipe indicated once rice is cooked, remove from heat, add shredded cheese and margarine. <BR/>Record review of the facility's Homemade Soup of the Day recipe provide on 12/03/24 indicated scratch, fresh vegetables. The recipe indicated any homemade soup of choice may be prepared. <BR/>During an interview on 12/02/24 at 9:35 a.m., Resident #52 said the portion sizes were small. She said sometimes they had enough for seconds and sometimes not. <BR/>During an observation on 12/02/24 at 12:00 p.m., a posted menu in the main lobby area indicated . Monday, December 2, 2024, Monday- Lunch, Spaghetti with Meat Sauce, Italian Tossed Salad, Iced Cinnamon Raisin Bars, Breadstick, Coffee or Tea, Water .<BR/>During an observation on 12/02/24 at 12:05 p.m., residents in the dining room were being served sliced white bread instead of breadsticks and chocolate chip cookies instead of iced cinnamon raisin bars. <BR/>During an observation and interview on 12/03/24 starting at 11:25 a.m., [NAME] Q had a pan of white rice on the stove. [NAME] Q added sliced yellow cheese to the white rice and stirred the mixture. The DM said the soup on the tray line was canned cream of mushroom soup. [NAME] Q placed a black handled ladle (4 oz) in the tomatoes and okra, a blue scooper (2 oz) in the pureed mashed potatoes, a green scooper (2.67 oz) in the pureed chicken, a blue scooper (2 oz) in the ground chicken, a gray ladle (4oz) then a gray scooper (4 oz) in the cheesy rice, and a green scooper (2.67 oz) in the pureed tomatoes and okra. Towards the end of the plating, [NAME] Q started scooping less than the amount of the serving size. At 12:32 p.m., there was no more cheesy rice, tomatoes and okra, or canned soup. Seven residents and the test tray received mashed potatoes instead of cheesy rice and tomatoes instead of tomatoes and okra. <BR/>During an interview on 12/05/24 at 1:26 p.m., CNA O said she received a lot of complaints from the residents about the menu not being followed, small portion sizes, and the kitchen running out of food. She said the residents got upset and sometimes asked for something else. <BR/>On 12/05/24 at 1:40 p.m., attempted phone interview with [NAME] Q. Unable to leave a message. <BR/>During an interview on 12/05/24 at 1:46 p.m., [NAME] P said the kitchen had a chart on the wall that showed the scoop and ladle sizes. She said the scoops and ladles themselves had the sizes on them. She said the recipes specified the portion size. She said it was important to follow the recipe instructions. She said not following the recipe instruction or portion size could cause weight loss. She said not following the recipe also had the potential to serve an unapproved ingredient a resident could be allergic to. She said if the recipe was followed correctly, you should not run out of food. She said she was the cook on 12/02/24. She said the residents did get served slices of white bread instead of breadsticks. She said she overlooked them in the freezer. She said the residents were served a different dessert because she did not have all the ingredients on hand to make the posted dessert. She said some items did not come on the delivery truck. She said only certain ingredients could be bought at the local grocery store. She said the kitchen notified the resident if they did not have something. She said the cooks were responsible for portion sizes, following the menu and recipes. <BR/>During an interview on 12/05/24 at 2:21 p.m., the Dietary Manager said cooks were responsible for portion sizes and following the menu and recipes. She said those things affected the resident weights, the consistency of the food and the caloric value of the food. She said the residents could experience weight loss. She said she was responsible for ensuring the cooks were serving the correct portion sizes and following the menu and recipes. She said substitution were allowed as long as it was documented. <BR/>During an interview on 12/05/24 at 2:42 p.m., the Director of Nursing said the cooks were responsible for serving the resident the correct portion sizes. She said the cooks should be following the recipes and the menus. She said the Dietary Manager should be overseeing the cooks to ensure it was happening. She said the resident had the potential to not get their nutritional needs met. She said the residents could experience weight loss or weight gain. <BR/>During an interview on 12/05/24 at 3:32 p.m., the Administrator said the cook and the Dietary Manager were responsible for portion control, following the menu and recipes. He said he expected the cook to serve the portion size on the recipe. He said he expected the cook to use the right scoops to serve the residents food. He said he expected the cook and Dietary Manager to ensure supplies were available for meals. He said all those things were important for the resident's caloric needs. <BR/>Record review of a facility's Portion Control policy revised 02/06/24, indicated .portion control will be maintained to ensure adequate nutritional value for all foods offered and to maintain inventory control .serving sizes and yield are listed on standardized recipes .spreadsheets indicating portion sizes per diet are posted at tray line and used to guide the serving at each meal .<BR/>Record review of a facility's Use of Recipes policy revise 02/06/24, indicated .recipes will be used when preparing menu items .recipes (in appropriate portion sizes) for each menu cycle are available .Nutrition Service employees are expected to use and follow the recipes provided .<BR/>Record review of a facility's Menus policy revised 02/06/24, indicated .nutrition service will provide a nourishing, palatable, well-balanced meal that observes the nutritional requirements .of each resident .<BR/>Record review of a facility's Tray Line policy revised 02/06/24, indicated .tray line positions and set up procedures should promote an efficient and accurate meal service .spreadsheets, indicating portion sizes per diet, are posted at the tray line and used to guide the serving at each meal .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to accommodate residents' food preferences for 4 of 21 residents (Resident #8, Resident #19, Resident #67, and Resident #70) reviewed for preference.<BR/>The facility failed to ensure Resident #8 received milk with all meals.<BR/>The facility failed to obtain and honor Resident #19, Resident #67's and Resident #70's meal preference.<BR/>These failures could result in a decrease in resident choices, diminished interest in meals, and weight loss. <BR/>Findings included:<BR/>1. Record review of the face sheet dated 09/14/22 revealed Resident # 8 was [AGE] years old, female and admitted on [DATE] with diagnosis including cerebral ischemia (acute brain injury that results from impaired blood flow to the brain), abnormal weight loss, and vitamin deficiency.<BR/>Record review of the consolidated physician orders dated 09/14/22 revealed Resident #8 had liquid consistency nectar/mildly thick diet ordered on 09/05/22. The consolidated physician ordered dated 09/05/22 revealed wavier against medical advice signed by resident/family to receive milk with every meal. <BR/>Record review of the MDS dated [DATE] revealed Resident #8 was understood and usually understood others. The MDS revealed Resident #8 had clear speech and highly impaired vision with corrective lenses. The MDS revealed Resident #8 had a BIMS score of 12 which indicated mild cognitive impairment and required limited assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. And was independent with eating. <BR/>Record review of the care plan dated 07/12/22 revealed Resident #8 had altered nutritional status related to need for assistance/cueing with meals, dysphagia/swallowing difficulty and thickened liquids as evidence by decrease appetite, mechanically altered diet, palliative care form signed, and waiver for AMA signed. Interventions included provide favorite foods and beverages and necessary assistance with food and fluids. <BR/>During an interview on 09/12/22 at 10:27 a.m., Resident #8 said she asked for milk with her meals and seldom got it. She said dietary had come by to find out what she liked to help with her appetite. She said she really liked the milkshakes they brought her, but they did not have it today. <BR/>During an observation on 09/12/22 at 12:17 p.m., Resident #8 had a pureed diet with no milk on her tray.<BR/>During an observation on 09/13/22 at 8:54 a.m., Resident #8 ate a good portion of her meal, but milk was not observed on the tray. <BR/>2. Record review of Resident #19's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), glaucoma (a group of eye conditions that damage the optic nerve, the health of which is vital for good vision), and hypertension (blood pressure that is higher than normal).<BR/>Record review of Resident #19's September 2022 physician orders revealed an order dated 07/22/2022 for a regular diet with thin liquids. An order dated 08/01/2022 indicated Resident #19 was to receive 2.0 Calorie Med Pass supplement 120 ml three times daily.<BR/>Record review of Resident #19's quarterly MDS, dated [DATE], reflected she had a BIMS score of 11, which indicated a minimal impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. <BR/>Record review of Resident #19's EHR reflected the following care plan interventions for nutrition on 07/12/2022: <BR/>- <BR/>Resident #19 would be provided favorite foods and beverages.<BR/>- <BR/>Resident #19's food preferences would be updated<BR/>During an interview on 09/12/2022 at 9:55 am, Resident #19 stated the food was disgusting and unappetizing. She stated she was supposed to get a choice for lunch and dinner and the CNA's were supposed to come around and circle the resident's choice on the menu. Resident #19 stated she could not remember the last time the CNA's came around and asked the residents what they wanted for each meal. Resident #19 stated, we are just served whatever the kitchen feels like putting on a plate. Resident #19 stated most of the time it is combinations of food that do not go together at all and turns my stomach. Resident #19 stated we have all reported this to the Nurses, Director, and Administrator until we are blue in the face.<BR/>During an observation on 09/12/2022 at 12:38pm, Resident #19 was not eating the lunch meal served by the facility. Resident #19 stated she was not eating fish with refried beans. The plate had a square breaded fish patty and a scoop of refried beans on it. The tray card had choices of fish or quesadilla, rice or refried bean, salad, and dessert. There were no choices circled on the tray card.<BR/>During an interview on 09/12/2022 at 1:15pm, CNA J stated it was the responsibility of the CNA's to ask the residents that could answer what choices they would like to make for lunch and supper. CNA J stated the kitchen gave the CNA's the tray cards either the day before or that morning and wanted them filled out and turned back in right after breakfast. CNA J stated they work short a lot of the time and do not have chance to get them done every day, but they try to do it when they can. CNA J stated her priority when she comes to work each day was to keep her residents clean and dry the best she can. CNA J stated she would like to be able to do it all, but it is not always possible.<BR/>3. Record review of the face sheet dated 09/15/22 revealed Resident #67 was [AGE] years old male and admitted on [DATE] with diagnoses including cerebral infarction (stroke), vitamin deficiency, and type 2 diabetes. <BR/>Record review of the consolidated physician orders dated 09/15/22 revealed on 02/10/22 Resident #67 had a reduced concentrated sweets diet.<BR/>Record review of the MDS dated [DATE] revealed Resident #67 was understood and usually understood others. The MDS revealed Resident #67 had a BIMS score of 09 which indicated mild cognitive impairment. The MDS revealed Resident #67 required limited assistance for transfers and dressing, extensive for toilet use, personal hygiene, and bathing. And independent for eating.<BR/>Record review of the care plan dated 03/30/22 revealed Resident #67 had altered nutritional status as evidence by diet, med pass supplement, increased nutrient needs, and medical diagnosis. Intervention included implement med pass, monitor oral intake of food and fluid, and provide prescribed diet. The care plan dated 03/30/22 revealed Resident preference with a goal of person-centered care plan developed and implemented to meet goals and address the resident's medical, physical, mental and psychosocial needs. <BR/>Record review of a blank meal ticket and note dated 08/30/22 revealed a written note by Resident #67 given to the dietary manager. The note stated, .did not order anything on list ur trying to force me to eat stuff I did not order. Stop it! I resent it! I did not order anything on plate .let me order and I'll eat but I ain't eating what other people order .this suck forcing other people's food on others .did not get any [NAME] .<BR/>During an interview on 09/12/22 at 11:38 a.m., Resident #67 was asleep with his breakfast tray on the bedside table. After interviewing Resident #54, his roommate, Resident #67 woke up and said he did not want his breakfast because it was probably not what he ordered and went back to sleep. <BR/>4. Record review of the face sheet dated 09/14/22 revealed Resident #70 was [AGE] years old female and admitted on [DATE] with diagnoses including acquired absence of right leg above the knee, cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and vitamin deficiency. <BR/>Record review of the consolidated physician orders dated 09/14/22 revealed Resident #70 had regular; no added salt diet ordered on 08/05/22.<BR/>Record review of the MDS dated [DATE] revealed Resident #70 was understood and understood others. The MDS revealed Resident #70 had a BIMS of 14 which indicated intact cognition and required extensive assistance for toilet use and total dependence for transfers, dressing, personal hygiene, and bathing. And independent for eating.<BR/>Record review of the care plan dated 08/05/22 revealed Resident #70 had altered nutritional status related to increased needs for wound care and missing teeth as evidence by regular, NAS diet. Interventions included provide diet as prescribed and provide snacks. The care plan dated 08/04/22 revealed Resident preference related to resident wants to be involved in care decisions. Goal of resident's wishes be respected, and autonomy will be maintained.<BR/>During an interview on 09/12/22 at 3:27 p.m., Resident #70 said she orders fried eggs for breakfast and gets them sometimes. She said she orders cranberry juice and gets apple juice instead which she hates. <BR/>During an interview on 09/14/22 at 9:15 a.m., the Dietary Manager said there was 103 residents so she could not make rounds and speak to all about their concerns. She said she learned about food complaints while visiting resident and received Resident #67 note. She said the biggest problem is the meal tickets are not being filled out with the resident's choices. <BR/>During an interview on 09/14/22 at 1:27 p.m., CNA V said most of the time she was able to do fill out meal tickets. She said she heard residents complain about not getting want they wanted. She said the residents get upset and asked for an alternative meal. She said this probably made the resident's feel frustrated not getting what they wanted.<BR/>During an interview on 09/14/22 at 2:52 p.m., LVN W said she had previously worked at the facility 5 years ago and returned last week. LVN W said certain residents did complain about not getting what they ordered. She said it probably made them upset because they do not have a lot of things in their control. <BR/>During an interview on 09/14/22 at 3:25 p.m., CNA X said she was the CNA coordinator but had been working the floor. CNA X said the dietary manager put the meal tickets at the nursing station and the aide for each hall was responsible for picking them up. She said they must be turned in by a certain time and placed in the box by the kitchen. She said she did not know if all the CNAs knew it was their responsibility or if they completed the tickets. She said she had heard residents complain about not getting want they wanted. She said it was important get their meal preference because they live here, and it probably made them frustrated.<BR/>During an interview on 09/14/2022 at 4:15pm the DON stated it was the responsibility of the CNAs to go to each resident that was able to communicate the types of food they wanted for each meal and collect that information for the kitchen. The tray cards were given to the CNA's the day prior to the meal and were to be returned to the kitchen by 10 am the morning of the meals. The DON stated she was aware this was not always done because staffing had been an issue and the facility was trying to keep the residents taken care of and things like meal tickets have been put on the back burner. The DON said not getting the desired food choices could lead to residents not eating and weight loss.<BR/>During an interview on 09/14/22 at 4:24 p.m., Resident #70 said she got upset when she did not get what she ordered. She said about 4 times a week she received what she ordered on her meal ticket. She said the dietary manager had not come to ask her about food preference nor did the facility ask during her admission.<BR/>During an interview on 09/15/2022 at 3:30 PM the Administrator stated that it was the duty of the CNA to give each resident their tray ticket and assist and allow them to choose their meals each day. The Administrator stated about 20% of the resident independently filled out the meal ticket. The Administrator stated the facility offered the main menu with 2 options, alternative choices, or write down food items. The Administrator stated the process did not always happen but if the resident did not like the meal served the facility would happily make them what they wanted to eat. The facility had an always available menu for the residents to choose from if they did not like any of the chooses for a particular meal. The Administrator stated for physician order food items should be listed on the dietary card. She stated Resident #8 not receiving her milk at every meal was a dietary and aide issue. The Administrator stated all staff should make sure what is list on dietary card, the residents received. The Administrator said she did not know about Resident #67's note to dietary and the dietary manager should had brought it to her to file a grievance. The Administrator stated she expected the staff to allow the residents to choose their meals because resident preferences and choices were important to the resident's autonomy. The Administrator stated giving the resident what they ordered was important but more importantly encouraged consumption of meals and adequate nutrition. <BR/>Record review of the Resident Council Minutes dated 3/28/22 revealed .old business .meal tickets are ongoing concern . <BR/>Record review of the Resident Council Minutes dated 6/27/22 revealed .some residents voiced concern of their meal tickets not being filled out by CNAs .<BR/>Record review of the Resident Council Minutes dated 7/25/22 revealed .old business .ongoing concern related to meal ticket are not always filled out prior to meal service . <BR/>Record review of the Resident Council Minutes dated 8/29/22 revealed .old business .filling out meal menu continue to be a concern . <BR/>Record review of the grievance book from 01/2022-09/2022 did not reveal any complaints related meal tickets.<BR/>Record review of a undated facility food likes and dislikes policy revealed .the dietary manager will interview the resident to determine the resident's food likes and dislikes .a written record shall be maintained .resident shall be visited periodically to determine if any changes .the dietary manage shall investigate complaints to determine if substitutions can be made .

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety.<BR/>The facility failed to ensure that all staff members wore hairnets appropriately.<BR/>The facility failed to ensure that all kitchen staff members wore N95 mask appropriately while on outbreak status. <BR/>These failures could place residents at risk of foodborne illness and food contamination.<BR/>Findings include: <BR/>During an observation on 9/12/2022 at 9:00 a.m., the Dietary Manager was in the kitchen. Her hair net did not cover all of her hair. There was exposed hair across her forehead and unrestrained hair all of the way around the hairnet. <BR/>During an observation on 9/12/2022 at 9:03 a.m., the plastic container for the sugar was open to air. <BR/>During an observation on 9/12/2022 at 9:10 a.m., Dietary Aide F was in the kitchen with a baseball cap on her head. She did not have on a hair net. She had unrestrained hair from around the baseball cap and had hair sticking out of the back of the cap in knotted up ponytail. There were loose hairs touching her shoulders and her back. <BR/>During an observation and interview on 9/12/2022 at 9:12 a.m., there were 3 tubes of expired dishwasher testing strips hanging on the wall opposite of the dishwasher. The tubes had expirations dates of 2-2021, 3-2022, and 8-2022. The Dietary Manager said she did not know the testing strips were expired and the company had just brought her some new ones. <BR/>During an observation on 9/13/22 at 7:56 a.m., Dietary Aide G was preparing breakfast trays with the N95 mask under his chin. His nose and mouth were exposed. <BR/>During an observation on 9/13/22 at 10:01 a.m., Dietary Aide G was at the dishwasher on the clean side (on the side of the dishwasher where the clean dishes are processed and put away) with his N95 mask below his chin and his nose and mouth exposed. Dietary Aide F was standing at the counter while food was being prepared. She had on a baseball cap and no hairnet. There was a ponytail out of the back and loose hairs were touching her back. There were unrestrained hairs sticking out around the baseball cap. <BR/>During an observation on 9/13/2022 at 10:33 a.m., [NAME] H began pureeing foods. At times her mask was down below her nose . <BR/>During an observation on 9/13/2022 at 10:34 a.m., the Dietary Manager was in the kitchen with her hair net only covering the top of her hair. There was exposed loose hair across her forehead and loose hairs all the way around the hairnet. <BR/>During an observation on 9/13/2022 at 10:51 a.m., Dietary Aide F was sweeping the kitchen during lunch preparation. She did not have on a hairnet. She had on a baseball cap with hair sticking out of the back and hair sticking out from under cap. There were 3 pieces of long hair, unattached from her head, stuck to the back of her shirt. <BR/>During an observation on 9/13/2022 at 11:29 a.m., [NAME] H was taking the temperature of the foods on the steam table. Her mask slid down under her nose on multiple occasions. <BR/>During an observation on 9/13/2022 at 11:30 a.m., the Dietary Manager and Dietary Aide F were wrapping silver ware in napkins. Dietary Aide F had on a baseball cap with unrestrained hair sticking out of the baseball cap. The Dietary Manager's hair was not completely covered with her hairnet. She had loose hair touching her shoulder and unrestrained hair across her forehead. <BR/>During an observation on 9/13/2022 at 11:41 a.m., Dietary Aide F was covering prepared plates and placing trays on cart with no hairnet. At times she would lean across incomplete trays during tray preparation. <BR/>During an observation on 9/13/2022 at 11:43 a.m., CNA A was standing in the kitchen sorting dietary tickets with no hairnet on while trays were being prepared. She was standing at a counter next to pre-prepared drinks for the residents. <BR/>During an interview on 9/14/2022 at 9:03 a.m., Dietary Aide F said she had been in-serviced on wearing hair nets in the kitchen. She said she did not wear a hair net because she wore a baseball cap and she thought all of her hair was tucked into her baseball cap. She said no one in the kitchen had told her the hair was not contained under the baseball cap and to wear a hairnet. <BR/>During an interview on 9/14/2022 at 9:05 a.m., Dietary Aide G said he had worked at the facility for a month. He said he had been oriented on COVID-19 and the importance of wearing a mask. He said it gets hot in the kitchen and he pulls his mask down .<BR/>During an interview on 9/14/2022 at 9:13 a.m., [NAME] H said she tried to keep her mask pulled up. She said her mask slid down her face when she was talking. She said she did know about COVID-19 and that she was supposed to be wearing her mask over her nose.<BR/>During an interview on 9/14/2022 at 9:15 a.m., the Dietary Manager said she thought wearing a baseball cap was ok. She said she thought all of her hair was contained in her hairnet. She said she in-services her staff monthly. She said residents could be negatively affected by hair contaminating food and the residents might not want to eat the food. She said due to Covid-19 all staff were supposed to be wearing masks that covered their nose and mouth. <BR/>During an interview on 9/14/2022 01:40 p.m., CNA A said she was unaware she was supposed to wear a hair net in the area she was in inside the kitchen. She said she thought it was only if you went past the preparation table. She said it made sense though since there were prepared drinks on the counter where she was standing.<BR/>During an interview on 9/15/2022 at 1:40 p.m., the DON said the facility had been on outbreak status, but she was not sure the exact date the outbreak started. She said all staff should have been wearing N95 mask appropriately. She said the Administrator wanted all staff to wear N95 mask and staff could not even wear a K-N95. <BR/>During an interview on 9/15/2022 at 2:16 p.m., the Administrator said anyone in the kitchen should be wearing a hair net and the hair net should be covering all their hair. She said wearing a hair net inappropriately could cause hair to get into the food and cause contamination of the food item. She said if there were undated and unlabeled food, then staff would not be aware the food might be out of date. She said all employees should be wearing a N95 mask. She said even in the kitchen staff should be wearing a mask and it should be covering their face. She said staff not wearing a mask appropriately around other staff or residents could lead to continued outbreak of Covid-19. <BR/>Review of a facility Employee Infection Control, Nutrition Services dated May 28, 2020 indicated, .anyone who enters the kitchen will have all hair restrained using bouffant caps, mesh or net, beard guard and clothing which covers body hair .<BR/>Review of a facility Competencies for Nutrition Services Employees checklist dated 7/2020 indicated, .Consistently uses hair restraints (and beard guards) properly .when indicated in the event of a respiratory or viral outbreak, wears a mask and other PPE as directed. SEE DIAGRAM pg. 6 .How to Wear a Medical Mask Safely .Do's .cover your mouth, nose, and chin .Don'ts .Do not wear mask only over mouth or nose .do not remove the mask to talk to someone .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Residents #1) reviewed for resident rights.<BR/>CNA E did not sit as she assisted Resident #1 with dining. <BR/>CNA E did not refrain from talking on her cell phone while she assisted Resident #1 with dining. <BR/>The facility did not ensure Resident #1 was clothed in his personal clothing. <BR/>These failures could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth.<BR/>Findings included:<BR/>Record review of Resident #1's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including Hemiplegia or hemiparesis (hemiplegia refers to a severe or complete loss of strength, whereas hemiparesis refers to a relatively mild loss of strength) following cerebral infarction (stroke) affecting the left non-dominant side, type II diabetes, shortness of breath, nausea/ vomiting, and depression. <BR/>Record review of Resident #1's MDS dated [DATE] indicated Resident #1 was usually understood and usually understood others. The MDS indicated Resident #1 had severe cognitive impairment (BIMS of 5). The MDS indicated he had no behavior of rejecting care during the 7 days look back period. The MDS indicated he required extensive assistance with bed mobility, transfers, locomotion in his wheelchair, dressings, eating, toilet use, and personal hygiene. The MDS indicated Resident #1 was completely dependent on staff for bathing. The MDS indicated Resident #1 was always incontinent of bowel and bladder. <BR/>Record review of Resident #1's care plan revised on 11/15/22 indicated Resident #1 had a self-care deficit. The care plan interventions included to give the resident as many choices as possible about care and provide assistance with self-care as needed. <BR/>During an observation on 2/8/23 at 11:10 a.m. revealed Resident #1 laid in his bed wearing a hospital gown. <BR/>During an observation on 2/8/23 at 12:45 p.m. revealed the door to Resident # 1's door was open. CNA E stood at Resident #1's bedside. CNA E said loudly Well what are you going to then?. A few moments later CNA E again said, Well what are you going to then? and then said I gotta go. The surveyor entered the room. CNA E continued to stand at Resident #1's bedside and fed him several bites from his food tray. <BR/>During an observation and interview on 2/8/23 at 2:50 p.m. revealed Resident #1 laid in his bed wearing a hospital gown. Resident #1 said he did not want to wear a hospital gown. Resident #1 said his family member had brought him some clothes and pointed at the armoire. There were multiple personal clothing items hanging in the armoire. Resident #1 said he guessed he had to wear the gown because that was what they (facility staff) put on him. Resident #1 could not say how long he had been wearing the hospital gown or who had placed the hospital gown on him. Resident #1 said CNA E talked on the phone while she fed him today (2/8/23) and felt it was rude. <BR/>During an interview on 2/10/23 at 10:28 a.m., CNA G said there was no reason for a resident to have been in a hospital gown. CNA G said the facility had clothes that were donated for resident use if a resident did not have any personal clothes available. CNA G said if a resident did not want to wear a hospital gown and was placed in hospital gown, it could take away the resident's dignity. CNA G said CNAs should not stand while feeding a resident because it could cause the resident to feel intimidated. CNA G said another reason CNAs should not stand while feeding a resident was to ensure the resident did not have any signs of aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). CNA G said under no circumstance should a CNA take a personal phone call while he/she administered resident care. CNA G said to take a personal call during the administration of patient care was not only disrespectful but would also divert attention away from the resident. <BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she should not have stood while feeding Resident #1. CNA E said she should have sat at Resident #1's bedside while she assisted him with eating because it was more respectful than standing. CNA E said she stood while she fed Resident #1 because she was in a hurry. CNA E said she did not notice Resident #1 was wearing a hospital gown and indicated he should have been wearing his personal clothes. CNA E said she should not have taken the personal call while she assisted Resident #1 but did so because she had a family situation. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected staff to sit while they assisted residents with eating in order to promote respect and safety. The DON said it was not acceptable for a resident to be in a hospital gown and to do so (place a resident in a hospital gown) could affect the resident's dignity. The DON said it was not acceptable for staff to have taken a phone call while assisting a resident. The DON said she expected staff to go to the break room or their car if they had to take a phone call. The DON said a staff member taking a phone call in front of a resident was a dignity issue and could also confuse the resident. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected staff to ensure residents were clothed in their personal clothing if it was the resident's preference. The Administrator said she expected staff to ensure respect and dignity were provided to residents. The Administrator indicated taking personal phone calls during resident care activities and standing while feeding a resident did not promote respect and dignity.<BR/>Record review of the undated facility policy and procedure titled, Exercise of Rights reflected, Policy Statement- Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to our facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #14) of 6 residents reviewed for quality of care. <BR/>The facility failed to ensure Resident #14 had supervision that prevented him from going outside and falling causing a hematoma and abrasion to his head.<BR/>This failure could result in residents experiencing accident, injuries, and diminished quality of life. <BR/>Findings included:<BR/>1. Record review of an undated face sheet reflected Resident #14 was a [AGE] year-old male that admitted to the facility on [DATE] with the diagnosis of dementia, atrial fibrillation (irregular heartbeat), and diabetes mellitus type II and discharged [DATE].<BR/>Record review of Resident #14's admission MDS dated [DATE] reflected he had a BIMS of 01 which indicated severe cognitive impairment. The MDS also indicated Resident #14 had some physically aggressive behavior and he required partial to moderate assistance with ADLs.<BR/>Record review of Resident #14's care plan dated 05/07/2024 reflected a care plan titled Behavioral Changes with the problem of high elopement risk. The goal was to keep the resident safe within the facility. <BR/>Record review of admission assessment dated [DATE] indicated Resident #14 was a high elopement risk scoring a 22 out of 25 points scored for elopement.<BR/>Record review of an incident report dated 06/22/2024 revealed Resident #14 exited the front of the building and fell from his wheelchair onto the ground outside the front entrance of the building. Resident #14 sustained an abrasion to his forehead and a hematoma.<BR/>During an interview on 08/14/2024 at 10:02 a.m., RN P stated Resident #14 attempted to find an exit all day every day since the day he was admitted . She stated he was hard to redirect about 50% of the time. She stated she learned to redirect him with food and sitting in the dining room and that worked most of the time. She stated he would push right past you if you were standing in the way of him and where he was attempting to go. She stated she had not felt he was being mean, she stated he just had not registered that someone was in front of him.<BR/>During an interview on 08/14/2024 at 2:20 p.m., LVN Q stated on 06/22/2024 at lunch time Resident #14 went outside the front door of the facility and fell from his wheelchair onto his right side striking his head on the ground causing a hematoma and abrasion to his right forehead. She stated she was alerted by a family member of his presence outside because the staff was busy serving lunch, and no one saw him go outside. She stated she was aware he was an elopement risk, and they were doing frequent checks on him every 15-20 minutes and keeping him in eyesight if he were out of this room. LVN Q stated all the staff pitched in and tried to keep an eye on Resident #14, but it was not always possible to watch him. She stated he just slipped out because all hands are on deck when it was meal service time. She stated he was exit seeking every day because of his dementia. She stated he had gotten outside once before but the staff saw him before the door even closed behind him and redirected him back into the facility. LVN Q stated she had not believed he would have fallen that time if he had not been outside because it appeared to her the wheel on his wheelchair went off the sidewalk and dumped him out onto the ground. She stated the next day he discharged to a secured unit on 06/23/2024.<BR/>During an interview on 08/15/2024 at 2:00 p.m., the DON stated she was aware Resident #14 was an elopement risk and she understood there were other facilities that could take better care of his needs, but his family insisted he stay at the facility. She stated the family was devastated when we informed them that he could no longer stay at our facility, and we needed to find him a safe place to live immediately. The DON stated Resident #14 had 4-5 falls while he was here from the wandering up and down the hall all day and night. She stated the fall he had on 06/22/2024 could have been prevented had Resident #14 not been exit seeking and found his way outside, where the sidewalk caused him to be dumped from his wheelchair.<BR/>During an interview on 08/15/2024 at 3:15 p.m., the ADM stated she was aware Resident #14 was an elopement risk and the facility was trying different things to see if an adjustment period might calm that behavior down. She stated unfortunately it was not a successful match for him to remain in the facility because all the resident's must be safe that stay at the facility.<BR/>Review of facility's fall prevention policy titled Fall Evaluation and Prevention, dated revised August 2020, reflected The facility will evaluate residents for their fall risk and develop interventions for prevention . Upon Admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 7 residents reviewed for pharmacy services. (Resident #1)<BR/>The facility failed administer all scheduled medications to Resident #1. <BR/>This failure could place residents at risk for inaccurate drug administration and side effects from missed doses of medication. <BR/>Findings included:<BR/>Record review of a face sheet dated 10/03/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), muscle spasms, and recurrent depressive disorders. <BR/>Record review of physician's orders dated 10/04/23 indicated an order for Amlodipine (blood pressure medication) 5 milligram tablet, 1 tablet 1 time per day with a start date on 06/27/21. There was an order for Claritin (medication for allergy symptoms) 10 milligram tablet, 1 tablet 1 time per day with a start date of 05/08/23. There was an order Clonidine HCL (blood pressure medication) 0.1 milligram tablet, 1 time per day with a start date of 06/27/21. There was an order for Citalopram (used for depression) 10 milligram tablet, 1 time per day with a start date of 06/27/21. There was an order for Colace (stool softener) 100 milligram tablet 2 times per day with a start date of 11/01/22. There was an order for Cyclobenzaprine (treats pain and muscle stiffness) 5 milligram tablet every 8 hours with a start date of 11/01/22. There was an order for a multi vitamin, 1 tablet 1 time per day with a start date of 11/01/22. There was an order for Esomeprazole Magnesium (used to treat stomach and esophagus problems such as acid reflex, ulcer) 20 milligram, delayed release, 1 time per day with a start date of 06/27/21. There was an order for Fluticasone Propionate 50 micrograms/actuation nasal spray, 1 spray nasally 2 times per day with a start date of 05/08/23. There was an order for Levetiracetam (used to treat seizures) 100 milligrams/milliliters oral solution, 10 milliliters 2 times per day with a start date of 06/27/21. There was an order for Robitussin Cough-Chest Congestion DM 5 milligram/50 milligrams/5 milliliters every 6 hours with a start date of 11/01/22. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #1 was rarely to never understood. The MDS indicated a BIMS was not conducted due to Resident #1 being rarely to never understood. The MDS indicated Resident #1 received an antidepressant. The MDS indicated Resident #1 had an active diagnosis of hypertension (high blood pressure), a seizure disorder or epilepsy, and depression. <BR/>Record review of a care plan last revised on 05/31/23 indicated Resident #1 was prescribed an anti-convulsant - Levetiracetam (used to treat seizures) 100 milligrams/milliliters oral solution, 10 milliliters 2 times per day. There was an intervention to administer the medication as ordered. The care plan indicated the resident was prescribed an anti-depressant, Citalopram (used for depression) 10 milligram tablet, 1 time per day. There was an intervention to administer the medication as ordered. The care plan indicated the resident was prescribed anti-hypertensive medications, Amlodipine (blood pressure medication) 5 milligram tablet, 1 tablet 1 time per day and Clonidine HCL (blood pressure medication) 0.1 milligram tablet, 1 time per day. There was an intervention to administer the medications as ordered. <BR/>Record review of an eMAR (electronic medication administration record) dated 07/01/23 - 07/31/23 indicated on 07/04/23, Amlodipine and Clonidine were not administered as ordered. On 07/05/23, Amlodipine, Citalopram, Claritin, Clonidine, Colace, Cyclobenzaprine, a multi-vitamin, Esomeprazole Magnesium, Fluticasone Propionate, Levetiracetam, and Robitussin Cough-Chest were not administered as ordered. On 07/08/23, 07/10/23, 07/13/23, 07/14/23, 07/18/23, 07/19/23, 07/20/23, 07/23/23, 07/24/23, 07/25/23 Resident #1 did not receive Amlodipine and Clonidine as ordered. On 07/28/23, Resident #1 did not receive Amlodipine and Clonidine as order. The eMAR indicated on 07/29/23, Resident #1 did not receive Clonidine, Colace, Robitussin Cough-Chest Congestion and Levetiracetam were not administered as ordered. <BR/>Record review of an eMAR dated 09/01/23 - 09/30/23 indicated on 9/10/23, Resident #1 did not receive Citalopram as ordered. The eMAR indicated on 09/18/23 and 09/26/23, Resident #1 did not receive Amlodipine and Clonidine as ordered. <BR/>Record Review of Nurse's notes dated 07/01/23 - 09/30/2023 indicated on 07/28/23 a nurse's note read, Medication was administered outside of scheduled parameters, provider informed that resident medication was delayed . The note was signed by the DON. There were no further notes concerning delayed medication or medications that were not administered. <BR/>During an interview on 10/3/23 at 4:20 p.m., a family member of Resident #1 said on 07/28/23 Resident #1 did not receive his medication as prescribed.<BR/>During an interview on 10/03/23 at 5:05 p.m., a family member said Resident #1 had not always received his scheduled medications. The family member said they had found medications at the bedside. <BR/>During an interview on 10/04/23 at 2:48 p.m., the DON said she did not know why Residents #1's medications were not given on time on 7/28/2023. She said she did not know what happened. She said for some reason the medications were delayed and the nurse practitioner was notified.<BR/>During an interview on 10/5/2023 at 9:32 a.m., LVN D said document did indicate Resident #1 did miss several medications in July and September. She said if they were held for any reason there should be a nurse's note. She said the blood pressure medications may have been held due the resident's blood pressure or heart rate. She said, if it's not documented it's not done.<BR/>During an interview on 10/5/23 at 10:33 a.m., the DON said according to the documentation for July and September it did appear Resident #1 did not receive all of his medications. She said that the blood pressure medicines were probably held because his vital signs. She said she would have expected if the medicine was being held because of the vital signs, this should be documented. She said residents' not receiving their medications could cause them to have high or low blood pressure.<BR/>During an interview on 10/05/23 at 11:50 a.m., the Administrator said she would expect Resident #1 to get his scheduled medications as ordered. She said any negative outcome would depend on the medication such affecting blood pressure.<BR/>Review of a Medications - Guidelines on Clinical Practice policy dated January 12, 2020 indicated, .Staff will provide medications in accordance with standard practice guidelines .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 7 of 22 residents reviewed for palatable food. (Residents #313, Resident #101, Resident #312, Resident #91, Resident #19, Resident #38 and Resident #44)<BR/>The facility failed to provide palatable food served at an appetizing temperature or taste to Residents #313, Resident #101, Resident #312, Resident #91, Resident #19, Resident #38 and Resident #44 who complained the food was served cold and did not taste good. <BR/>This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. <BR/>Findings included:<BR/>1. Record review of the face sheet dated 9/15/22 revealed Resident #313 was a [AGE] year old, male, and admitted on [DATE] with diagnoses including acute kidney injury (abrupt deterioration in kidney function), acute posthemorrhagic anemia (quickly losing a large volume of circulating red blood cells that carry oxygen), acute cystitis with hematuria (sudden inflammation of the urinary bladder also known as a urinary tract infection, with blood in the urine), diabetes (disease of too much sugar in the blood), congestive heart failure (the heart does not pump blood as well as it should), depression (mood disorder that causes persistent feelings of sadness and loss of interest), and COPD (chronic obstructive pulmonary disease- constriction of the airways and difficulty breathing). <BR/>Record review of the admission MDS dated [DATE] revealed Resident #313 had a BIMS of 6, which indicated he was severely cognitively impaired. He required supervision and set up for eating. He required one to two- person limited to extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, toilet use, bathing, and personal hygiene. <BR/>Record review of the Resident #313s order summary report dated 9/15/22 revealed an order for a regular reduced concentrated sweets diet.<BR/>During an interview on 9/12/22 at 11:14 AM, Resident #313 revealed the food had no seasoning and he did not like it. <BR/>2. Record review of the face sheet dated 9/15/22 revealed Resident #101 was a [AGE] year-old, female, and admitted on [DATE] with diagnoses including left femur (upper leg) fracture, urinary tract infection, diabetes (disease of too much sugar in the blood), and history of falls.<BR/>Record review of the admission MDS dated [DATE] revealed Resident #101 had a BIMS of 13, which indicated she was cognitively intact. She required set up only for eating. <BR/>Record review of the Resident #101s order summary report dated 9/15/22 revealed an order for a regular reduced concentrated sweets diet.<BR/>During an interview on 9/15/22 at 10:18 AM, Resident #101 revealed the food was terrible and had only one good meal since she was admitted to the facility. She said the chicken was tough and dry, meals had no flavor, and her eggs were always cold. She said her family had to bring her food to the facility. <BR/>3. Record review of the face sheet dated 9/15/22 revealed Resident #312 was a [AGE] year-old, female, and admitted on [DATE] with diagnoses including back pain with recent back surgery, high blood pressure, and heart disease.<BR/>Record review of the admission MDS dated [DATE] revealed Resident #312's MDS had not been completed.<BR/>Record review of the baseline care plan dated 9/15/22 revealed Resident #312 was on a regular diet (non-restrictive diet).<BR/>Record review of the Resident #312's order summary report dated 9/15/22 revealed an order for a regular diet.<BR/>During an interview on 9/15/22 at 10:08 AM, Resident #312 revealed the food was cold, had no flavor, and did not taste good. She said she often could not tell what the food was. Resident #312 appeared to be cognitively intact. <BR/>4. Record review of the face sheet dated 9/15/22 revealed Resident #91 was a [AGE] year-old, female, and admitted on [DATE] with diagnoses including right femur (upper leg) fracture, ESRD (end stage renal (kidney) disease), diabetes (disease of too much sugar in the blood), and osteoarthritis (when flexible tissue at the ends of bones wears down).<BR/>Record review of the admission MDS dated [DATE] revealed Resident #91 had a BIMS of 13, which indicated she was cognitively intact. She required set up only for eating. <BR/>Record review of the Resident #91s order summary report dated 9/15/22 revealed an order for a regular renal diet (a diet low in sodium, phosphorous, and protein) <BR/>During an interview on 9/15/22 at 10:33 AM, Resident #91 revealed the food was cold, especially the eggs, most of the meat was so tough she could not chew it, and the food had no seasonings/flavor .<BR/>During an interview on 9/15/22 at 10:44 AM with ADON J, revealed she had received complaints from residents stating the food did not taste good. She said she had reported the food complaints to the Dietary Manager and the Administrator.<BR/>5. Record review of Resident #19's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), glaucoma (a group of eye conditions that damage the optic nerve, the health of which is vital for good vision), and hypertension (blood pressure that is higher than normal).<BR/>Record review of Resident #19's September 2022 physician orders revealed an order dated 07/22/2022 for a regular diet with thin liquids. An order dated 08/01/2022 indicated Resident #19 was to receive 2.0 Calorie Med Pass supplement 120 ml three times daily.<BR/>Record review of Resident #19's quarterly MDS, dated [DATE], reflected she had a BIMS score of 11, which indicated a minimal impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. <BR/>Record review of Resident #19's EHR reflected the following care plan interventions for nutrition on 07/12/2022: <BR/>- Resident #19 would be provided favorite foods and beverages.<BR/>- Resident #19's food preferences would be updated<BR/>During an interview on 09/12/2022 at 9:55 am, Resident #19 stated the food was disgusting and unappetizing. Resident #19 stated, we are just served whatever the kitchen feels like putting on a plate. Resident #19 stated most of the time it is combinations of food that do not go together at all and turns my stomach. Resident #19 stated we have all reported this to the nurses, Director, and Administrator until we are blue in the face.<BR/>During an observation on 09/12/2022 at 12:38pm, Resident #19 was not eating the lunch meal served by the facility. Resident #19 stated she was not eating fish with refried beans. The plate had a square breaded fish patty and a scoop of refried beans on it. The tray card had choices of fish or quesadilla, rice or refried bean, salad, and dessert. Resident #19 ate 25% of her lunch meal eating only 3 bites of the fish patty and eating the banana strawberry dessert.<BR/>6. Record review of Resident 38's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: rheumatoid arthritis (A chronic inflammatory disorder affecting many joints, including those in the hands and feet), dementia (A group of thinking and social symptoms that interferes with daily functioning), and anemia (A condition in which the blood doesn't have enough healthy red blood cells).<BR/>Record review of Resident #38's September 2022 physician orders revealed an order dated 01/27/2021 for a regular mechanical soft diet with thin liquids. <BR/>Record review of Resident #38's annual MDS, dated [DATE], reflected she had a BIMS score of 11, which indicated a minimal impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. <BR/>Record review of Resident #38's EHR reflected the following care plan goal for nutrition on 09/03/2022: <BR/>- Resident #38 would be comfortable with food and fluids provided over the next 90 days<BR/>During an interview on 09/12/2022 at 9:40 am, Resident #38 stated the food served at the facility was cold and tasteless. Resident #38 stated she did not like over 50% of the things served for lunch and supper. Resident #38 stated she felt the facility served a menu that people from the north would enjoy. Resident #38 stated she survived on snacks brought in by her relatives and provided by the facility.<BR/>During an observation on 09/12/2022 at 12:45 pm. Resident #38 had a plate with a square breaded fish patty and a scoop of rice. Resident #38 stated the fish was cold, the rice was hard, and she ate the strawberry and banana dessert and drank her tea. Resident #38 stated she would be ok until they brought snacks around. Resident #38 stated the CNA asked her if she wanted something different but Resident #38 stated she did not know what a quesadilla was, and it did not sound good.<BR/>7. Record review of the face sheet dated 9/14/2022 indicated Resident #44 was [AGE] years old and was admitted on [DATE] with diagnoses including kidney failure, atrial fibrillation (abnormal heart rhythm), and depressive episodes.<BR/>Record review of a care plan last revised on 7/20/2022 indicated Resident #44 had an altered nutritional status. There was an intervention for a diet as ordered by the physician. There was a goal of the resident will be comfortable with food and fluids provided. <BR/>Record review of the MDS dated [DATE] indicated Resident #44 usually understood others and was understood. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 12, indicating Resident #44 was moderately cognitively impaired. <BR/>During an interview on 9/12/2022 10:45 a.m., Resident #44 said the food was not cooked well and was undercooked. She said the food was always cold. She said she had been served rolls that were still doughy inside. She said her family member brings her food because she cannot eat the food. <BR/>During an observation on 9/12/2022 at 12:06 p.m., the food tray cart was delivered to the 400 Hall. There was no aides or nurses present. <BR/>During an observation on 9/12/2022 at 12:19 p.m., the first tray was being passed to residents on the 400 Hall. <BR/>During an observation on 9/12/2022 12:34 p.m., the final tray was served on the 400 Hall. <BR/>During an observation and interview on 9/13/2022 at 12:20 p.m., a tray was sampled by the Dietary Manager and 5 surveyors. The spaghetti with meat sauce was tepid, the peas were undercooked and unseasoned, the toast was tough and there was no butter or garlic seasoning (flavorless), and the brownie was dry. The Dietary Manager said the spaghetti was not hot enough because the bottom plate insulator was not present. She said the brownie was dry. <BR/>During an interview on 9/14/22 at 9:15 a.m., the Dietary Manager said she randomly talks to residents daily about food concerns. She said there were 103 residents, so she did not make rounds and speak to all of them about their concerns. She said she learned of food complaints while visiting with residents and from resident counci l. She said when staff brought her a specific complaint, she visited with the resident to resolve the issue. She said she even went to a resident council meeting to talk to residents. She said if the food was cold it was because the trays were not being passed immediately on the hall.<BR/>During an interview on 9/14/2022 at 3:23 p.m., CNA C said there are days the food trays come and none of her residents will eat the food. She said the main complaint is they do not get the food they ordered. She said she has reported food complaints to kitchen staff. <BR/>During an interview on 9/14/2022 at 3:34 p.m., CNA D had heard complaints of food trays being too cold and not seasoned correctly . She said she did offer substitutes when the resident does not like the food. She said if the food was cold she reheated the food and reported the issue to kitchen staff.<BR/>During an interview on 9/15/2022 at 10:10 a.m., LVN E said she did occasionally hear food complaints. She said most complaints were that they just did not like the food, or the food was cold. She said she reports complaints to the Dietary Manager. <BR/>During an interview on 9/15/2022 at 1:40 p.m., the DON said she heard food complaints every now and then. She said she was usually in the dining room and the complaints she heard was that the resident did not like what they are served. She said there are always substitutes available. <BR/>During an interview on 9/15/2022 at 2:16 p.m., the Administrator said she heard food complaints when residents told her, told the kitchen staff and from resident council. She said Resident #44 had a sensitive palate and her family brought her food. She said they did have a food committee to handle food complaints. She said she felt the food had improved and they no longer needed to have a food committee. She said they were doing food surveys and those have been coming back positive. She said she sampled food trays 3 times a week. She said after the sample tray was tasted by the Dietary Manager and the surveyors she tasted the peas, and they were undercooked.<BR/>Review of a facility Hot and Cold Food Temperatures dated August 1, 2018, indicated, .the temperatures of the food items will be managed to conserve maximum nutritive value and flavor and to be free of harmful organisms and substances .all hot food items must be served to the resident at a palatable temperature .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 9 residents (Residents #2 and Resident #3) reviewed for infection control practices.1. The facility failed to ensure CNA A and CNA B did not contaminate Resident #2's clothing, draw pad, bedding, pillows, and feeding tube pole after performing incontinent care.2. The facility failed to ensure CNA A and CNA B donned (put on) a gown while performing incontinent care on Resident #2, who was on Enhanced Barrier Precautions (EBP).3. The facility failed to ensure LVN C donned a gown while disconnecting Resident #3's feeding tube, assessing feeding tube placement, and attempting to flush the feeding tube, and the resident was on Enhanced Barrier Precautions.These failures could place residents at risk for cross contamination, at an increased risk of infection, and the spread of infection.Findings included:1. Record review of Resident #2's face sheet dated 7/14/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #2 had diagnoses which included quadriplegia (inability to move upper or lower body), shortness of breath, and lack of coordination.Record review of Resident #2's quarterly MDS assessment dated [DATE], indicated he was unable to complete the BIMS score, which indicated he had cognitive impairment. The MDS indicated Resident #2 was dependent on staff for all ADLs. The MDS indicated Resident #2 had a feeding tube.Record review of Resident #2's Care Plan dated 7/14/25 indicated he had a care area/problem of infection control with intervention of Enhanced Barrier Precautions, gown and glove use during high-contact resident care activities, which included providing hygiene, changing briefs, and assisting with toileting.Record review of Resident #2's Physician Orders did not reflect an order for Enhanced Barrier Precautions.During an observation on 7/14/25 at 11:45 AM, Resident #2 was lying in bed with head of bed elevated with tube feeding being infused by an infusion device. There was a blue name tag on the outside of his room, a PPE cart and EBP sign just to the inside of his door in his room.During an observation on 7/14/25 beginning at 1:30 PM, CNA A and CNA B entered Resident #2's room and washed their hands and put on gloves. CNA A and CNA B positioned themselves on opposite sides of Resident #2's bed to perform incontinent care on Resident #2. CNA A pulled a male incontinent pad from between Resident #2's legs and placed it in the trash bag. CNA B was on the window side of Resident #2 and rolled resident toward her and held him on his side while CNA A cleansed the head of his penis with a wipe, then used another wipe to cleanse the shaft of the penis, then another 2 wipes to cleanse down each side of his inner thighs. CNA A then used the same gloves to reposition the resident's pillow, moved his feeding tube pole, placed one hand on his shoulder and one on his thigh and pulled him toward her without changing her gloves. CNA B then cleansed Resident #2's bottom with 3 wipes and went between his legs, there was no bowel movement present. Then CNA B and CNA A still wearing the same gloves used during incontinent care, repositioned Resident #2, stuffed a 3-sided body pillow all around Resident #2, used the draw pad under him to pull Resident #2 up in bed, pulled his gown down and then removed their gloves. Neither CNA A nor CNA B wore a gown during Resident #2's incontinent care. Resident #2 had a blue name tag outside his door, an EBP sign posted on the wall just inside his door along with a PPE cart with EBP supplies. During an interview on 7/14/25 at 1:50 PM, CNA A said she had worked at the facility since 2019 and normally worked the 6 AM to 2 PM shift. CNA A said staff should change gloves during incontinent care more times than she did on Resident #2. CNA A said she should have changed her gloves after cleaning Resident #2's front perineal (private) area and before touching multiple surfaces in his room. CNA A said it was a hygiene thing and cross-contamination and could give Resident #2 an infection. CNA A said it was an infection control issue and could cause skin irritation too. CNA A said she would know someone was on EBP if there was a bucket and a sign outside the resident's door. CNA A said staff had to suit up with gown, gloves, and mask if a resident was on EBP. CNA A said residents on EBP were the residents with something in their urine or bowel. CNA A said Resident #2 probably should be on EBP because he had a feeding tube. CNA A said she did not see the EBP sign or the bucket just inside Resident #2's room and did not know what EBP was. CNA A said she did not know why Resident #2 had a EBP sign and cart, because they did not use it. CNA A said she had been on Resident #2's hall since April 2025 and had not ever used a gown during Resident #2's care.During an interview on 7/14/25 at 1:56 PM, CNA B said she had worked at the facility since May of 2025 and normally worked the 2 PM -10 PM shift but picked up a 6 AM -2 PM on 7/14/25. CNA B said she should have changed her gloves after performing incontinent care on Resident #2 and before touching multiple surfaces in his room. CNA B said it was cross-contamination and could cause him an infection. CNA B said they should have worn gowns while performing incontinent care on Resident #2 because he had a feeding tube. CNA B said EBP was to protect the staff and the resident from cross-contamination. CNA B said not wearing a gown during incontinent care could spread infection. CNA B said she did not see the EBP cart or EBP sign that was just inside Resident #2's room.Record review of the facility's Nursing Services-Competency Evaluation for Skill/Procedure: Perineal Care without catheter of CNA A dated 5/21/25 had a check mark in the met column which indicated CNA A had performed the procedure of perineal care and met the performance criteria, which included discarding used supplies, removed gloves, and performed hand hygiene and applied new gloves and placed new brief and changed lines as needed and positioned resident comfortably, and gave table and call light. Record review of the facility's Nursing Services-Competency Evaluation for Skill/Procedure: Perineal Care without catheter of CNA B dated 5/30/25 had a check mark in the met column which indicated CNA B had performed the procedure of perineal care and met the performance criteria, which included discarding used supplies, removed gloves, and performed hand hygiene and applied new gloves and placed new brief and changed lines as needed and positioned resident comfortably, and gave table and call light. 2. Record review of Resident #3's face sheet dated 7/15/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #3 had diagnoses which included myotonic muscular dystrophy (genetic condition characterized by progressive muscle weakness and wasting), diabetes (high blood sugar), and gastrostomy (feeding tube).Record review of Resident #3's quarterly MDS assessment dated [DATE], indicated she had a BIMS of 10, which indicated she had moderate cognitive impairment. The MDS indicated Resident #3 required moderate to dependent on staff for most ADLs. The MDS indicated Resident #3 had a feeding tube.Record review of Resident #3's Care Plan dated 7/15/25 indicated she had a care area/problem of altered nutritional status: enteral feeding monitor. Resident #3 also had a care area/problem of Infection control with intervention of Enhanced Barrier Precautions, gown and glove use during high-contact resident care activities.Record review of Resident #3's Physician Orders dated 7/01/25 - 7/31/25 did not reveal an order for Enhanced Barrier Precautions.Record review of Resident #3's Medication Record dated 6/23/25 - 7/15/25 indicated Enhanced Barrier Precautions every shift.During an observation and interview on 7/15/25 at 9:53 AM, Resident #3 was lying in bed and had a feeding tube infusion device connected to her feeding tube and the alarm was going off that it had completed. Resident #3 said staff wear gloves when administering her feedings and medications through her feeding tube and when providing incontinent care, but the staff never wear gowns during her care. There was a blue name tag outside her door, a PPE cart just inside Resident #3's door, but there was no EBP sign posted.During an observation and interview on 7/15/25 beginning at 10:04 AM, LVN C entered Resident #3's room and put on gloves. LVN C then pulled back the Resident #3's covers to expose her feeding tube. LVN C unhooked the feeding tube, then placed her stethoscope on the resident's abdomen, and checked placement of the feeding tube with 60 cc of air. LVN C then attempted to flush the feeding tube with water and then begun rolling the feeding tube between her fingers as she was leaned against the resident's bed/bedding. LVN C did not wear a gown as part of EBP. LVN C said they often had difficulty flushing the resident's feeding tube. LVN C said she was going to have someone else come try to flush it. During an interview on 7/15/25 at 10:35 AM, LVN C said she had worked at the facility for approximately twelve years and normally worked on the day shift. LVN C said she would know a resident was on EBP because they should have a PPE box in their room. LVN C said the EBP was for residents that had urinary catheters, wounds, feeding tubes, or any openings that could introduce infection. LVN C said residents on EBP should also have a sign posted indicating they were on EBP. LVN C said if staff were in direct contact with the resident, they should suit up and I did not do it on Resident #3. LVN C said she should have also worn a gown with her gloves during Resident #3's care. LVN C said it was important to follow EBP due to the at-risk residents had ports of entry for infection and EBP protected both the resident and staff. LVN C said EBPs was so staff did not carry anything from one resident to another resident. LVN C said if staff did not follow the EBP, it could place the residents at a higher risk of infection.During an interview on 7/15/25 at 2:17 PM, the ADON said he was also the Infection Preventionist. The ADON said staff should change their gloves during incontinent care any time they were doing different tasks. The ADON said the staff should have changed their gloves and performed hand hygiene after cleaning the Resident #2's front perineal area and prior to touching any other surfaces in the resident's room. The ADON said then staff should have changed gloves and performed hand hygiene after cleaning the resident's back perineal area and prior to touching any other of the resident's surfaces to prevent cross-contamination. The ADON said it was important to perform hand hygiene and change gloves appropriately to prevent cross-contamination and prevent the spread of infection. The ADON said all staff were responsible for ensuring staff were following the infection control policy and procedures. The ADON said residents who were on EBP was indicated by the blue name tags outside the resident's door and a PPE cart inside the resident's room. The ADON said they do not use the EBP signs, but staff had been educated that the blue name tags were indicative of the resident being on EBP. The ADON said any resident who had an invasive device, such as urinary catheter, a feeding tube, dialysis access, wounds or anything that would increase the risk of infections from an outside source would be on EBP. The ADON said the purpose of EBP was to protect the resident from an outside source of infection from direct care contact. The ADON said the resident, who was on EBP, was at an increased risk of infection if staff did not wear gown and gloves during direct care. The ADON said staff could spread infection from one resident to another resident if they were not wearing a gown during direct care. During an interview on 7/15/25 at 2:45 PM, the DON said staff should know a resident was on EBP from the blue name tags outside the resident's door and a PPE cart inside the resident's room. The DON said they do not use the EBP signs and only used the blue name tags outside the resident's room. The DON said the reasons a resident would be on EBP would be anyone with a feeding tube, urinary catheter, wounds, and any other indwelling device. The DON said the purpose of EBP was almost a reversed precaution, to protect the resident from getting something from the staff due to the resident was at a higher risk of infection and cross-contamination. The DON said staff should have changed their gloves when going from a dirty surface to a clean surface. The DON said staff should wash or sanitize their hands prior to and post incontinent care. The DON said the Infection Preventionist and herself would be responsible for ensuring staff were following the infection control policy and procedures. The DON said staff could transfer any bad bugs anywhere they touched with their contaminated gloves. The DON said the resident had the potential of infection if staff were not following EBP and transferred germs or bacteria from one resident to another resident. During an interview on 7/15/25 at 4:10 PM, the ADM said he would expect staff to follow the facility's infection control policy and procedures and change gloves and perform hand hygiene per their policies. The ADM said he would expect the EBP to be followed to protect the residents from anything staff may have come in to contact with. The ADM said not changing gloves, performing hand hygiene, following the EBP could be a potential infection control issue.Requested an Infection Control policy on 7/15/25 at 5:00 PM from the facility's Regional Nurse and was provided a policy titled Infection Prevention, Control & Surveillance, which did not contain pertinent information. Record review of the facility's policy titled Perineal Care dated revised April 10, 2023 indicated . staff would provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection . procedure . perform hand hygiene. Apply clean gloves . 5. Perineal care for a male resident . d. wash tip of penis . f. cleanse the shaft of the penis . 6. observe perineal area . 8. Turn resident to clean all areas of buttocks . 9. Dispose of gloves and used supplies and perform hand hygiene . 10. Apply new gloves and place new brief . 11. Position resident comfortably . Record review of the facility's policy titled Hand Hygiene for Staff and Residents dated revised February 2025 indicated . purpose . to reduce the spread of infection with proper hand hygiene . hand hygiene was the most important component for preventing the spread of infection . hand hygiene was done . before . before resident contact . after . contact with soiled or contaminated articles, such as articles that were contaminated with body fluids . resident contact . contact with contaminated object or source where there was a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds . toileting or assisting others with toileting .Record review of the facility's policy titled Enhanced Barrier Precautions dated revised March 2025 indicated . many residents in nursing homes were at increased risk of becoming colonized and developing infections with multi-drug-resistant organisms (MDROs) . facility utilized Enhanced Barrier Precautions (EBP) as a strategy to decrease transmission of CDC-targeted and epidemiologically important MDROs when Contact Precautions do not apply . indications . wounds and/or indwelling medical devices . indwelling medical devices include central lines . urinary catheters, feeding tubes . high contact resident care activities . providing hygiene . changing briefs or assisting with toileting . device care or use . feeding tube . communication . indicate the residents who were on EBP by subtle means, such as an alternate color of the resident's name badge on door .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Residents #1) reviewed for resident rights.<BR/>CNA E did not sit as she assisted Resident #1 with dining. <BR/>CNA E did not refrain from talking on her cell phone while she assisted Resident #1 with dining. <BR/>The facility did not ensure Resident #1 was clothed in his personal clothing. <BR/>These failures could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth.<BR/>Findings included:<BR/>Record review of Resident #1's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including Hemiplegia or hemiparesis (hemiplegia refers to a severe or complete loss of strength, whereas hemiparesis refers to a relatively mild loss of strength) following cerebral infarction (stroke) affecting the left non-dominant side, type II diabetes, shortness of breath, nausea/ vomiting, and depression. <BR/>Record review of Resident #1's MDS dated [DATE] indicated Resident #1 was usually understood and usually understood others. The MDS indicated Resident #1 had severe cognitive impairment (BIMS of 5). The MDS indicated he had no behavior of rejecting care during the 7 days look back period. The MDS indicated he required extensive assistance with bed mobility, transfers, locomotion in his wheelchair, dressings, eating, toilet use, and personal hygiene. The MDS indicated Resident #1 was completely dependent on staff for bathing. The MDS indicated Resident #1 was always incontinent of bowel and bladder. <BR/>Record review of Resident #1's care plan revised on 11/15/22 indicated Resident #1 had a self-care deficit. The care plan interventions included to give the resident as many choices as possible about care and provide assistance with self-care as needed. <BR/>During an observation on 2/8/23 at 11:10 a.m. revealed Resident #1 laid in his bed wearing a hospital gown. <BR/>During an observation on 2/8/23 at 12:45 p.m. revealed the door to Resident # 1's door was open. CNA E stood at Resident #1's bedside. CNA E said loudly Well what are you going to then?. A few moments later CNA E again said, Well what are you going to then? and then said I gotta go. The surveyor entered the room. CNA E continued to stand at Resident #1's bedside and fed him several bites from his food tray. <BR/>During an observation and interview on 2/8/23 at 2:50 p.m. revealed Resident #1 laid in his bed wearing a hospital gown. Resident #1 said he did not want to wear a hospital gown. Resident #1 said his family member had brought him some clothes and pointed at the armoire. There were multiple personal clothing items hanging in the armoire. Resident #1 said he guessed he had to wear the gown because that was what they (facility staff) put on him. Resident #1 could not say how long he had been wearing the hospital gown or who had placed the hospital gown on him. Resident #1 said CNA E talked on the phone while she fed him today (2/8/23) and felt it was rude. <BR/>During an interview on 2/10/23 at 10:28 a.m., CNA G said there was no reason for a resident to have been in a hospital gown. CNA G said the facility had clothes that were donated for resident use if a resident did not have any personal clothes available. CNA G said if a resident did not want to wear a hospital gown and was placed in hospital gown, it could take away the resident's dignity. CNA G said CNAs should not stand while feeding a resident because it could cause the resident to feel intimidated. CNA G said another reason CNAs should not stand while feeding a resident was to ensure the resident did not have any signs of aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). CNA G said under no circumstance should a CNA take a personal phone call while he/she administered resident care. CNA G said to take a personal call during the administration of patient care was not only disrespectful but would also divert attention away from the resident. <BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she should not have stood while feeding Resident #1. CNA E said she should have sat at Resident #1's bedside while she assisted him with eating because it was more respectful than standing. CNA E said she stood while she fed Resident #1 because she was in a hurry. CNA E said she did not notice Resident #1 was wearing a hospital gown and indicated he should have been wearing his personal clothes. CNA E said she should not have taken the personal call while she assisted Resident #1 but did so because she had a family situation. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected staff to sit while they assisted residents with eating in order to promote respect and safety. The DON said it was not acceptable for a resident to be in a hospital gown and to do so (place a resident in a hospital gown) could affect the resident's dignity. The DON said it was not acceptable for staff to have taken a phone call while assisting a resident. The DON said she expected staff to go to the break room or their car if they had to take a phone call. The DON said a staff member taking a phone call in front of a resident was a dignity issue and could also confuse the resident. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected staff to ensure residents were clothed in their personal clothing if it was the resident's preference. The Administrator said she expected staff to ensure respect and dignity were provided to residents. The Administrator indicated taking personal phone calls during resident care activities and standing while feeding a resident did not promote respect and dignity.<BR/>Record review of the undated facility policy and procedure titled, Exercise of Rights reflected, Policy Statement- Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to our facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for 2 of 27 residents (Resident #1 and Resident #3) reviewed for resident abuse. <BR/>1.The facility failed to ensure Resident #1 was free from abuse when on 11/02/2023 CNA H shook Resident #1's wheelchair when pushing into the bathroom for incontinent care.<BR/>2.The facility failed to ensure Resident #3 was free from abuse when on 6/20/24 CNA J forcefully pushed Resident #3's wheelchair with her in it, from the doorway of her room to the doorway of another room across the hallway (approximately 13 foot). <BR/>These failures could place residents at risk of physical harm, mental anguish, and/or emotional distress.<BR/>The findings included:<BR/>1.Record review of Resident #1's face sheet, dated 8/13/24, revealed she was [AGE] years old and initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses of dementia (progressive loss of intellectual functioning, especially with impaired memory), weakness, abnormality of gait and mobility, lack of coordination, and hypertension (high blood pressure).<BR/>Record review of Resident #1's quarterly MDS assessment, dated 10/17/23, revealed she sometimes understood others and was sometimes understood by others. The MDS revealed Resident #1 had a BIMS score of 2, which indicated severe cognitive impairment. The MDS revealed Resident #1 used a wheelchair for mobility. The MDS revealed Resident #1 required maximal to moderate assistance for most ADLs. The MDS revealed Resident #1 was always incontinent of bowel and bladder.<BR/>Record review of Resident #1's comprehensive care plan dated 8/13/24, revealed Resident #1 had cognitive deficit related to dementia; she had impaired physical mobility; she had self-care deficit; and she was at risk for problems with elimination.<BR/>Record review of the facility's PIR dated 11/02/23 with an incident category of abuse was signed by the ADM on 11/09/23. The PIR revealed CNA L had reported CNA H had become agitated during Resident #1's incontinent care of bowel movement and shook Resident #1's wheelchair while she was sitting in it. The PIR included a form titled Interview Statement Employee completed on 11/2/23 at 10:50 AM for CNA L who stated CNA H was agitated and shook Resident #1's wheelchair. CNA L said the other aide (CNA H) did not help CNA L provide incontinent care after shaking Resident #1's wheelchair. CNA L stated, I realize CNA H was old, but that was not an excuse to have an attitude. The ADM signed The Interview Statement Employee form on 11/2/23 as being the one who conducted the interview. The PIR revealed CNA H was suspended during the investigation and then was not allowed to return. The PIR revealed staff was to be in-serviced promptly on abuse. <BR/>During an observation on 8/14/24 at 11:54 AM, Resident #1 was self-propelling herself in her wheelchair around the nurse's station and hallway. Resident #1 was clean and well groomed.<BR/>During an interview on 8/14/24 at 3:08 PM, Resident #1 said she was doing fine and self-propelled herself away and went down the hallway.<BR/>During an interview on 8/15/24 at 8:20 AM, Resident #1's RP said Resident #1 was a difficult patient at times and she was incontinent of bowel and bladder. Resident #1's RP said she did not remember being notified about the incident from 11/02/23 but it was back in November of last year. Resident #1's RP said the facility normally notified her when anything happened.<BR/>During an interview on 8/15/24 at 8:32 AM, CNA H said another staff member said she shook Resident #1's wheelchair during incontinent care, but CNA H said she did not shake Resident #1's wheelchair. CNA H said she was suspended during the investigation, and she decided to not return to the facility because she was getting too old to do the amount of work that was required when there was frequent call-ins.<BR/>Attempted to call CNA L on 8/15/24 at 12:31 PM and at 4:02 PM, but there was no answer and was unable to leave a message. CNA L did not return call prior to exit.<BR/>2. Record review of Resident #3's face sheet, dated 8/13/24, revealed she was [AGE] years old and admitted to the facility on [DATE]. Resident #3 had diagnoses of cerebral palsy (lifelong condition affecting movement, coordination, and muscle tone), intellectual disabilities (below average intelligence and set of life skills present before age [AGE]), scoliosis (sideways curvature of the spine), and bladder disorder.<BR/>Record review of Resident #3's quarterly MDS assessment, dated 7/3/24, revealed she had unclear speech and rarely understood others and was rarely understood by others. The MDS revealed Resident #3 was unable to complete the BIMS, which indicated she had severe cognitive impairment. The MDS revealed Resident #3 had severely impaired cognitive skills for daily decision making. The MDS revealed Resident #3 used a wheelchair for mobility. The MDS revealed Resident #3 required maximal to dependent assistance for most ADLs. <BR/>Record review of Resident #3's comprehensive care plan dated 8/13/24, revealed Resident #3 had cognitive deficit related to intellectual disability; she had speech deficit expressive related to developmental disabilities; she was a fall risk; impaired physical mobility with an intervention to provide appropriate level of assistance to promote safety of resident; she was physically aggressive and had interventions of all staff educated about triggers, what de-escalates, what signals onset of agitation, guide away from source of distress, intervene before resident agitation escalates.<BR/>Record review of the facility's PIR dated 6/20/24 with an incident category of abuse was signed by the ADM on 6/26/24. The PIR revealed LVN K had reported CNA J had pushed Resident #3's wheelchair while she was sitting in it from one side of the hallway to the other quickly. The PIR revealed CNA J responded inappropriately to Resident #3's behaviors. The PIR revealed CNA J was interviewed and did not deny the actions, but stated she was being hit and she pushed the wheelchair and not the resident. CNA J was suspended during the investigation and ultimately was not allowed to return. The PIR revealed staff was in-serviced on abuse. <BR/>During on observation on 8/14/24 at 11:43 AM, Resident #3 was observed sitting in a specialized wheelchair in dining room, feeding herself. Resident #3 had difficulties with feeding self. Resident #3 had abnormal spastic jerking type arm movements. Resident #3 had a divided plate and large handle spoon. Resident #3 had unrecognizable mumbles, loud noises, and un-understandable speech. Resident #3 was clean, well groomed, and was wearing a helmet. <BR/>Attempted to call Resident #3's RP on 8/15/24 at 8:43 AM and at 2:48 PM, but there was no answer, a voice mail was left requesting a return call. Resident #3's RP did not return call prior to exit.<BR/>Attempted to call CNA J on 8/15/24 at 9:17 AM and at 4:58 PM, but there was no answer and was unable to leave a message. CNA J did not return call prior to exit.<BR/>During an interview on 8/15/24 at 12:36 PM, LVN K said she recalled the incident with CNA J and Resident #3. LVN K said she was standing by her medication cart facing hall 100 and saw Resident #3 being combative, flailing her arms backwards, and agitated while CNA J was pushing Resident #3's wheelchair out of the doorway of her room. LVN K said she then saw CNA J forcefully shove Resident #3's wheelchair across the hallway. LVN K said Resident #3 went from her doorway to the doorway of the room on the other side of the hall. LVN K said she immediately told CNA J that she could not do that under no circumstance due to Resident #3 could have fallen out of her chair or hit the wall and been injured. LVN K said CNA J said she was not going to get whooped by her. LVN K said she told CNA J that she should have walked away or gotten someone else to help and not have shoved Resident #3's wheelchair across the hallway. LVN K said Resident #3 had difficulty making her needs known and continued to be agitated after the incident, but she was able to take over Resident #3's care and was able to determine Resident #3 wanted her glasses from out of her room. LVN K said Resident #3 was assessed to have no injuries and was given her glasses. Resident #3 calmed down and she did not have any other issues. LVN K said she wrote CNA J up and contacted the ADM and CNA K was suspended during the investigation. LVN K said that was the first time she had ever witnessed a staff member being abusive toward a resident in her nursing career and she would not tolerate it.<BR/>During an interview on 8/15/24 beginning at 5:15 PM, the DON said she had been the DON since 1/29/24 and would not have knowledge of incidents occurring before then. The DON said the nurse said CNA J was frustrated with Resident #3 and had pushed Resident #3 out of the doorway and across the hallway and did not go with her. The DON said the nurse told CNA J it was not okay to push Resident #3 across the hallway and sent CNA J home. The DON said there was potential for harm to Resident #3 when CNA J pushed her and did not go with her. The DON said CNA J could have walked away and gotten assistance of another staff member and not have pushed Resident #3 across the hallway. The DON said if CNA J had done that to her mom, it would not have been okay. The DON said CNA J was suspended during the investigation and she had been counseled previously related customer service and she felt there was potential for harm and CNA J was terminated. The DON said it would never be appropriate to shake a resident's wheelchair and it would be an act of abuse and it could intimidate the resident. <BR/>During an interview on 8/15/24 beginning at 5:45 PM, the ADM said she was the Abuse Coordinator. The ADM said CNA L was training with CNA H during the time of the incident on 11/2/23 with Resident #1. The ADM said CNA L came to her office with tears in her eyes and said she had witnessed CNA H visibly upset when Resident #1 had an episode of diarrhea and shook Resident #1's wheelchair by the handles while pushing it. The ADM said CNA L completed the incontinent care and Resident #1 was unharmed and unable to recall the event due to confusion. The ADM said CNA H denied the allegation. The ADM said CNA H was suspended during the investigation and was terminated due to that was not the customer service she wanted portrayed in her facility. The ADM said on 6/20/24 LVN K reported CNA J had pushed Resident #3's wheelchair from one side of the hall to the other quickly and said she was not going to be whooped by her. The ADM said Resident #3 had cerebral palsy and had spastic arm movements and could become agitated and combative at times. The ADM said Resident #3 was assessed by LVN K and was found to be agitated but was not harmed. The ADM said LVN K was able to calm Resident #3. The ADM said CNA J could have dealt with the situation differently, such as walking away or calling for assistance. The ADM said CNA J did not deny the actions, but stated she was being hit and she pushed the wheelchair and not the resident. The ADM said CNA J was suspended during the investigation and was terminated for poor customer service. <BR/>Record review of the facility's abuse policy, titled Abuse, Neglect and Exploitation and Misappropriation of Resident Property, dated revised 6/23/17 revealed . this policy was to ensure that all healthcare facilities comply with federal and state regulations regarding protecting facility patients and residents from abuse . each resident had the right to be free from abuse . by anyone, including but not limited to facility staff .

**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 4 of 12 residents (Residents #18, #6, #8, and #10), reviewed for care plans.<BR/>1.The facility failed to revise and update Resident #18's care plan following physically aggressive behaviors against another resident. No interventions for aggressive behavior were listed on the behavior care plan.<BR/>2.The facility failed to revise and update Resident #6's care plan with interventions following a fall with major injury. The care plan did not include Resident #6's hip fracture or interventions for the care of the hip fracture.<BR/>3.The facility failed to revise and update Resident #8 and add interventions of a scoop mattress, move bedroom closer to nurses' station, and applying a fall mat beside bed after fall on 04/10/2024. <BR/>4. The facility failed to include added interventions of a fall mat and pommel cushion for #10's care plan following 04/24/2024 fall with fall interventions following falls with injury.<BR/>These failures 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/>1. Record review of an undated face sheet indicated Resident #18 was an [AGE] year-old male admitted to the facility on [DATE] with the diagnose of hemiplegia (one-sided paralysis), cerebral infarction (stroke), and dysphagia (difficulty swallowing).<BR/>Record review of the annual MDS dated [DATE] indicated Resident #18 had a BIMS of 09, which indicated moderate cognitive impairment. The MDS indicated physical behavior towards others. The MDS indicated Resident #18 required set up assistance only for eating and oral hygiene. The MDS indicated Resident #18 required substantial assistance for toileting and transfer.<BR/>Record review of the care plan titled 'Behavioral Changes' dated 07/07/2023 indicated Resident #18 was a moderate risk for elopement. No other behaviors were addressed in the care plan. No interventions for behaviors were listed in the care plan.<BR/>Record review of nurses note for Resident #18 dated 11/28/2023 written by LVN A revealed: The CNA called out to this Nurse that resident [#18] is kicking his roommate, (Resident #19). When resident [#18] was asked why he was doing this resident refused to answer. Left note to Administrator also text her. Will monitor resident [#18's] behavior, roommate (Resident #19) was placed in bed and resident (#18) was talked to and told to stay on his side of room.<BR/>During an interview on 08/14/2024 at 2:30 p.m., the MDS Coordinator stated all behaviors that are considered verbal or physical behaviors should be care planned no later than 7 days following the completion of the MDS. The MDS Coordinator stated she was not aware that Resident #18 had any further behavior of physical aggressiveness, but it should be care planned with interventions, so that if it occurred again the staff would know how to address the issue.<BR/>2. Record review of an undated face sheet indicated Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with dementia, hypertension (high blood pressure), repeated falls, and a right hip fracture.<BR/>Record review of a significant change MDS dated [DATE] indicated Resident #6 had a short- and long-term memory problem. It indicated he required partial to moderate assistance with oral care, toileting, dressing and hygiene. It also indicated he had a hip fracture and one major fall with injury since the last assessment.<BR/>Record review of the care plan titled Fall Risk indicated Resident #6 had a fall on 03/23/2024 less than 24 hours after admitting. <BR/>Record review of the care plan for Resident #6 dated 04/04/2024 indicated no care plan for his hip fracture care plan with interventions for the care of his hip fracture.<BR/>During an interview on 08/14/2024 at 2:30 p.m., the MDS Coordinator stated interventions for falls and any injury related to the fall should be updated on the care plan as the falls happen. She stated the falls were reviewed in the clinical stand up meeting each morning and the care plans are to be updated with interventions as they were discussed in the meeting. The MDS Coordinator stated she was not aware that Resident #6 was not care planned for his hip fracture and interventions for care.<BR/>3. Record review of an undated face sheet indicated Resident #8 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of depression, atrial fibrillation (irregular heartbeat), and left femur (long bone in leg) fracture. <BR/>Record review of the admission MDS dated [DATE] indicated Resident #8 had a BIMS of 14 which indicated no cognitive impairment. Resident #8 required total dependency for toileting, hygiene, dressing and supervision for eating.<BR/>Record review of the care plan dated 04/10/2024 titled Fall Risk indicated Resident # 8 had a fall on 04/10/2024. The intervention was listed as keeping call light within reach. No other interventions were listed for 04/10/2024 fall.<BR/>Record review of the incident report for 04/10/2024 for Resident #8's fall, indicated he fell and suffered a fractured nose and received staples to his head. The interventions for the fall on the incident report read: add a scoop mattress, move bedroom closer to nurses' station, and apply a fall mat beside bed. <BR/>During an interview on 08/14/2024 at 2:30 p.m., the MDS Coordinator stated interventions for falls and any injury related from the fall should be updated on the care plan as the falls happen. She stated the falls were reviewed in the clinical stand up meeting each morning and the care plans are to be updated with interventions as they are discussed in the meeting. The MDS Coordinator stated she was unaware why all the interventions were not listed on Resident #8's care plan. She stated it was important to have all interventions listed because the care plan was the blueprint of the specific resident's care instructions.<BR/>4. Record review of an undated face sheet revealed Resident #10 was an [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of cerebral infarction (stroke), diabetes mellitus type II, and hemiplegia (paralysis to one side).<BR/>Record review of the annual MDS dated [DATE] indicated Resident #10 had a BIMS of 04 which indicated severe cognitive impairment. The MDS indicated Resident #10 was dependent for ADLs. The MDS indicated Resident #10 had a fall with injury since the last assessment.<BR/>Record review of the care plan dated 05/30/2024 for Resident #10 titled Fall Risk had the intervention for the resident to maintain safety over next 90 days and have frequent checks. No interventions for Resident #10 to have a fall mat or pommel cushion were listed on the care plan.<BR/>Record review of the incident report dated 04/24/2024 indicated Resident #10 had a fall with a closed head injury. Interventions listed were fall mat at bedside and pommel cushion in chair.<BR/>During an observation on 08/14/2024 at 2:25 p.m., Resident #10 had a fall mat beside his bed and a pommel cushion in his wheelchair. <BR/>During an interview on 08/14/2024 at 2:30 p.m., the MDS Coordinator stated interventions for falls and any injury related from the fall should be updated on the care plan as the falls happen. She stated the falls were reviewed in the clinical stand up meeting each morning and the care plans are to be updated with interventions as they are discussed in the meeting. The MDS Coordinator stated she was unaware why all the interventions were not listed on Resident #10's care plan. She stated it was important to have all interventions listed because the care plan was the blueprint of the specific resident's care instruction. She stated Resident #10 had to have the fall mat and pommel cushion because he was impulsive and would attempt to transfer himself unsafely.<BR/>During an interview on 08/15/2024 at 2:20 p.m., the DON stated that all care plans should be reviewed and revised quarterly, but acute items such as behaviors and falls should be updated with intervention as they happen and are discussed in morning meeting. She stated it was important for all staff to be able to quickly access the care plan and know the up-to-date interventions in place for the residents. She stated this information was critical to assist with prevention of further behavioral issues and falls with injury.<BR/>During an interview on 08/15/2024 at 3:30 p.m., the ADM stated it was the responsibility of nurse management, mainly the DON to follow up and ensure the care plans were being updated both quarterly and acutely. She stated not having up to date care plans could result in staff not knowing how to treat different situations with different residents.<BR/>Review of a Care Plans, Comprehensive Person-Centered facility policy dated December 2016 reflected, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .The comprehensive, person-centered care plan will .Describe the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being .Incorporate identified problem areas .Assessments of residents are on-going and care plans are revised as information about the residents and the resident's condition change .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement an effective discharge planning process for 1 of 15 residents (Resident #32) reviewed for care plans. <BR/>The facility failed to prepare Resident #32 to effectively transition to post-discharge care and the reduction of factors leading to preventable readmissions. <BR/>These negative findings could cause a resident to have an unsafe living environment upon discharge.<BR/>Findings included: <BR/>Record review of an undated face sheet indicated Resident #32 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of PVD (peripheral vascular disease- poor circulation), sepsis (severe infection), and diabetes mellitus type II.<BR/>Record review of Resident #32's 5-day MDS assessment dated [DATE] indicated she had a BIMS of 15 and required substantial to maximum assistance for toileting, transfer and hygiene. The MDS indicated Resident #32 received dialysis during her stay. No behaviors were noted on the MDS. The MDS indicated Resident #32 planned to go back to her home upon discharge.<BR/>Record review of Resident #32's EHR revealed no care plans for discharge.<BR/>Record review of Resident #32's EHR revealed a blank discharge instruction care sheet dated 07/16/2024 and a blank recapitulation summary sheet dated 07/17/2024.<BR/>During an interview on 08/14/2024 at 10:00 a.m., Resident #32 stated she discharged on 07/15/2024 from the facility. She stated prior to discharge she was given no written or oral instruction on her medication or treatment regimen. She stated when she arrived at home, she had no DME. She stated the SSD told her she would have a hospital bed, mechanical lift, bedside commode, and home health services the day after she discharged . She stated she had to sleep on her loveseat because that was the only surface, she could transfer to being a double amputee. She stated she had no idea what medication changes had been made or when the medications should have been taken because she got no education or instruction on her medication. Resident #32 stated she returned to the hospital on [DATE] and no home health or DME arrived prior to her admission to the hospital. She stated she was admitted to the hospital for hypokalemia (low potassium) related to her dialysis. She stated her family was able to take her to and from dialysis.<BR/>During an interview on 08/14/2024 at 10:30 p.m., Resident #32's family member stated they were able to take the resident to and from dialysis and they were able to adminster all her medications to her. Resident #32's family member stated the only medication that changed for her while in the nursing home was the MD added a multivitamin with iron. He stated no other changes were made in her medications. He said the resident did not have an order for Potassium and she did not receive Potassium at the facility. <BR/>During an interview on 08/15/2024 at 9:45 a.m., the SSD remembered that Resident #32 was supposed to have discharged on 07/17/2024 and decided to leave 2 days early. She stated she had already turned her information in for her DME and home health to start after 07/17/2024. She stated she had not called the home health or DME company to inform them Resident #32 had gone home early. She stated not having home health or DME at home could cause a decreased quality of life or injury.<BR/>During an interview on 08/15/2024 at 2:15 p.m., the DON stated she remembered Resident #32 discharging early. She stated Resident #32 had cancer and wanted to seek treatment for the cancer and because she wanted to go to the oncologist and that interfered with her insurance she decided to discharge early. The DON stated Resident #32 was not ready to go home without support. The DON stated Resident #32's family member could help her with most tasks but not all of them. The DON stated Resident #32 needed the hospital bed, the mechanical lift and the bedside commode. The DON stated since failure to ensure discharge plans were carried out for Resident #32, the discharge process had been revamped to avoid missing important information such as that. She stated it was the social service department that was responsible for all aspects of discharge planning before. She stated now there are 5-6 people responsible for different parts of the discharge process and it was working much better.<BR/>During an interview on 08/15/2024 at 3:00 p.m., the ADM stated she recalled Resident #32 leaving the facility earlier than expected. She stated she was unaware Resident #32 had not received her medication instructions or any of her DME. She stated not having the DME needed when you discharge can lead to accidents such as falls. She stated not knowing how to take you medications correctly could lead to hospitalizations. She stated at the time it would have been the SSD's sole responsibility to ensure all those things were completed. She stated now there were 5 people involved in the discharge process and it had helped keep everyone safe and happy.<BR/>Record review of the facility discharge /Transfer Policy dated December 2018 reflected a facility must establish, maintain and implement identical policies and practices regarding transfer and discharge provision of services for all individuals regardless of payor source. The provisions included home health and durable medical equipment needed for a safe living environment post discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #14) of 6 residents reviewed for quality of care. <BR/>The facility failed to ensure Resident #14 had supervision that prevented him from going outside and falling causing a hematoma and abrasion to his head.<BR/>This failure could result in residents experiencing accident, injuries, and diminished quality of life. <BR/>Findings included:<BR/>1. Record review of an undated face sheet reflected Resident #14 was a [AGE] year-old male that admitted to the facility on [DATE] with the diagnosis of dementia, atrial fibrillation (irregular heartbeat), and diabetes mellitus type II and discharged [DATE].<BR/>Record review of Resident #14's admission MDS dated [DATE] reflected he had a BIMS of 01 which indicated severe cognitive impairment. The MDS also indicated Resident #14 had some physically aggressive behavior and he required partial to moderate assistance with ADLs.<BR/>Record review of Resident #14's care plan dated 05/07/2024 reflected a care plan titled Behavioral Changes with the problem of high elopement risk. The goal was to keep the resident safe within the facility. <BR/>Record review of admission assessment dated [DATE] indicated Resident #14 was a high elopement risk scoring a 22 out of 25 points scored for elopement.<BR/>Record review of an incident report dated 06/22/2024 revealed Resident #14 exited the front of the building and fell from his wheelchair onto the ground outside the front entrance of the building. Resident #14 sustained an abrasion to his forehead and a hematoma.<BR/>During an interview on 08/14/2024 at 10:02 a.m., RN P stated Resident #14 attempted to find an exit all day every day since the day he was admitted . She stated he was hard to redirect about 50% of the time. She stated she learned to redirect him with food and sitting in the dining room and that worked most of the time. She stated he would push right past you if you were standing in the way of him and where he was attempting to go. She stated she had not felt he was being mean, she stated he just had not registered that someone was in front of him.<BR/>During an interview on 08/14/2024 at 2:20 p.m., LVN Q stated on 06/22/2024 at lunch time Resident #14 went outside the front door of the facility and fell from his wheelchair onto his right side striking his head on the ground causing a hematoma and abrasion to his right forehead. She stated she was alerted by a family member of his presence outside because the staff was busy serving lunch, and no one saw him go outside. She stated she was aware he was an elopement risk, and they were doing frequent checks on him every 15-20 minutes and keeping him in eyesight if he were out of this room. LVN Q stated all the staff pitched in and tried to keep an eye on Resident #14, but it was not always possible to watch him. She stated he just slipped out because all hands are on deck when it was meal service time. She stated he was exit seeking every day because of his dementia. She stated he had gotten outside once before but the staff saw him before the door even closed behind him and redirected him back into the facility. LVN Q stated she had not believed he would have fallen that time if he had not been outside because it appeared to her the wheel on his wheelchair went off the sidewalk and dumped him out onto the ground. She stated the next day he discharged to a secured unit on 06/23/2024.<BR/>During an interview on 08/15/2024 at 2:00 p.m., the DON stated she was aware Resident #14 was an elopement risk and she understood there were other facilities that could take better care of his needs, but his family insisted he stay at the facility. She stated the family was devastated when we informed them that he could no longer stay at our facility, and we needed to find him a safe place to live immediately. The DON stated Resident #14 had 4-5 falls while he was here from the wandering up and down the hall all day and night. She stated the fall he had on 06/22/2024 could have been prevented had Resident #14 not been exit seeking and found his way outside, where the sidewalk caused him to be dumped from his wheelchair.<BR/>During an interview on 08/15/2024 at 3:15 p.m., the ADM stated she was aware Resident #14 was an elopement risk and the facility was trying different things to see if an adjustment period might calm that behavior down. She stated unfortunately it was not a successful match for him to remain in the facility because all the resident's must be safe that stay at the facility.<BR/>Review of facility's fall prevention policy titled Fall Evaluation and Prevention, dated revised August 2020, reflected The facility will evaluate residents for their fall risk and develop interventions for prevention . Upon Admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 12 residents reviewed for medications. (Resident #32)<BR/>The facility failed to ensure Resident #32's IV antibiotic (meropenem) was initiated per MD orders to begin on 06/07/2024. <BR/>These failures could cause prolonged illness and increased recovery time for residents.<BR/>Findings included:<BR/>Record review of an undated face sheet indicated Resident #32 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of PVD (peripheral vascular disease- poor circulation), sepsis (severe infection), and diabetes mellitus type II.<BR/>Record review of Resident #32's 5-day MDS 06/12/2024 assessment indicated she had a BIMS of 15 and required substantial to maximum assistance for toileting, transfer and hygiene. The MDS indicated Resident #32 received dialysis during her stay. No behaviors were noted on the MDS.<BR/>Record review of Resident #32's EHR revealed no care plans for IV antibiotics.<BR/>Record review of Resident #32's discharge orders from the acute hospital on [DATE] revealed the following discharge instructions:<BR/>Additional instructions- She will need to continue vancomycin and meropenem until 06/18/2024.<BR/>Record review of Resident #32's dialysis MAR dated 06/07/2024 indicated Vancomycin 750 mg IV once daily on Monday- Wednesday and Friday were administered every Monday, Wednesday and Friday from 06/07/2024 to 06/18/2024.<BR/>Record review of Resident #32's facility MAR dated June 2024 indicated meropenem 1 gram daily was not started until 06/10/2024. <BR/>During an interview on 08/14/2024 at 7:00 p.m., LVN N stated she was the nurse that admitted Resident #32 on 06/06/2024. LVN N stated she saw on the discharge order sheet that the resident was to continue her vancomycin that she was receiving at dialysis and meropenem until 06/18/2024. The meropenem had no dose or frequency so I put on the 24-hour report that clarification was needed on her [Resident #32's] antibiotic. She stated she was off the next couple of days and never thought about it after that.<BR/>During an interview on 08/15/2024 at 2:15 p.m., the DON stated Resident #32's meropenem was not started on 06/07/2024 because it was overlooked on the discharge orders, and it was not until a chart audit was done on 06/10/2024 that a clarification order was received that it was okay to start the meropenem 1 gram on 06/10/2024 and continue it for 14 days. The resident and her family were informed, as well as the wound care specialist that ordered the antibiotic. No increased white blood cells, no change in the wound drainage was noted. The DON stated Resident #32 was still getting the vancomycin with her dialysis treatment three times per week. She stated she assessed Resident #32, and no acute issues were found.<BR/>During an interview on 08/15/2024 at 2:30 p.m., NP O stated he was called and was informed the facility missed 3 doses of IV meropenem for Resident #32. NP O stated in his medical opinion that since the resident was receiving the other antibiotics, it was only 3 missed doses, and there were no physical signs of decline, and no harm was done to the resident by postponing the treatment. He stated if Resident #32 had developed a temperature or pain to the affected area he would have had cause for concern, but she had not so he just began the IV and continued it for the same duration originally ordered. He stated he gave a clarification order to start the meropenem when it was available from the pharmacy and continue it for the original 14 days ordered.<BR/>During an interview on 08/15/2024 at 3:20 p.m., the ADM stated she was made aware of the 3 missed doses of meropenem by the DON on 06/10/2024 when it was noticed and a staff in-service on clarification of medication orders was conducted. The ADM stated it was the DON's responsibility to check behind the nurses and make sure all medications were ordered per the discharge instructions. The mistake was noticed during that reconciliation. The ADM stated not receiving ordered antibiotics could lead to prolonged infections, recurrent infections, or sepsis.<BR/>Record review of policy dated April 2019 was documented Administering Medications, Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the residents and/or representatives had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for three (Resident #19, #47, #74) of five residents reviewed for care planning. <BR/>The facility failed to ensure the IDT, Resident #19, Resident #47 and Resident #74, and the POA/RP of Resident #19, Resident #47, and Resident #74 were involved in the review of the comprehensive assessment and were able to discuss their individualized care needs for services to include their need for medical and nursing care, medications, therapy, psychological and dietary needs. <BR/>The failure could affect residents by placing them at risk for not receiving adequate or individualized care. <BR/>Findings included:<BR/>1. <BR/>Record review of Resident 29's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), glaucoma (a group of eye conditions that damage the optic nerve, the health of which is vital for good vision), and hypertension (blood pressure that is higher than normal).<BR/>Record review of Resident #19's quarterly MDS, dated [DATE], reflected she had a BIMS score of 11, which indicated a minimal impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. <BR/>Review of Resident #19's face sheet reflected she had a resident representative who was also listed as her primary contact.<BR/>An interview with Resident #19 on 09/13/2022 at 11:15 am revealed she had not been to her own care plan meeting in six months or greater. Resident #19 stated it was important to her to be a part of her plan of care and she did not want strangers to decide her care. Resident #19 stated that she used to get a letter from the social worker that said when the care plan meetings would be held but she had not gotten one in more than 6 months.<BR/>An interview with Resident #19's primary contact on 09/13/2022 at 12:50 PM revealed she had not known of a care plan meeting but once this year.<BR/>2. <BR/>Record review of Resident 47's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: cerebral infarction ((also known as a stroke) refers to damage to tissues in the brain due to a loss of oxygen to the area), diabetes mellitus (is an impairment in the way the body regulates and uses sugar (glucose) as a fuel), and hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone).<BR/>Record review of Resident # 47's quarterly MDS, dated [DATE], reflected he had a BIMS score of 12, which indicated a minimal impaired cognitive status. His functional status reflected he required extensive assistance with bed mobility, toilet use and personal hygiene. He required set up only for eating.<BR/>Record review of last recorded care plan meeting was dated 11/27/2021. The care plan meeting was recorded as a discharge care plan meeting with the goal of returning home with home health services. The attendees were recorded as the resident representative and the social worker.<BR/>An interview with Resident #47 on 09/12/2022 at 2:12 pm revealed Resident #47 had not had a care plan meeting in over a year. Resident #47 stated he had a family member that would attend if they were invited. Resident #47 wanted to have a care plan meeting to discuss his need for therapy services related to his loss of ROM to his right side. Resident #47 stated he had mentioned his need for therapy to the CNA's and nurses that came to care for him but no one from therapy came to check on him.<BR/>3. <BR/>Record review of Resident 74's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: fracture of left femur (a break in the thighbone), seizures (a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements, or feelings, and in levels of consciousness), Chronic Obstructive Pulmonary Disease (a group of diseases that cause airflow blockage and breathing-related problems).<BR/>Record review of Resident # 74's admission MDS, dated [DATE], reflected she had a BIMS score of 14,which indicated no impaired cognitive status. Her functional status reflected she required limited assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. <BR/>Review of Resident #74's face sheet reflected she had a resident representative who was also listed as her primary contact.<BR/>An interview with Resident #74 on 09/13/2022 at 11:30 am revealed she had not been to her own care plan meeting. Resident #74 stated it was important to her to be a part of her plan of care and she had a lot of questions and things she wished to discuss with the directors of different departments. <BR/>An interview with Resident #74's primary contact on 09/13/2022 at 12:45 PM revealed she had not been informed of a care plan meeting being held for Resident #47.<BR/>Record review of Resident #74's EHR revealed no care plan letter invitations. <BR/>An interview with the SW on 09/14/2022 at 4:15pm revealed she was the one in charge of coordinating the care plan meetings. She stated care plan meetings for skilled resident's occurred on Tuesday and non-skilled residents occurred on Thursday each week. The SW stated she sent out a care plan letter to inform the primary contacts of the care plan meetings and gave a copy to the residents to invite them. Then she scanned the letter into the EHR. The SW stated that she recorded each meeting in the care plan section of the EHR. The SW stated that each care plan meeting the SW, dietary manager, activities, rehab coordinator, resident and resident representative were invited. The SW stated the care plan meetings were held quarterly and as needed. The SW did not know specifically why Resident #19, Resident #47 and Resident #74 did not have recorded care plan meetings. The SW stated not having a care plan meeting with the family and resident present could make the resident feel like they are not part of important decisions about their care and life.<BR/>An interview with the DON on 09/14/2022 at 3:30 pm revealed the care plan meetings were important to be held quarterly and as needed so they family and resident could be a part of their plan of care. The DON stated it was the MDS nurse that gave the schedule of who was due for a care plan meeting and the SW was to schedule and hold the care plan meetings. The DON stated she was unaware that this was not happening quarterly and as needed. The DON stated it was the responsibility of the Social Worker and MDS nurse to ensure the care plan meetings were happening and everyone attended.<BR/>An interview with the Administrator on 09/15/2022 at 3:30 pm revealed the care plan meetings were to be attended by all members of the IDT team and were to be done quarterly and as needed. The Administrator stated the SW was responsible for coordinating the care plan meetings and it had not been brought to her attention that care plan meetings were being missed. The Administrator stated it was important for the residents and family to have a say it the resident's care. The Administrator stated if the residents and family did not get as say in the care of the resident, they could feel their autonomy was not being honored.<BR/>Review of an undated policy titled Care Planning/Interdisciplinary Team on 09/15/2022 at 4:15 pm revealed, The care planning team shall be composed of but not necessarily limited to the following personnel: a. RN assessment coordinator, b. Director of nursing, c. Medical director, d. attending physician, e. Therapist, f. Activity director, g. Social service director, h. Dietician/food service manager, i. Pharmacist, j. other individuals as the resident's need dictates and meet quarterly.the secretary to the team shall be responsible for notifying team members when a meeting is scheduled, providing reports, ect., to be reviewed, and maintaining written reports of all meetings.

**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 11 of 22 residents (Residents #19, #60, #33, #61, #93, #97, #54, #8, #70, #23, and #76) reviewed for reasonable accommodations.<BR/>-The facility failed to ensure Residents #19, #60, #33, #61, #93, #97, #70, and #54 call lights were accessible. <BR/>-The facility failed to replace Resident #93's toilet with a taller, more accessible toilet.<BR/>- The facility failed to respond to Resident #8, Resident #70, Resident #23, and Resident #76 in a timely manner.<BR/>This failure could place residents at risk of injuries, health complications and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of Resident 19's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), glaucoma (a group of eye conditions that damage the optic nerve, the health of which is vital for good vision), and hypertension (blood pressure that is higher than normal).<BR/>Record review of Resident #19's quarterly MDS, dated [DATE], reflected she had a BIMS score of 11, which indicated a minimal impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. <BR/>Record review of Resident #19's care plan dated 06/24/2022 titled self-care deficit revealed Resident #19 required extensive assistance with bed mobility, transfer, ambulation, and toileting. <BR/>During an observation on 09/12/2022 at 10:02 am Resident #19 was looking for her call light and could not find her call light. The call light was noted to be on the floor underneath the bed.<BR/>During an observation and interview on 09/13/2022 at 11:18am Resident #19 was looking for her call light and could not find her call light. The call light was on the floor bedside the bed. Resident #19 was unable to reach the call light. Resident #19 stated she had no way of getting help if she could not use her call light. She stated her call light was not within reach at least once daily. She stated no one can hear you if you scream and she was not able to get out of bed to look for the call light on her own.<BR/>2. Record review of Resident 60's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: dementia (A group of thinking and social symptoms that interferes with daily functioning.), anemia (a condition in which the number of red blood cells is below normal), and major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).<BR/>Record review of Resident # 60's MDS, dated [DATE], reflected he had a BIMS score of 05, which indicated moderately impaired cognitive status. His functional status reflected he required extensive assistance with bed mobility, toilet use and personal hygiene. She required supervision only for eating. <BR/>Record review of Resident #60's care plan dated 07/06/2022, reflected Resident #60 required extensive assistance with bed mobility, transfer, toileting, and personal hygiene. The fall care plan dated 07/06/2022 reflected Resident #60 was a fall risk with multiple falls and call light was to be in reach at all times.<BR/>During an observation and interview on 09/12/2022 at 9:45 am, Resident #60 was lying in bed and stated he could not find his call light. The call light for Resident #60 was noted on the floor beside the bed. Resident #60 stated he had fallen the previous night because he was unable to reach his call light and get help out of the bed.<BR/>During an observation and interview on 09/13/2022 at 4:40 pm, Resident #60 was sitting up on the side of his bed attempting to get out of bed. Resident #60 stated he had to get to the organ to play music. Resident #60's call light was on the floor behind the headboard.<BR/>3. Record review of the face sheet dated 9/14/2022 indicated Resident #33 was [AGE] years old and was admitted on [DATE] with diagnoses including liver cell carcinoma (liver cancer), stroke, and heart disease. <BR/>Record review of a care plan dated 9/3/2022 indicated Resident #33 had a history of anxiety and was prescribed an anti-anxiety medication. Resident #33 had impaired physical mobility and required assistance with self-care. <BR/>Record review of the MDS dated [DATE] indicated Resident #33 was understood and usually understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 8 which indicated Resident #33 was moderately cognitively impaired. Resident #31 required extensive to total assistance from staff with ADLs. <BR/>During an observation on 9/12/2022 at 11:00 a.m., revealed Resident #33 in her bed. The cord to her call light was draped over the rail and the call light was near the floor. The call light was out of reach of the resident. <BR/>During an observation on 09/14/22 at 8:32 a.m., revealed Resident #33 was in her bed. Her call light was on the floor on the right side of bed, out of reach of the resident.<BR/>4. Record review of a face sheet dated 9/14/2022 revealed Resident #61 was [AGE] years old and was initially admitted on [DATE] with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone, or posture), paranoid schizophrenia (a mental disorder characterized by continuous or relapsing episode of psychosis), and moderate intellectual disabilities. <BR/>Record review of a care plan dated 7/19/2022 indicated Resident #61 had a history of cerebral palsy and required extensive assistance with bed mobility and transfers. The care plan indicated Resident #61 was immobile.<BR/>Record review of the most recent MDS dated [DATE] indicated Resident #61 was sometimes understood and sometimes understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) of 8. This score indicated moderate cognitive impairment for Resident #61. The MDS also indicated Resident #61 required limited to extensive assistance from staff for ADLs. <BR/>During an observation on 9/12/22 at 10:21 a.m., Resident #61 was in bed and her call light was on the floor on the right side of her bed and was under a trash can. The call light was out of reach of Resident #61.<BR/>During an observation on 9/12/22 at 12:08 p.m., Resident #61 was in bed and her call light was on the floor on the right side of her bed and was under a trash can. The call light was out of reach of Resident #61.<BR/>During an observation on 9/12/22 at 2:38 p.m., incontinent care was provided for Resident #61. Resident #61's call light was on floor on the right side of her bed and was under the trash can at bedside. The call light was out of Resident #61's reach. <BR/>During an observation on 9/13/22 at 8:55 a.m., Resident #61 was asleep in bed. The resident's call light was on the floor on the right side of her bed and was under the trash can. <BR/>During an interview on 9/15/22 at 10:10 a.m., LVN E said she did see call lights off to the side and out of reach of residents. She said the morning of 9/15/2022, Resident #61's call light was on her bedside table. She said it would probably be better with a clip on the cord. She said if a resident cannot reach their call light, they would not be able to call for help .<BR/>5. Record review of a face sheet dated 9/14/2022 indicated Resident #93 was [AGE] years old and was initially admitted on [DATE] with diagnoses of presence of right artificial shoulder joint, diabetes, and abnormality gait and mobility. <BR/>Record review of consolidated physician orders dated 9/14/2022 for Resident #93 indicated an order dated 8/22/2022 for a sling ever am shift, monitor sling to right arm QD (every day). <BR/>Record review of a care plan with dated 6/16/2022 indicated Resident #93 had decrease ROM (range of motion) to right shoulder, right elbow, and right wrist. <BR/>Record review of the MDS dated [DATE] indicated Resident #93 was understood and understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 13 indicating Resident #93 was cognitively intact. The MDS indicated Resident #93 required supervision only during toilet use. The MDS indicated Resident #93 had mood disorders of anxiety and depression. <BR/>During an observation and interview on 9/12/2022 at 3:17 p.m., Resident #93 said his toilet is too low and he has trouble getting off the toilet and back into his wheelchair. The resident had amputations to both lower extremities. There was a motorized wheelchair at bedside. The resident said he can transfer himself. The bathroom was observed. The toilet did appear low and other than a bar on the far wall there was not adaptive equipment. <BR/>During an interview on 9/14/2022 at 11:01 a.m., Resident #93 said he had resided in his current room since February 2022. He said he had complained to Maintenance Supervisor several times about his toilet being too low. He said he remembers reporting this to the Maintenance Supervisor in February 2022. He said at one point they did bring him an over the commode seat, but it did not help him. He said he complained to the administrator at least twice. He said on 9/13/2022 the administrator told him that she thought the toilet had already been replaced. He said since February he has had trouble getting on and off the toilet from his electric wheelchair. He said it had been worse the last 3 weeks because his right arm had been in a sling.<BR/>During an observation and interview on 9/14/2022 at 11:22 a.m., Maintenance Supervisor said the procedure for maintenance issues was for staff to fill out a work order and place it in his box. He said Resident #93 had complained to him weeks ago about his toilet being too low for him. He said he could not remember exactly how long it had been. He said the issue was never reported to him in writing and he said he had carried him a taller over the commode toilet seat, but he could not use it because it kept moving on him. He said there was a delay in getting the toilet replaced because the taller toilet was on backorder. He said he had a new toilet in the back of his truck. He said he went to a hardware store on 9/13/2022 and bought a new taller toilet. The Maintenance Supervision measured the lower toilet in Resident #93 bathroom. The toilet measured 15 inches from the floor to the toilet seat. The Maintenance Supervisor measured Resident #93's electric wheelchair. The wheelchair measured 25 inches from the floor to the top of seat. <BR/>During an interview on 09/14/2022 at 3:23 p.m., CNA C said it had been at least 6 months since she had provided care to Resident #93. She said at that time he reported to her that his toilet was too low. She said he had told her he might need help because it was too low. She said she reported the issue to the nurses and to the Maintenance Supervisor at that time.<BR/>6. Record review of a face sheet dated 9/14/2022 revealed Resident #97 was [AGE] years old and was initially admitted on [DATE] with diagnoses including urinary tract infection, pressure ulcer, and chronic pain syndrome. <BR/>Record review of a care plan dated 9/12/2022 indicated Resident #97 had impaired physical mobility and required assistance from staff. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #97 was usually understood and understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) of 9 which indicated Resident #97 was moderately cognitively impaired. The MDS indicated Resident #97 required extensive assistance with ADLs.<BR/>During an interview on 9/14/2022 at 11:45 a.m., Resident #97 said her mattress was changed on 9/13/2022. While her mattress was being changed, her call light was draped over the end table beside her bed. She said afterwards she was uncomfortable in the bed but could not use the call light to call for help. She said she had to yell out for help until someone came to her room to help her reposition in the bed. <BR/>During an interview on 9/14/2022 at 3:34 p.m., CNA D said every shift she comes in for her shift, call lights are in the floor and out of reach of resident. She said call lights should be in reach of each resident. <BR/>7. Record review of the face sheet dated 09/14/22 revealed Resident #54 was [AGE] years old, female, and admitted on [DATE] with diagnosis including cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and heart failure (heart doesn't pump enough blood for your body's needs). <BR/>Record review of the MDS dated [DATE] revealed Resident #54 was usually understood and usually understood others. The MDS revealed Resident #54 had clear speech and impaired vision with corrective lenses. The MDS revealed Resident #54 had a BIMS of 08 which indicated mild cognitive impairment and required total dependence for all ADLs except eating. <BR/>Record review of the care plan dated 08/17/22 revealed Resident #54 was a fall risk related to history of heart failure and peripheral vascular disease and high fall risk as evidence by right and left lower extremity weakness and cognitive status: mildly/moderately impaired. Interventions include keep call light and most frequently used personal items within reach. <BR/>During an interview and observation on 09/12/22 at 2:59 p.m., Resident #54 was lying in bed visibly upset and crying. She said she had been needing help, but no one came. She said it happens all the time. She said she could not find her call light. The call light was at the head of the bed out of reach.<BR/>8.Record review of the face sheet dated 09/14/22 revealed Resident # 8 was [AGE] years old, female and admitted on [DATE] with diagnosis including cerebral ischemia (acute brain injury that results from impaired blood flow to the brain), unsteadiness on feet, abnormal posture, lack of coordination, muscle weakness, and muscle wasting and atrophy(shortening). <BR/>Record review of the MDS dated [DATE] revealed Resident #8 was understood and usually understood others. The MDS revealed Resident #8 had clear speech and highly impaired vision with corrective lenses. The MDS revealed Resident #8 had a BIMS score of 12 which indicated mild cognitive impairment and required limited assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing.<BR/>Record review of the care plan dated 05/26/22 revealed Resident #8 was a fall risk related to history of stroke, heart failure, hypertension, and high fall risk assessment as evidence by joint mobility interferes with balance, generalized weakness, and extensive assist for transfer. Interventions included assist resident with ADLs as needed and keep call light and most frequently used items within reach. <BR/>During an observation on 09/12/22 at 9:42 a.m., Resident #8 was hollering out and mumbling to herself. Resident #8 was standing up in front of her recliner with her brief off. Resident #8 told a CNA, I tried to wait for help, but no one came.<BR/>During an interview on 09/12/22 at 10:47 a.m., Resident #8 said staff take a long time to answer the call and did not think she needed assistance with being changed. She said sometimes she must take matters in her own hands and change herself, like this morning. <BR/>During an observation on 09/13/22 at 11:40 a.m., Resident #8 call light was going off. CNA V answered the call light at 12:14 p.m. Resident #8 told CNA V she needed to be changed.<BR/>9. Record review of the face sheet dated 09/14/22 revealed Resident #70 was [AGE] years old female and admitted on [DATE] with diagnoses including acquired absence of right leg above the knee, age related debility (physical weakness), and cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). <BR/>Record review of the MDS dated [DATE] revealed Resident #70 was understood and understood others. The MDS revealed Resident had clear speech and adequate vision with corrective lenses. The MDS revealed Resident #70 had a BIMS of 14 which indicated intact cognition and required extensive assistance for toilet use and total dependence for transfers, dressing, personal hygiene, and bathing. <BR/>Record review of the care plan dated 08/04/22 revealed Resident #70 was a fall risk related to high fall risk assessment as evidence by amputation, joint mobility interferes with balance, and cognitive status. Interventions included keep call light and most frequently used personal items within reach. <BR/>During an interview on 09/12/22 at 3:27 p.m., Resident #70 said there was a delay in the call light response time, from 30 to 45 minutes. <BR/>During an interview on 09/13/22 at 9:25 a.m., Resident #70 said she could not find her call light in the middle of the morning. She said she needed to call the nurse for some pain medication because she was in pain. Resident #70 said when she could not find her call light in the middle of the morning, it was attached to her body pillow that fell on the floor. She said someone came in and picked up the pillow but not her call light.<BR/>During an interview and observation on 09/13/22 at 4:24 p.m., Resident #70's call light was on the floor, and she said she needed to be changed. <BR/>10. Record review of the face sheet dated 09/15/22 revealed Resident # 23 was [AGE] years old, male, and admitted on [DATE] with diagnosis including transient ischemic attack (is a stroke that lasts only a few minutes) and cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). <BR/>Record review of the MDS dated [DATE] revealed Resident #23 was understood and understood others. The MDS revealed Resident #23 had a BIMS score of 12 which indicated mild cognitive impairment and required limited assistance with transfers and dressing but extensive assistance with toilet use and bathing. <BR/>Record review of the care plan dated 06/29/22 revealed Resident #23 was a fall risk related to fall evidence by generalized weakness and cognitive status: mildly/moderately impaired. Interventions included keep call light and most frequently used personal items within reach. <BR/>During an interview on 09/12/22 at 11:38 a.m., Resident #23 said staff did not answer the call light timely. He said sometimes it takes them 1-2 hours for staff to answer the light. He said it happened on all the shifts.<BR/>11. Record review of the face sheet dated 09/14/22 revealed Resident #76 was [AGE] years old, male, and admitted on [DATE] with diagnoses including cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), heart failure (heart doesn't pump enough blood for your body's needs), and obesity. <BR/>Record review of the MDS dated [DATE] revealed Resident #76 was understood and understood others. The MDS revealed Resident #76 had clear speech, moderate difficulty hearing, and impaired vision with corrective lenses. The MDS revealed Resident #76 had a BIMS score of 09 which indicated mild cognitive impairment and required extensive assistance for bed mobility, dressing, personal hygiene and total dependence for transfers, toilet use and bathing. <BR/>Record review of the care plan dated 05/04/22 had fall risk related to fall, history of heart failure, and high fall risk assessment as evidence by generalized weakness and cognitive status. Interventions included keep call light and most frequently used personal items within reach.<BR/>During an interview on 09/12/22 at 11:24 a.m., Resident #76 said the CNAs take forever to answer the call light.<BR/>During an interview on 09/14/22 at 1:27 p.m., CNA V said she had worked at the facility 2 years ago and returned 2 days ago. She said call lights should be answered within 2 minutes. She said 2 CNAs are normally on the halls. She said no residents had complained to her about call light response time. She said the day Resident #8's call light was unanswered for an extended period was because she and the other CNA were off the floor. She said they both were in the dining room helping with lunch. She said both CNAs are not both supposed to leave the floor and she did not inform the ADON. She said call lights being within reach and answered timely prevented falls and accidents for continent residents. She said resident probably felt frustrated when the call lights were not answered or could not find it to get help. <BR/>During an interview on 09/14/22 at 2:52 p.m., LVN W said she had previously worked at the facility 5 years ago and returned last week. She said call lights should be answered asap because you do not know if the issues were minor or major. She said any staff member can answer call lights and ensure they are within reach. She said call lights are mostly answered timely. She said properly placed call light and timely response could prevent falls and the resident could be calling about chest pain, shortness of breath, or incontinent care. <BR/>During an interview on 09/14/22 at 3:25 p.m., CNA X said she was the CNA coordinator but had been working the floor. She said call lights should be answered asap and the facility trained CNAs to follow the same guidelines. She said call lights should be hooked out something within reach and eyesight. She said she had not heard any residents complain but she did not work the 100-hall often. She said proper placed call light and timely response could prevent falls and residents could be calling for help because they were having a stroke or heart attacked. She said call lights not being answered timely and within reach could make the resident feel neglected. She said it was the CNAs responsibility for timely call lights response and placing them within reach. <BR/>During an interview on 09/15/22 at 11:07 a.m., CNA Y said she had worked at the facility since August 2019. She said she worked 2pm-10pm shift and worked the 100-hall frequently. She said call lights should be answered within 2-3 minutes and attached to the bed remote control or bed sheets. She said call lights were important because it was the resident's line of communication and could prevent falls. She said it was the CNAs responsibility for timely call lights response and placing them within reach.<BR/>During an interview on 9/14/22 at 4:59 p.m., the DON said she expected the nurses and CNAs to put the call lights within reach of the residents even if they could not use it. The DON said call lights being in reach was important for the resident to be able to have access to call out for assistance and comforting in knowing the call light was there to call out for help. The DON said not having call lights in reach could result in a fall and a need unnoticed until a routine check. She said it was her responsibility to ensure all direct care staff placed the call lights within reach of each resident. The DON said daily routine rounds were made by the ADON to ensure call lights were in reach. The DON said it was her understanding that rounds were made, and call lights were in reach. <BR/>A policy dated 02/12/2022 titled Call Light Answering revealed: Standards of Practice: The staff will provide an environment that helps meet the residents needs by answering call lights appropriately. Respond to patients/resident's call lights and emergency lights in a timely manner .when leaving room, be sure the call light is placed within the resident's reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 2 residents reviewed for care plans. (Resident# 29)<BR/>The facility failed to implement the care plan intervention to report to Resident #29's provider, of his blood glucose levels (is a test that mainly screens for diabetes by measuring the level of glucose (sugar) in your blood) that were less than 100 per the physician orders.<BR/>This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services.<BR/>Findings included:<BR/>Record review of Resident #29's face sheet dated 10/30/23 indicated Resident #29 was 91-years-old male and admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)). <BR/>Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated Resident #29 was usually understood and usually understood others. The MDS indicated Resident #29's BIMS score was 10 which indicated moderate cognitive impairment and required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and bathing. <BR/>Record review of Resident #29's care plan dated 11/11/22 indicated Resident #29 received an antidiabetic (are medicines developed to stabilize and control blood glucose levels amongst people with diabetes). Interventions included observe for signs of hypoglycemia (low blood sugar, the body's main energy source) and treat per hypoglycemic protocol and report pertinent lab results to physician. <BR/>Record review of Resident #29's Physician Summary Report dated 10/01/23-10/31/23 Novolin 70/30 (is used for the treatment of diabetes only) Unit-100 Insulin (helps your body turn food into energy and controls your blood sugar levels) 100 unit/ml subcutaneous (a short needle is used to inject a drug into the tissue layer between the skin and the muscle) suspension 35 units/units subcutaneous 1 time per day, Notify MD/NP for FSBS (blood glucose monitoring) less than 60 or greater than 350. Hold if blood sugar is less than 100 and contact MD. *MD call. Dx: diabetes mellitus (a group of diseases that result in too much sugar in the blood (high blood glucose)), Started on 09/14/23. Discontinued by LVN Q on 10/05/23.<BR/>Record review of Resident #29's Physician Summary Report dated 10/01/23-10/31/23 Humulin 70/30 Unit-100 Insulin 100 unit/ml subcutaneous 20 Units/units subcutaneous daily at bedtime, Blood Glucose Check Site Location, hold if Blood sugar is less than 100 and contact MD. MD call. Dx: Type 2 diabetes mellitus, Started on 09/14/23. Discontinued by LVN Q on 10/05/23.<BR/>Record review of Resident #29's Consolidated Physician Order dated 10/05/23 reflected Novolin 70/30 Unit-100 Insulin 100 unit/ml subcutaneous suspension 30 units/units subcutaneous 1 time per day, Notify MD/NP for FSBS less than 60 or greater than 350. Hold if blood sugar is less than 100 and contact MD. MD call. <BR/>Record review of Resident #29's Consolidated Physician Order dated 10/05/23 reflected Humulin 70/30 Unit-100 Insulin 100 unit/ml subcutaneous 15 Units/units subcutaneous daily at bedtime, Blood Glucose Check Site Location, hold if Blood sugar is less than 100 and contact MD. MD call.<BR/>Record review of Resident #29's MAR dated 10/01/23-10/31/23 indicated Novolin 70/30 Unit-100 Insulin 100 unit/ml subcutaneous suspension 35 units/units subcutaneous 1 time per day, Notify MD/NP for FSBS less than 60 or greater than 350. Hold if blood sugar is less than 100 and contact MD. MD call. Dx: diabetes mellitus. Start date: 09/14/23. End date: 10/05/23. Blood glucose results indicated:<BR/>*10/02/23 BSG 63 (LVN T)<BR/>*10/03/23 BSG 81 (LVN T)<BR/>*10/04/23 BSG 90 (LVN Q)<BR/>*10/05/23 BSG 58 (LVN Q)<BR/>Record review of Resident #29's MAR dated 10/01/23-10/31/23 indicated Novolin 70/30 Unit-100 Insulin 100 unit/ml subcutaneous suspension 30 units/units subcutaneous 1 time per day, Notify MD/NP for FSBS less than 60 or greater than 350. Hold if blood sugar is less than 100 and contact MD. MD call. Dx: diabetes mellitus. Start date: 10/05/23. Blood glucose results indicated:<BR/>*10/06/23 BSG 69 (LVN T)<BR/>*10/08/23 BSG 60 (LVN T)<BR/>*10/11/23 BSG 64 (LVN T)<BR/>*10/13/23 BSG 85 (LVN Q)<BR/>*10/18/23 BSG 85 (LVN Q)<BR/>*10/22/23 BSG 61 (LVN T)<BR/>*10/29/23 BSG 87 (Agency LVN)<BR/>Record review of Resident #29's nurses note dated 01/30/23-10/30/23 indicated on 10/05/23 by LVN Q . [Resident #29] BS at 0630 a.m. was 58 . [Resident #29] was a little sweaty but other signs or symptoms of hypoglycemia .APRN QQ was notified orders given to give 2 glasses of juice and recheck after breakfast .recheck was done [Resident #29] BS 98 . No other entries noted regarding BS less than 100 or notification of the MD/NP. <BR/>During an interview on 11/01/23 at 9:30 a.m., APRN QQ said Resident #29 recently joined his services. He said the facility had notified him about Resident #29's BSGs being less than 100 about 3 times. He said he had not been notified of Resident #29's BSG being less than 100, a total of 10 times noted on the MAR. He said the facility may had called Resident #29's hospice company about the BSG results. He said he recalled once modifying Resident #29's insulin orders due to a low BSG result. He said he gave verbal orders and wrote some on his rounding paperwork. He said reporting Resident #29's BSG results were important to monitor recurring trends of hypoglycemia. He said it was also important to avoid sympathetic hypoglycemia (the nutritionally deprived brain also stimulates the sympathetic nervous system, leading to neurogenic symptoms such as sweating, palpitations, tremulousness, anxiety, and hunger). He said it important to be notified to decrease the dosage of Resident #29's insulin to reduce the risk of hypoglycemia. <BR/>On 11/02/23 at 1:20 p.m., attempted to contact LVN T by phone. A voice message was left but no to return call prior or after exit. <BR/>During an interview on 11/02/23 at 2:06 p.m., LVN N said when a MD/NP was notified regarding lab results such as low BSGs, the nurse should document in a progress note. She said it was important to follow the Resident #29's care plan interventions. She said most care plan interventions correlated with physician's orders. She said if the MD/NP made changes it could be documented in a nurses note and 24-hour report. She said it was important to notify the MD/NP in case they needed to be sent to the hospital or receive intravascular fluid. She said untreated hypoglycemia could result in a coma and death. <BR/>During an interview on 11/02/23 at 3:04 p.m., the DON said nursing administration tried to go over too high and low BSG in morning meetings. She said they mostly went over high BSG because the computer system flagged high BSG. She said she did not recall being notified or reviewing Resident #29's BSG results less than 100. She said she did recall APRN QQ gave an order to give Resident #29 some juice to address a BSG result less than 100. She said low BSG could indicate infection. She said if a resident was sympathetic, gel should be given, and provider contacted. She said notifying a MD/NP for BSG less than 100 was not a standard order, it normally was less than 60. She said nurses should document notification of the physician and new orders if received in a nurses note or on the MAR. She said a resident being hypoglycemia was not good. She said Resident #29 could go into a diabetic coma or DKA (diabetic ketoacidosis is a serious complication of diabetes that can be life-threatening). She said she tried to monitor all resident BSG results every morning, but it was easier to monitor the high results because they sent an alert. She said she also reviewed and monitored the 24-hour report of pertinent lab results. She said some days it did not happened due to other duties. She said care plans are used by nurses to outline a plan of care for a resident. She said when care plan interventions were not followed, needs could not be addressed. <BR/>During an interview on 11/02/23 at 4:07 p.m., the ADM said care plan are used to determine individualized care needs of the resident and intervention put in place to address those needs. She said if the intervention was not followed the resident's needs could not be addressed or met by the staff. <BR/>Record review of a facility's Comprehensive Care Plans policy reviewed 04/17/23 indicated .the services that are to be furnished to attain or maintain the resident's highest practicable physical .qualified staff responsible for carrying out interventions specified in the care plan will be notified of their role and responsibilities for carrying out the interventions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 7 residents (Resident #27) reviewed for appropriate treatment and services to prevent urinary tract infections (an infection in any part of the urinary system, the kidneys, bladder, or urethra (is a hollow tube that lets urine leave your body)). <BR/>The facility failed to ensure Resident #27's indwelling catheter (drains urine from your bladder into a bag outside your body) remained free of dependent loops (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag) and had a leg strap to anchor catheter to his leg. <BR/>This failure could place residents at risk for urinary tract infections.<BR/>Findings included:<BR/>Record review of Resident #27's face sheet dated 10/30/23 indicated Resident #27 was a [AGE] year-old male and admitted on [DATE] and 04/06/23 with diagnoses including cerebral infarction ((also known as a stroke) refers to damage to tissues in the brain due to a loss of oxygen to the area), pressure ulcer of buttock (also known as bedsores, are an injury that breaks down the skin and underlying tissue), stage 3, and pain. <BR/>Record review of Resident #27's annual MDS assessment dated [DATE] indicated Resident #27 was usually understood and usually understood others. The MDS indicated Resident #27 had a BIMS score of 09 which indicated moderately impaired cognition and required limited assistance with dressing, extensive assistance with bed mobility, toilet use, personal hygiene, and bathing. The MDS indicated Resident #27 had an indwelling catheter and always had bowel incontinence.<BR/>Record review of Resident #27's care plan dated 09/21/23 indicated Resident #27 was at risk for problem with elimination related to Foley catheter placement, history of urinary tract infection as evidence by diagnosis of obstructive uropathy (is a disorder of the urinary tract that occurs due to obstructed urinary flow). Intervention catheter care every shift and as needed and monitor for signs and symptoms of urinary tract infection. <BR/>Record review of Resident #27's consolidated physician order dated 08/07/23 indicated Foley Catheter 16 fr, night shift to continuous gravity drainage and catheter care. Bulb size 10 mL. ***Privacy bag checked, and placement of leg strap verified every shift**** The consolidated physician order indicated Resident #27 had an diagnosis of urinary tract infection. <BR/>Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated Foley Catheter 16 fr, night shift to continuous gravity drainage and catheter care. Bulb size 10 mL. ***Privacy bag checked, and placement of leg strap verified every shift**** Dx: Obstructive (is a disorder of the urinary tract that occurs due to obstructed urinary flow) and reflux (is kidney scarring caused by urine flowing backward from the bladder into a ureter and toward a kidney) uropathy. Start date: 08/07/23. The TAR indicated documentation of verification 10/01/23-10/31/23. <BR/>During an interview and observation on 10/30/24 at 11:24 a.m., Resident #27 was lying in bed on his back. Resident #27 looked confused and said he did not know about a strap around his leg to hold the catheter. <BR/>During an observation on 10/31/23 at 3:02 p.m., Resident #27 got wound care performed by WCN NN and no leg strap to hold his indwelling catheter was noted. Resident #27's indwelling catheter tubing was looped through the brief tabs forming a dependent loop. <BR/>During an interview om 11/02/23 at 10:26 a.m., WCN NN said she did not recall seeing a leg strap on Resident #27's leg for his indwelling catheter during his dressing changes. She said leg strap was important to prevent pulling. She said no leg strap and dependent loops placed residents at risk for infection and damage to the urethra. She said the nurses should be checking for a leg strap and no dependent loops. <BR/>On 11/02/23 at 11:20 a.m., an indwelling catheter policy was requested from the ADM. The policy was not provided prior or after exit.<BR/>During an interview on 11/02/23 at 12:47p.m., an anonymous staff member said Resident #27 currently did not have leg strap and never had a leg strap for his catheter. They said a leg strap helped the catheter not move. They said they normally looped the tubing in his brief to prevent it from pulling. They said not having a leg strap could cause a tear in Resident #27 genital and leakage. They said they had not been instructed to not loop catheter tubing. <BR/>During an interview on 11/02/23 at 2:06 p.m., LVN N said all residents with an indwelling catheter should have a leg strap. She said the LVNs were responsible for making sure residents had a leg strap. She said the leg strapped helped the catheter from pulling. She said not having a leg strap could cause pain and trauma to the urethra. She said those issues could cause problem with urinations. <BR/>During an interview on 11/02/23 at 2:52 p.m., RN TT said this was her 3rd shift working at the facility. She said she did not know if Resident #27 had a leg strap on. She said the CNAs should tell the nurses if a resident did not have one. She said Resident #27 should have a leg strap on to secure his catheter. She said the leg strap prevented pulling and from the catheter coming out. She said pulling of the catheter could cause a tear and damage the urethra or split the penis. She said the damage of the urethra could cause bleeding and pain during urination. She said dependent loops cause increased risk of infection. <BR/>During an interview on 11/02/23 at 3:04 p.m., the DON said Resident #27 should have a leg strap for his indwelling catheter. She said it was the nurse's responsibility to make sure resident had a leg strap. She said the leg strap kept the catheter in place and prevented dislodgement. She said pulling placed resident at risk for bleeding, irritation, and damaged to the urethra. She said loops through the resident's brief was not recommended due to the increased risk of infection. <BR/>Record review of a facility's .<BR/>The article from the Journal of Community Nursing December 12, 2014 titled The importance of fixation and securing devices in supporting indwelling catheters accessed at the Magonline Library website on 11/08/23 https://levityproducts.com/wp-content/uploads/2020/09/The-importance-of-fixation-and-securing-indwelling-catheters-2013.pdf stated, .catheter securing devices are vital part of catheter management .the catheter and attached drainage system should be well supported in a comfortable position for individual at catheter insertion to prevent complications .possible complications when not using adequate securing devices included .if the catheter migrates or is removed accidently, it can lead to urethral trauma, infection, patient discomfort and/or urinary retention .damage to the bladder neck can occur .lead to cleaving, causing discomfort and irritation .high potential risk for urinary tract infection .inflammation can lead to infection, tissue necrosis, blockage of urethra, bladder irritability, spasms and bypassing .high incidence of unplanned catheter changes .<BR/>The article from the Journal of wound Ostomy Continence Nursing May/June 2015 titled Prevalence of Dependent Loops in Urine Drainage Systems accessed at the National Library of Medicine website on 11/08/23 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4423413/ stated, . A dependent loop is formed by excess drainage tubing in a urine drainage system where urine or liquid can accumulate. Dependent loops trap drained urine and are suspected of impeding bladder drainage and increasing the residual volume of retained urine in the bladder. Dependent loops have been associated with an odds ratio of 2.1 for developing catheter-associated urinary tract infection (CAUTI) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 2 of 3 resident (Resident #3, Resident #6) reviewed for hydration. <BR/>The facility failed to ensure Resident #3 and Resident #6 hydration was within reach.<BR/>This failure could place residents at risk for dehydration (occurs when your body loses more fluid than you take in), electrolyte imbalance (occurs when certain mineral levels in your blood get too high or too low), and infections. <BR/>Findings included:<BR/>1. Record review of Resident #3's face sheet dated 11/02/23 indicated Resident #3 was 91-years-old male and admitted on [DATE] with diagnosis including dementia (a group of thinking and social symptoms that interferes with daily functioning), malignant neoplasm of prostate (is a disease in which malignant (cancer) cells form in the tissues of the prostate) and muscle weakness.<BR/>Record review of Resident #3's significant change in status MDS assessment dated [DATE] indicated Resident #3 was usually understood and sometimes had the ability to understand others. The MDS indicated Resident #3 had a BIMS score of 04 which indicated severely impaired cognitive impairment and required extensive assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and total dependence for bathing.<BR/>Record review of Resident #3's care plan dated 09/21/22 indicated Resident #3 received a diuretic (medicines that help reduce fluid buildup in the body). Intervention included monitor for blood potassium level, hypotension (low blood pressure), and signs/symptoms of dehydration. <BR/>Record review of Resident #3's care plan dated 09/07/23 indicated Resident #3 had an altered nutritional status related to risk of malnutrition as evidence by thin liquid consistency. Intervention included monitor oral intake of food and fluid. <BR/>Record review of Resident #3's, October 2023-November 2023 ADL report, category: eating, fluid intake in ml indicated:<BR/>*10/27/23 no documentation of fluid intake <BR/>*10/28/23 no documentation of fluid intake<BR/>*10/29/23 at 11:56 a.m. 0 ml fluid intake (CNA MM), no documentation for 2pm-10pm or 10pm-6am shift<BR/>*10/30/23 at 7:30 a.m. 25 ml (CNA H), 11:30 a.m. 25 ml (CNA H), 4:30 p.m. 600 ml (CNA OO)<BR/>*10/31/23 at 7:30 a.m. 25 ml (CNA H), 11:30 a.m. 25 ml (CNA H), 4:30 p.m. 360 ml (CNA PP)<BR/>*11/01/23 at 7:30 a.m. 25 ml (CNA H), 11:30 a.m. 25ml (CNA H), 4:4:30 p.m. 360 ml (CNA PP)<BR/>Record review of Resident #3's Comprehensive Metabolic (is a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working) lab work dated 08/14/23 did not show electrolyte imbalance related to dehydration. No recent lab work drawn. <BR/>During an observation on 10/31/23 at 9:52 a.m., Resident #3's water pitcher was on his bedside table against the wall, not within reach. <BR/>During an observation on 10/31/23 at 2:10 p.m., Resident #3's water pitcher was on his bedside table against the wall, not within reach.<BR/>2. Record review of Resident #6's face sheet dated 10/30/23 indicated Resident #6 was a [AGE] year-old female and admitted on [DATE] and 09/07/20 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), paraplegia (is a specific pattern of paralysis (which is when you can't deliberately control or move your muscles) that affects your legs), and chronic kidney disease (means your kidneys are damaged and can't filter blood the way they should). <BR/>Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was sometimes understood and sometimes had the ability to understand others. Resident #6 had unclear speech. The MDS indicated Resident #6 was unable to complete BIMS and had short-and-long term memory problem recall. The MDS indicated Resident #6 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #6 required limited assistance for eating and dressing, extensive assistance for bed mobility and bathing, and total dependence for toilet use. <BR/>Record review of Resident #6's care plan dated 09/29/22 indicated Resident #6 had altered nutritional status related to use of diuretics, laxative and/or cardiovascular as evidence by resident has inadequate fluid intake. Intervention included monitor oral intake of food and fluid. <BR/>Record review of Resident #6's, October 2023 -November 2023 ADL report, category: eating, fluid intake in ml indicated:<BR/>*10/27/23 no documentation of fluid intake <BR/>*10/28/23 no documentation of fluid intake<BR/>*10/29/23 at 7:30 a.m. 360 ml (CNA MM), at 11:30 a.m. 360 ml (CNA MM)<BR/>*10/30/23 at 7:30 a.m. 50 ml (CNA H), at 11:30 a.m. 50 ml (CNA H), at 4:30 p.m. 600 ml (CNA OO)<BR/>*10/31/23 at 7:30 a.m. 25 ml (CNA H), at 11:30 a.m. 50 ml (CNA H), at 4:30 p.m. 600 ml (CNA OO)<BR/>*11/01/23 at 7:30 a.m. 50 ml (CNA H), at 11:30 a.m. 50 ml (CNA H), at 4:30 p.m. 600 ml (CNA OO)<BR/>Record review of Resident #6's lab work, provided by the facility, indicated no electrolyte lab work had been drawn since 09/09/20.<BR/>During an interview on 10/30/23 at 2:16 p.m., family member C said one of her main concerns was her family member's water was never within reach when she visited. Family member C said her family member also did not have the strength to lift the water pitcher and she brought smaller cups for her to use. Family member C said she had to fill her family members pitcher herself and sometimes other residents too. <BR/>During an observation on 10/30/23 at 3:43 p.m. Resident #6's clear water pitcher with ml marking on the side, was full of water with no ice and on the bedside tray not within reach. <BR/>During an observation on 10/31/23 at 9:26 a.m. Resident #6's clear water pitcher was filled between the 600ml-700ml marking with no ice. The water pitcher was on the bedside tray not within reach.<BR/>During an observation on 10/31/23 at 9:42 a.m., CNA H started passing out ice water on the 100-hall.<BR/>During an observation on 10/31/23 at 11:35 a.m., Resident #6 had fresh ice water filled to 700 ml but was on the bedside tray not within reach.<BR/>During an observation on 10/31/23 at 2:05 p.m., Resident #6's water pitcher was still at 700 ml of water with no ice and on the bedside tray not within reach.<BR/>During an observation on 10/31/23 at 4:00 p.m., Resident #6's water pitcher was still at 700 ml of water with no ice and on the bedside tray not within reach.<BR/>During an interview on 11/02/23 at 12:47 a.m., an anonymous staff member said they passed out ice water at the start of each shift and after dinner. They said CNAs should make sure resident's water was within reach. They said they filled up the water pitcher to about 700 ml and counted down from there how much the resident drank. They said they had arrived on their shift and a resident water pitcher was filled to top with no ice. They said they had arrived on their shift and Resident #3 and Resident #6 bedside tray holding the water pitcher would be pushed out of reach. They said Resident #6 needed her water poured in smaller cups with a straw to help her drink. They said drinking adequate water helped prevent dehydration and dry skin. They said not having enough water could hurt the kidneys. <BR/>During an interview on 11/02/23 at 2:06 p.m., LVN N said anybody could pass water out. She said anybody could make sure it was within reach. She said the LVNs should ensure the aides are passing and offering hydration and keeping it within reach. She said she monitored hydration by asking resident if they had water during med pass and offered water to resident who need encouragement. She said hydration should be passed every shift and when asked by the resident. She said aides should offer hydration to resident every time they went into their rooms. She said adequate hydration prevented dehydration which could result in death. <BR/>During an interview on 11/02/23 at 3:04 p.m., the DON said hydration should be passed out on each shift and as needed. The DON said anyone could pass out hydration, but the aides were initially responsible. She said the LVNs should ensure hydration was passed out as needed and offered to resident frequently. She said when she did morning rounds, she monitored hydration. She said hydration was important to prevent dehydration and skin issues. She said dehydration could cause imbalances and decrease fluid volume which can affect vital signs. <BR/>Record review of a facility's Hydration policy revised 04/07 indicated .the staff will provide supportive measures such as providing fluids .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 7 residents reviewed for pharmacy services. (Resident #1)<BR/>The facility failed administer all scheduled medications to Resident #1. <BR/>This failure could place residents at risk for inaccurate drug administration and side effects from missed doses of medication. <BR/>Findings included:<BR/>Record review of a face sheet dated 10/03/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), muscle spasms, and recurrent depressive disorders. <BR/>Record review of physician's orders dated 10/04/23 indicated an order for Amlodipine (blood pressure medication) 5 milligram tablet, 1 tablet 1 time per day with a start date on 06/27/21. There was an order for Claritin (medication for allergy symptoms) 10 milligram tablet, 1 tablet 1 time per day with a start date of 05/08/23. There was an order Clonidine HCL (blood pressure medication) 0.1 milligram tablet, 1 time per day with a start date of 06/27/21. There was an order for Citalopram (used for depression) 10 milligram tablet, 1 time per day with a start date of 06/27/21. There was an order for Colace (stool softener) 100 milligram tablet 2 times per day with a start date of 11/01/22. There was an order for Cyclobenzaprine (treats pain and muscle stiffness) 5 milligram tablet every 8 hours with a start date of 11/01/22. There was an order for a multi vitamin, 1 tablet 1 time per day with a start date of 11/01/22. There was an order for Esomeprazole Magnesium (used to treat stomach and esophagus problems such as acid reflex, ulcer) 20 milligram, delayed release, 1 time per day with a start date of 06/27/21. There was an order for Fluticasone Propionate 50 micrograms/actuation nasal spray, 1 spray nasally 2 times per day with a start date of 05/08/23. There was an order for Levetiracetam (used to treat seizures) 100 milligrams/milliliters oral solution, 10 milliliters 2 times per day with a start date of 06/27/21. There was an order for Robitussin Cough-Chest Congestion DM 5 milligram/50 milligrams/5 milliliters every 6 hours with a start date of 11/01/22. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #1 was rarely to never understood. The MDS indicated a BIMS was not conducted due to Resident #1 being rarely to never understood. The MDS indicated Resident #1 received an antidepressant. The MDS indicated Resident #1 had an active diagnosis of hypertension (high blood pressure), a seizure disorder or epilepsy, and depression. <BR/>Record review of a care plan last revised on 05/31/23 indicated Resident #1 was prescribed an anti-convulsant - Levetiracetam (used to treat seizures) 100 milligrams/milliliters oral solution, 10 milliliters 2 times per day. There was an intervention to administer the medication as ordered. The care plan indicated the resident was prescribed an anti-depressant, Citalopram (used for depression) 10 milligram tablet, 1 time per day. There was an intervention to administer the medication as ordered. The care plan indicated the resident was prescribed anti-hypertensive medications, Amlodipine (blood pressure medication) 5 milligram tablet, 1 tablet 1 time per day and Clonidine HCL (blood pressure medication) 0.1 milligram tablet, 1 time per day. There was an intervention to administer the medications as ordered. <BR/>Record review of an eMAR (electronic medication administration record) dated 07/01/23 - 07/31/23 indicated on 07/04/23, Amlodipine and Clonidine were not administered as ordered. On 07/05/23, Amlodipine, Citalopram, Claritin, Clonidine, Colace, Cyclobenzaprine, a multi-vitamin, Esomeprazole Magnesium, Fluticasone Propionate, Levetiracetam, and Robitussin Cough-Chest were not administered as ordered. On 07/08/23, 07/10/23, 07/13/23, 07/14/23, 07/18/23, 07/19/23, 07/20/23, 07/23/23, 07/24/23, 07/25/23 Resident #1 did not receive Amlodipine and Clonidine as ordered. On 07/28/23, Resident #1 did not receive Amlodipine and Clonidine as order. The eMAR indicated on 07/29/23, Resident #1 did not receive Clonidine, Colace, Robitussin Cough-Chest Congestion and Levetiracetam were not administered as ordered. <BR/>Record review of an eMAR dated 09/01/23 - 09/30/23 indicated on 9/10/23, Resident #1 did not receive Citalopram as ordered. The eMAR indicated on 09/18/23 and 09/26/23, Resident #1 did not receive Amlodipine and Clonidine as ordered. <BR/>Record Review of Nurse's notes dated 07/01/23 - 09/30/2023 indicated on 07/28/23 a nurse's note read, Medication was administered outside of scheduled parameters, provider informed that resident medication was delayed . The note was signed by the DON. There were no further notes concerning delayed medication or medications that were not administered. <BR/>During an interview on 10/3/23 at 4:20 p.m., a family member of Resident #1 said on 07/28/23 Resident #1 did not receive his medication as prescribed.<BR/>During an interview on 10/03/23 at 5:05 p.m., a family member said Resident #1 had not always received his scheduled medications. The family member said they had found medications at the bedside. <BR/>During an interview on 10/04/23 at 2:48 p.m., the DON said she did not know why Residents #1's medications were not given on time on 7/28/2023. She said she did not know what happened. She said for some reason the medications were delayed and the nurse practitioner was notified.<BR/>During an interview on 10/5/2023 at 9:32 a.m., LVN D said document did indicate Resident #1 did miss several medications in July and September. She said if they were held for any reason there should be a nurse's note. She said the blood pressure medications may have been held due the resident's blood pressure or heart rate. She said, if it's not documented it's not done.<BR/>During an interview on 10/5/23 at 10:33 a.m., the DON said according to the documentation for July and September it did appear Resident #1 did not receive all of his medications. She said that the blood pressure medicines were probably held because his vital signs. She said she would have expected if the medicine was being held because of the vital signs, this should be documented. She said residents' not receiving their medications could cause them to have high or low blood pressure.<BR/>During an interview on 10/05/23 at 11:50 a.m., the Administrator said she would expect Resident #1 to get his scheduled medications as ordered. She said any negative outcome would depend on the medication such affecting blood pressure.<BR/>Review of a Medications - Guidelines on Clinical Practice policy dated January 12, 2020 indicated, .Staff will provide medications in accordance with standard practice guidelines .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview 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 1 of 5 residents (Resident #29) reviewed for unnecessary medications in that: <BR/>The facility failed to ensure Resident #29 had appropriate diagnoses for the use of Acetaminophen (is used to treat many conditions such as headache, muscle aches, arthritis, backache, toothaches, colds and fevers), Albuterol (is used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways)), Boost (a nutrient-packed high protein nutritional drink for muscle health and immune support), House shake (Fortified Nutritional Shakes provides a convenient way to supplement calories and protein), bedtime snack, Linezolid (is used to treat infections, including pneumonia, and infections of the skin), Magnesium (is used as a dietary supplement for individuals who are deficient in magnesium), and Tussin (is used to relieve coughs caused by the common cold, bronchitis, and other breathing illnesses). <BR/>This failure 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/>Record review of Resident #29's face sheet dated 10/30/23 indicated Resident #29 was 91-years-old male and admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), acute respiratory failure (happens when not enough oxygen passes from your lungs to your blood), Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), vitamin deficiency (a deficiency of one or more essential vitamins), pain, abnormal weight loss<BR/>Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated Resident #29 was usually understood and usually understood others. The MDS indicated Resident #29's BIMS score was 10 which indicated moderate cognitive impairment and required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and bathing.<BR/>Record review of Resident #29's care plan dated 11/11/22 indicated Resident#29 had pain related to severe cognitive impairment as evidence by acetaminophen 325 mg 2 tablet by mouth. Intervention included administer pain medication as ordered. <BR/>Record review of Resident #29's care plan dated 11/11/22 indicated Resident#29 had altered nutritional status related to increase needs for wound care and admission status: recent weight loss as evidence by increase nutrients needs, pressure ulcer, and significant weight loss. Intervention included provide vitamins. <BR/>Record review of Resident #29's care plan dated 09/25/23 indicated antibiotic as evidence by Zyvox (Linezolid) 600 mg 1 tablet by mouth 2 times a day for 10 days (09/25/23). Intervention included observe for possible side effects, please review medication information listed on electronic healthcare record for specific antibiotic side effects. <BR/>Record review of Resident #29's consolidated physician order dated:<BR/>*05/03/22 HS snack daily at bedtime (ordered as a snack food or beverage items to be given at the hour of sleep for diabetics)<BR/>*05/03/22 Magnesium 200mg 2 tablets by mouth 1 time per day<BR/>*07/08/22 House Shake 1 can by mouth 3 times per day<BR/>* 12/12/22 Acetaminophen 325mg tablet 2 tablets by mouth 2 times per day<BR/>*06/21/23 Boost Plus 0.06 gram-1.5 kcal/ml oral liquid (Lactose-reduced food) 1 bottle by mouth 1 time per day at lunch<BR/>*06/30/23 Tussin DM Clear 10mg-100mg/5ml oral syrup 10 ml by mouth 2 times per day<BR/>*09/25/23 Linezolid 600mg tablet 1 tablet by mouth 2 times per day 10 days<BR/>*10/19/23 Albuterol sulfate 2.5mg/3ml solution for nebulization 1 solution for nebulization inhalation 4 times per day as needed for shortness of breath nebulization<BR/>Record review of Resident #29's MAR dated 10/01/23-10/31/23 indicated:<BR/>* HS snack daily at bedtime. Dx: Acute respiratory failure. Start date: 05/30/22. Acute respiratory failure was related to the lungs not snacks at bedtime for diabetics.<BR/>* Magnesium 200mg 2 tablets by mouth 1 time per day. Dx: diabetes mellitus without complication. Start date: 06/28/23. Diabetes was related to the glucose level not Magnesium vitamin deficiency. <BR/>* House Shake 1 can by mouth 3 times per day. Dx: Cellulitis of left lower limb. Modification date: 06/28/23. Cellulitis was a deep infection of the skin caused by bacteria not related to fortified shake for nutrition.<BR/>* Acetaminophen 325mg tablet 2 tablets by mouth 2 times per day. Dx: Type 1 diabetes mellitus (is a condition in which your immune system destroys insulin-making cells in your pancreas) with diabetic neuropathy (a type of nerve damage that can occur with diabetes). Modification date: 04/14/23. Acetaminophen was used to treat fever or pain not blood glucose levels. <BR/>*Boost Plus 0.06 gram-1.5 kcal/ml oral liquid (Lactose-reduced food) 1 bottle by mouth 1 time per day at lunch. Dx: Dementia. Start date: 06/21/23. Boost was used for weight loss management not used to Dementia.<BR/>* Tussin DM Clear 10mg-100mg/5ml oral syrup 10 ml by mouth 2 times per day. Dx: Dementia. Start dated: 06/30/23.Tusssin DM was a cough medicine not used to treat Dementia.<BR/>*Linezolid 600 mg 1 tablet by mouth 2 times per day 10 days ESBL in urine Dx: Chronic kidney disease (means your kidneys are damaged and can't filter blood the way they should). Modification date: 09/25/23. End date: 10/05/23. Linezolid was an antibiotic and should be used to treat a diagnosis of infection. <BR/>* Albuterol sulfate 2.5mg/3ml solution for nebulization 1 solution for nebulization inhalation 4 times per day as needed for shortness of breath nebulization. Dx: dementia. Modification date: 07/23/23. End date: 10/19/23. Albuterol sulfate was used to treat difficulty breathing not Dementia. <BR/>During an interview on 11/02/23 at 2:06 p.m., LVN N said she had been working at the facility for 4 years. She said the nurse who put the medication order in should make sure the right diagnosis is selected for the medication. She said other LVNs who administered the medication and the ADON should also monitor appropriate diagnoses with medications. She said the appropriate diagnosis was important to understand why a medication was given, know if the resident received the right medication for the prescribed diagnosis, and for billing purposes. She said it could negatively affect the resident if a wrong medication was given for the wrong diagnosis which could harm the resident. She said Acetaminophen was normally given for pain and/or fever (elevated body temperature) and Linezolid was an antibiotic. She said Albuterol was normally prescribed for resident with COPD or upper respiratory infections. She said Tussin DM was normally ordered for coughing or respiratory issues so Dementia was not an appropriate diagnosis. She said Boost and House shakes were normally ordered for resident with weight loss. She said Magnesium was used for resident with vitamin deficiencies. <BR/>During an interview on 11/02/23 at 3:04 p.m., the DON said all nursing staff was responsible for appropriate diagnoses with medications. She said on admission the orders should be inputted correctly with the appropriate diagnoses by the nurse. She said the MDS coordinator and DON tried to review orders for appropriate diagnoses, but the facility received a lot of admission. She said most nursing staff when inputting medication orders, select the first diagnoses listed. She said the resident's orders got behind because each order had to be manually fixed and she was only one person. She said the responsibility untimely fell on her to ensure medications had appropriate diagnoses. She said appropriate diagnosis was important to understand why a medication was be given and was the treatment effective. <BR/>During an interview on 11/02/23 at 4:07 p.m., the ADM said she expected nursing administration to handle appropriate diagnoses with medication for the residents. <BR/>Record review of a facility's Medication Ordering and Receiving from Pharmacy Providers policy revised 01/12/20 indicated .staff will order and receive medication from pharmacy providers in accordance with standard practice guideline .<BR/>Review of Nursing Process: Patient Safety during drug therapy (2024), https://www.nursingcenter.com/clinical-resources/nursing-drug-handbook/ndh-toolkit/nursing-process was accessed on 11/08/2023 indicated .drug therapy is a complex process that can easily lead to adverse patients events .applying the nursing process .assessment, nursing diagnosis .during drug therapy enables the nurse to systemically identify the drug therapy needs of each patient .administer medication utilizing the eight rights .right drug .right reason .

**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 2 of 5 residents (Resident #5, Resident #6) reviewed for unnecessary psychotropic medications.<BR/>The facility failed to limit Resident #5's Lorazepam (anti-anxiety) prn medications to 14 days and the prescribing practitioner did not provide a rationale for extended use.<BR/>The facility failed to have an appropriate diagnosis or indication of use for Resident #5's Lorazepam. <BR/>The facility failed to document Resident #5's behaviors to justify administration of Lorazepam and effectiveness of administration.<BR/>The facility failed to have an appropriate diagnosis or indication of use for Resident #6's Seroquel (Quetiapine Fumarate; antipsychotic).<BR/>The facility failed to have an appropriate diagnosis or indication of use for Resident #6's Clonazepam (anti-anxiety; is used to treat seizures, panic attacks, and anxiety). <BR/>The facility failed to document behavior monitoring for Resident #6's antipsychotic use.<BR/>These failures could put residents at risk of receiving unnecessary psychotropic medications. <BR/>Findings included:<BR/>1. Record review of Resident #5's face sheet dated 10/30/23 indicated Resident #5 was a [AGE] year-old female and admitted on [DATE] with diagnosis including psychosis (a mental disorder characterized by a disconnection from reality), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), personality disorder (are conditions where an individual differs significantly from an average person), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). <BR/>Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated Resident #5 was usually understood and usually had the ability to understand others. The MDS indicated Resident #5 had a BIMS score of 13 which indicated intact cognition and required supervision for transfer, limited assistance for bathing, and extensive assistance for bed mobility, dressing, toilet use, personal hygiene. The MDS indicated Resident #5 received 1 days of an antianxiety medication in the 7-day assessment period.<BR/>Record review of Resident #5's care plan dated 06/21/23 indicated Resident #5 received an antianxiety medication as evidence by Lorazepam 0.5mg tablet 1 tablet by mouth 2 times per day as needed for anxiety. Interventions included monitor behaviors every shift and ask physician to review medication for possible dose reduction every 3 months. <BR/>Record review of Resident #5's consolidated physician order dated 06/29/22 indicated Lorazepam 0.5mg 1 tablet by mouth 2 times per day as needed for Anxiety.<BR/>Record review of Resident #5's MAR dated 10/01/23-10/31/23 indicated Lorazepam 0.5mg 1 tablet by mouth 2 times per day as needed for Anxiety. Dx: Bipolar disorder, current manic without psychotic features. Start date: 06/29/22. No end date noted. Resident #5 received as needed doses on 10/03/23 at 10:01 p.m. (LVN FF), 10/04/23 at 4:17 a.m. (LVN FF), 10/04/23 at 10:13 p.m. (RN RR), 10/07/23 at 3:55 a.m. (LVN QQ), 10/19/23 at 12:10 p.m. (ADON P), 10/22/23 at 6:57 p.m. (LVN FF), 10/23/23 at 5:40 p.m. (ADON P), 10/26/23 at 8:12 p.m. (LVN FF). <BR/>Record review of Resident #5's Behavior Monitoring report dated 10/01/23-11/01/23 indicated no episodes of restlessness or interventions related to use of Lorazepam 0.5mg. <BR/>Record review of Resident #5's Medication Review Record dated 06/29/23 indicated .prn psychotropic orders need a 14 day stop date .at the time physician will need to reevaluate need for the following . Lorazepam 0.5mg PO BID PRN .duration greater than 14 days will need physician rationale .<BR/>On 11/01/23 at 3:36 p.m., attempted to contact LVN FF by phone. No return call prior or after exit.<BR/>2. Record review of Resident #6's face sheet dated 10/30/23 indicated Resident #6 was a [AGE] year-old female and admitted on [DATE] and 09/07/20 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance (sleep challenges, psychosis, agitation, and mood swings), psychotic disturbance (a mental disorder characterized by a disconnection from reality), mood disturbance (disorders are described by marked disruptions in emotions (severe lows called depression or highs called hypomania or mania)), and anxiety (is a feeling of unease, such as worry or fear, that can be mild or severe) major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder, delusional disorder (is characterized by one or more firmly held false beliefs that persist for at least 1 month), and histrionic personality disorder (is a mental condition in which people act in a very emotional and dramatic way that draws attention to themselves). <BR/>Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was sometimes understood and sometimes had the ability to understand others. Resident #6 had unclear speech. The MDS indicated Resident #6 was unable to complete BIMS and had short-and-long term memory problem recall. The MDS indicated Resident #6 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #6 required limited assistance for eating and dressing, extensive assistance for bed mobility and bathing, and total dependence for toilet use. The MDS indicated Resident #6 received 3 days of an antipsychotic and antianxiety medications in the 7-day assessment period. The MDS indicated Resident #6 received an antipsychotic medication on a routine basis only. <BR/>Record review of Resident #6's care plan dated 09/21/23 indicated Resident #6 received anti-anxiety related to diagnosis and yells out with history of combative behaviors as evidence by clonazepam 0.5 mg tablet 1 tablet by mouth 3 times per day. Intervention monitor behaviors every shift. <BR/>Record review of Resident #6's care plan dated 09/21/23 indicated Resident #6 received psychotropic drug use related to diagnosis and history of hallucinations, delusions as evidence by Seroquel 25mg tablet (Quetiapine Fumarate) 1 tablet by mouth at bedtime. Intervention included monitor behavior every shift and document. <BR/>Record review of Resident #6's consolidated physician order dated 08/02/23 Quetiapine Fumarate 25mg 1 tablet by mouth at bedtime.<BR/>Record review of Resident #6's consolidated physician order dated 08/08/23 Clonazepam 0.5 mg tablet 1 tablet by mouth 3 times per day. <BR/>Record review of Resident #6's MAR dated 10/01/23-10/31/23 indicated Quetiapine Fumarate 25mg 1 tablet by mouth at bedtime. Dx: dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Modification date: 08/04/23.<BR/>Record review of Resident #6's MAR dated 10/01/23-10/31/23 indicated Clonazepam 0.5 mg tablet 1 tablet by mouth 3 times per day. Dx: dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Start date: 08/08/23. <BR/>On 11/01/23 at 4:07 p.m., Resident #6's behavioral monitoring on the facility's EHR was assessed and no information was noted. On 11/02/23 at 3:04 p.m., the DON assessed Resident #6's behavioral monitoring on the facility's EHR and no information was noted. <BR/>During an interview on 11/02/23 at 2:06 p.m., LVN N said she had been working at the facility for 4 years. She said Dementia was not an appropriate diagnosis for Seroquel. She said the nurse who received the ordered, should have clarified with the ordering provider an appropriate diagnosis. She said Clonazepam was anti-anxiety medication and the diagnosis for use should not be dementia. She said the facility had behavior monitor on the computer system. She said behaviors and interventions should be charted every shift or when a prn medication was given. She said prn psychotropic medication should be ordered for only 14 days then reevaluate for use. She said the nurse who entered the prn order should make sure it was only for 14-day intervals. She said giving an inappropriate psychotropic medication could hurt a resident if not given for the right reason. She said before psychotropic prn medications were given, other things should have been tried. She said it was important not to over sedate the resident. <BR/>During an interview on 11/02/23 at 3:04 p.m. the DON said Dementia was not an approved diagnosis for Seroquel or Clonazepam. She said Lorazepam was an antianxiety medication and if it was ordered prn then it needed to be for 14 days. She said nursing staff should document behaviors at least every shift that correlated with the medication. She said nursing staff should document why a prn medication was given and if it was effective. She said the LVN should do review the diagnosis, make sure prn orders are 14 days, and chart behaviors prior to administering antipsychotic medications. She said she should be monitoring this process and antipsychotic medications were discussed during morning standard of care meetings. <BR/>Record review of a facility's Psychotropic Drugs-Use policy revised 07/27/20 indicated .assess the patient/resident for the use of .antipsychotics .only appropriate for the following acceptable diagnosis (es) .schizophrenia .Huntington's disease .Tourette's syndrome .non-pharmacological approaches must be attempted and documented instead of using psychotropic medications .careful evaluate of the resident's records should be reviewed for appropriate diagnosis for medication use .antianxiety .need supporting diagnosis and documentation .staff will complete and sign the monitoring/behavior form each shift .menu .EMR .Nurse .Monitoring .to identify and document number of episodes, interventions, and outcomes of targeted behaviors .documentation will include that staff ruled out .medical causes and unmet needs .residents do not receive PRN psychotropic medications unless necessary to treat a diagnosed specific condition which must be documented in the record .prn orders for psychotropic medications which are not antipsychotic medication are limited to 14 days .the attending physician/prescriber may extend the order .the medical record must contain a documented rationale and determined duration .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 18.92%, based on 7 errors out of 37 opportunities, which involved 4 of 7 residents (Resident #18, Resident #50, Resident #25, and Resident #39) reviewed for medication administration. <BR/>The facility failed to administer Resident #18's loratadine (used to temporarily relieve the symptoms of hay fever [allergy to pollen, dust, or other substances in the air] and other allergies.) as ordered on 10/31/23.<BR/>The facility failed to administer Resident #18's fluticasone propionate (used to relieve seasonal and year-round allergic and non-allergic nasal symptoms, such as stuffy/runny nose, itching, and sneezing) as ordered on 10/31/23<BR/>The facility failed to administer Resident #50's potassium chloride extended release (a mineral supplement used to treat or prevent low amounts of potassium in the blood) as ordered on 10/31/23. <BR/>The facility failed to administer Resident #25's calcium carbonate-vitamin D3 (a combination medication that is used to prevent or treat low blood calcium levels) as ordered on 10/31/23. <BR/>The facility failed to administer Resident #39's lisinopril (used alone or in combination with other medications to treat high blood pressure) as ordered on 10/31/23. <BR/>The facility failed to administer Resident #39's pantoprazole (used to treat damage from gastroesophageal reflux disease [a condition in which backward flow of acid from the stomach causes heartburn and possible injury of the esophagus {the tube between the throat and stomach}]) as ordered on 10/31/23. <BR/>The facility failed to administer Resident #39's fluticasone propionate (used to relieve seasonal and year-round allergic and non-allergic nasal symptoms, such as stuffy/runny nose, itching, and sneezing) as ordered on 10/31/23. <BR/>These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. <BR/>Findings included:<BR/>1. Record review of Resident #18's face sheet, dated 11/02/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included quadriplegia (paralysis of all four limbs), colostomy status (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon), and shortness of breath (an intense tightening in the chest, air hunger, difficulty breathing, breathlessness or a feeling of suffocation). <BR/>Record review of Resident #18's annual MDS assessment, dated 10/07/23, indicated he was rarely/never understood, and he rarely/never understood others. A BIMS score was not entered into the MDS because Resident #18 was rarely/never understood. He did not exhibit behaviors of rejection of care or wandering. Resident #18 was coded as dependent (helper does all of the effort) for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated he had a diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). <BR/>Record review of Resident #18's physician's orders, dated 11/02/23, indicated he had these orders:<BR/>*Claritin 10mg tablet (loratadine) 1 tablet by mouth 1 time per day (used to temporarily relieve the symptoms of hay fever [allergy to pollen, dust, or other substances in the air] and other allergies.). The start date was 05/08/23.<BR/>*fluticasone propionate 50mcg/actuation nasal spray, 1 spray nasally 2 times per day (used to relieve seasonal and year-round allergic and non-allergic nasal symptoms, such as stuffy/runny nose, itching, and sneezing). The start date was 05/08/23.<BR/>During an observation on 10/31/23 at 07:50AM, RN W administered cetirizine 10mg, when loratadine 10mg was ordered for Resident #18. He also administered fluticasone propionate 1 spray in each nostril when only one spray nasally was ordered for Resident #18. <BR/>Record review of Resident #18's MAR for the month of October 2023, printed on 11/02/23, indicated the Claritin 10 mg had been administered on 10/31/23. The MAR further indicated the fluticasone propionate had been administered on 10/31/23. <BR/>2. Record review of Resident #50's face sheet, dated 11/02/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), autistic disorder (a developmental disability caused by differences in the brain), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and vitamin deficiency (lower than normal level of vitamins in the body). <BR/>Record review of Resident #50's annual MDS assessment, dated 09/09/23, indicated he was usually able to make himself understood and usually able to understand others. He had BIMS score of 01, which indicated severe cognitive impairment. He did not exhibit behaviors of rejection of care or wandering. <BR/>Record review of Resident #50's physician's orders, dated 11/02/23, indicated he had this order:<BR/>*potassium chloride ER 20mEq tablet, extended release, 1 tablet by mouth every morning, give with food or after a meal with 4-8 oz of water or juice (a mineral supplement used to treat or prevent low amounts of potassium in the blood). The start date was 11/02/22. <BR/>During an observation on 10/31/23 at 8:35AM, Medication Aide X, administered potassium chloride ER 20mEq 1 tablet to Resident #50. She crushed the medication and mixed it with yogurt before giving it to Resident #50.<BR/>Record review of Resident #50's MAR for the month of October 2023, printed on 11/02/23, indicated the potassium chloride ER 20 mEq tablet was administered on 10/31/23. <BR/>3. Record review of Resident #25's face sheet, dated 11/02/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), and essential hypertension (blood pressure that is abnormally high that is not the result of an identified medical condition). <BR/>Record review of Resident #25's annual MDS assessment, dated 10/09/23, indicated she was usually able to make herself understood, and was usually able to understand others. She had a BIMS score of 10 which indicated moderately impaired cognition. She did not exhibit behaviors of rejection of care or wandering. <BR/>Record review of Resident #25's physician's orders, dated 11/02/23, indicated she had this order:<BR/>*calcium carbonate 600mg-vitamin D3 10 mcg (400 unit) tablet, 1 tablet by mouth 2 times per day (a combination medication that is used to prevent or treat low blood calcium levels). The order start date was 02/21/23. <BR/>During an observation and interview on 10/31/23 at 9:26AM, Medication Aide X, did not administer Resident #25's calcium carbonate-vitamin d3 medication. <BR/>Record review of Resident #25's MAR for the month of October 2023, dated 11/02/23, indicated the calcium carbonate/vitamin D3 was marked as administered for the 9:00 AM dose on 10/31/23. <BR/>4. Record review of Resident #39's face sheet, dated 11/02/23, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and essential hypertension (blood pressure that is abnormally high that is not the result of an identified medical condition).<BR/>Record review of Resident #39's quarterly MDS assessment, dated 08/19/23, indicated she was able to make herself understood and she was usually able to understand others. She had a BIMS score of 10, which indicated moderate cognitive impairment. She did not exhibit behaviors of rejection of care or wandering. <BR/>Record review of Resident #39's physician's orders, dated 11/02/23, indicated Resident #39's order for lisnopril had been discontinued on 11/02/23. The physician's orders further indicated she had these orders:<BR/>*pantoprazole 40mg tablet, delayed release 1 tablet by mouth 2 times per day (used to treat damage from gastroesophageal reflux disease [a condition in which backward flow of acid from the stomach causes heartburn and possible injury of the esophagus {the tube between the throat and stomach}]). The order start date was 05/21/23. <BR/>*fluticasone propionate 50mcg/actuation nasal spray 1 spray nasally 2 times per day, one spray each nostril every 12 hours (used to relieve seasonal and year-round allergic and non-allergic nasal symptoms, such as stuffy/runny nose, itching, and sneezing). The order start date was 11/01/22.<BR/>During an observation on 10/31/23 at 9:26AM, medication aide X did not administer Resident #39's lisinopril medication. She further administered Resident #39 omeprazole 40mg when she was ordered pantoprazole, and administered 2 sprays of fluticasone propionate to each nostril for Resident #39, when only 1 spray per nostril was ordered.<BR/>Record review of Resident #39's MAR for the month of October 2023, dated 11/02/23, indicated she had this order:<BR/>*lisinopril 10 mg tablet 1 tablet by mouth 1 time per day. Hold if pulse less than 60 or systolic blood pressure less than 110 or diastolic blood pressure less than 60. The start date was 11/01/22. The end date was 11/02/23. This medication was marked as not administered on 10/30/23 and 10/31/23. <BR/>Record review of Resident #39's MAR for the month of October 2023, dated 11/02/23, further indicated her pantoprazole and fluticasone propionate were marked as administered on 10/31/23. <BR/>During an interview on 10/31/23 at 9:26AM, medication aide X said she did not have the omitted calcium carbonate-vitamin D3 or the lisinopril. She said it had been ordered to come in from the pharmacy and had not yet arrived to the facility. She said typically she tries to order medication refills when there is 7 days left of supply. She said she had not notified the nurse about the held medications, and that the nurse will know when the medication is out. She said someone looks back at the MAR every so often and see what medications were held. She said if the medication was held for a long period she would notify the ADON or DON. She was unable to specify who looks back at the MAR. She was unable to specify who tells the nurse when the medications are out. She was unable to specify what a long period meant. <BR/>During an interview on 11/02/23 at 12:25PM, Medication Aide X said she did not know you could not give the potassium chloride ER medication crushed. She said neither the lisinopril or calcium carbonate came in on 10/31/23 during her shift. She said she did not administer Resident #25 or Resident #39's omitted medications on 10/31/23. She said not receiving blood pressure medication could cause the resident's blood pressure to rise. She said if a resident received a wrong medication, they could have side effects or a reaction. <BR/>During an interview on 11/02/23 at 12:33 PM, RN W said that he should have reviewed and clarified the fluticasone propionate order with the physician before administering the medication. He said he was nervous and pulled the wrong medication to give to Resident #18. He said that Resident #18 could suffer side effects by receiving the wrong medication. <BR/>During an interview on 11/02/23 at 01:47 PM, ADON P said she expected the correct medication to be given to the resident as per the physician's orders. She expected the potassium chloride ER to not have been given, and the medication aide should have notified the nurse that they needed another form of the medication because she could not administer it. She said the med aide should have notified the nurse about the missing medications and the nurse could have pulled the medications out of the emergency kit and administered it to the resident. She said she expected the nurse and med aide to follow the physician's orders. She said if the wrong medication was administered there could be an adverse reaction. She said there could have been an allergy to the other medication.<BR/>During an interview on 11/02/23 at 02:21 PM, the DON said she expected the medications to be given as ordered. She said the resident could suffer decline or adverse side effects. She expected both the nurse and medication aide to give the medications as ordered. She said the medication aide should have notified the DON about the missing medications so it could be obtained from the emergency kit. She said she was not contacted about either of the omitted medications. She expected the doctor to be contacted about the missed lisinopril. <BR/>During an interview on 11/02/23 at 03:10 PM, the Administrator said she expected the staff to administer the medications per the physician's order. She said she expected the medication aide to notify the nurse so that the doctor can get the medication that cannot be crushed changed to an appropriate form. She said she expected the correct medication to be given. She said the resident could suffer harm as a result of errors in medication administration.<BR/>The National Library of Medicine website, accessed on 11/13/23 at 5:56PM, stated: <BR/> .extended-release (ER) . medications should not be crushed .<BR/> .Crushed .ER .drugs can lead to dangerous and erratic blood levels as well as dangerous side effects .<BR/>Record review of the facility's policy, medication - guidelines on clinical practice, last revised 01/12/20, stated:<BR/> .Staff will provide medications in accordance with standard practice guidelines .<BR/> .refer to the Pharmerica Nursing Care Center Pharmacy Policy & Procedure Manual regarding:<BR/>Medication Administration .<BR/>The Pharmerica Nursing Care Center Pharmacy Policy & Procedure Manual was requested by this surveyor but was not provided by the facility. <BR/>Record review of the facility's policy, medication, last revised on 02/12/20, stated:<BR/> .Staff will assist the physician and authorized prescriber with medication orders in accordance with standard practice guidelines .<BR/>Procedure: .<BR/> .2. When medications are not available to administer, medication aides will notify charge nurse.<BR/>3. Charge nurse will attempt to obtain medication from emergency kit. If not available, charge nurse will reach out to pharmacy for STAT delivery <BR/>4. Physician will be notified of missed doses due to medication availability

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety.<BR/>The facility failed to ensure that all staff members wore hairnets appropriately.<BR/>The facility failed to ensure that all kitchen staff members wore N95 mask appropriately while on outbreak status. <BR/>These failures could place residents at risk of foodborne illness and food contamination.<BR/>Findings include: <BR/>During an observation on 9/12/2022 at 9:00 a.m., the Dietary Manager was in the kitchen. Her hair net did not cover all of her hair. There was exposed hair across her forehead and unrestrained hair all of the way around the hairnet. <BR/>During an observation on 9/12/2022 at 9:03 a.m., the plastic container for the sugar was open to air. <BR/>During an observation on 9/12/2022 at 9:10 a.m., Dietary Aide F was in the kitchen with a baseball cap on her head. She did not have on a hair net. She had unrestrained hair from around the baseball cap and had hair sticking out of the back of the cap in knotted up ponytail. There were loose hairs touching her shoulders and her back. <BR/>During an observation and interview on 9/12/2022 at 9:12 a.m., there were 3 tubes of expired dishwasher testing strips hanging on the wall opposite of the dishwasher. The tubes had expirations dates of 2-2021, 3-2022, and 8-2022. The Dietary Manager said she did not know the testing strips were expired and the company had just brought her some new ones. <BR/>During an observation on 9/13/22 at 7:56 a.m., Dietary Aide G was preparing breakfast trays with the N95 mask under his chin. His nose and mouth were exposed. <BR/>During an observation on 9/13/22 at 10:01 a.m., Dietary Aide G was at the dishwasher on the clean side (on the side of the dishwasher where the clean dishes are processed and put away) with his N95 mask below his chin and his nose and mouth exposed. Dietary Aide F was standing at the counter while food was being prepared. She had on a baseball cap and no hairnet. There was a ponytail out of the back and loose hairs were touching her back. There were unrestrained hairs sticking out around the baseball cap. <BR/>During an observation on 9/13/2022 at 10:33 a.m., [NAME] H began pureeing foods. At times her mask was down below her nose . <BR/>During an observation on 9/13/2022 at 10:34 a.m., the Dietary Manager was in the kitchen with her hair net only covering the top of her hair. There was exposed loose hair across her forehead and loose hairs all the way around the hairnet. <BR/>During an observation on 9/13/2022 at 10:51 a.m., Dietary Aide F was sweeping the kitchen during lunch preparation. She did not have on a hairnet. She had on a baseball cap with hair sticking out of the back and hair sticking out from under cap. There were 3 pieces of long hair, unattached from her head, stuck to the back of her shirt. <BR/>During an observation on 9/13/2022 at 11:29 a.m., [NAME] H was taking the temperature of the foods on the steam table. Her mask slid down under her nose on multiple occasions. <BR/>During an observation on 9/13/2022 at 11:30 a.m., the Dietary Manager and Dietary Aide F were wrapping silver ware in napkins. Dietary Aide F had on a baseball cap with unrestrained hair sticking out of the baseball cap. The Dietary Manager's hair was not completely covered with her hairnet. She had loose hair touching her shoulder and unrestrained hair across her forehead. <BR/>During an observation on 9/13/2022 at 11:41 a.m., Dietary Aide F was covering prepared plates and placing trays on cart with no hairnet. At times she would lean across incomplete trays during tray preparation. <BR/>During an observation on 9/13/2022 at 11:43 a.m., CNA A was standing in the kitchen sorting dietary tickets with no hairnet on while trays were being prepared. She was standing at a counter next to pre-prepared drinks for the residents. <BR/>During an interview on 9/14/2022 at 9:03 a.m., Dietary Aide F said she had been in-serviced on wearing hair nets in the kitchen. She said she did not wear a hair net because she wore a baseball cap and she thought all of her hair was tucked into her baseball cap. She said no one in the kitchen had told her the hair was not contained under the baseball cap and to wear a hairnet. <BR/>During an interview on 9/14/2022 at 9:05 a.m., Dietary Aide G said he had worked at the facility for a month. He said he had been oriented on COVID-19 and the importance of wearing a mask. He said it gets hot in the kitchen and he pulls his mask down .<BR/>During an interview on 9/14/2022 at 9:13 a.m., [NAME] H said she tried to keep her mask pulled up. She said her mask slid down her face when she was talking. She said she did know about COVID-19 and that she was supposed to be wearing her mask over her nose.<BR/>During an interview on 9/14/2022 at 9:15 a.m., the Dietary Manager said she thought wearing a baseball cap was ok. She said she thought all of her hair was contained in her hairnet. She said she in-services her staff monthly. She said residents could be negatively affected by hair contaminating food and the residents might not want to eat the food. She said due to Covid-19 all staff were supposed to be wearing masks that covered their nose and mouth. <BR/>During an interview on 9/14/2022 01:40 p.m., CNA A said she was unaware she was supposed to wear a hair net in the area she was in inside the kitchen. She said she thought it was only if you went past the preparation table. She said it made sense though since there were prepared drinks on the counter where she was standing.<BR/>During an interview on 9/15/2022 at 1:40 p.m., the DON said the facility had been on outbreak status, but she was not sure the exact date the outbreak started. She said all staff should have been wearing N95 mask appropriately. She said the Administrator wanted all staff to wear N95 mask and staff could not even wear a K-N95. <BR/>During an interview on 9/15/2022 at 2:16 p.m., the Administrator said anyone in the kitchen should be wearing a hair net and the hair net should be covering all their hair. She said wearing a hair net inappropriately could cause hair to get into the food and cause contamination of the food item. She said if there were undated and unlabeled food, then staff would not be aware the food might be out of date. She said all employees should be wearing a N95 mask. She said even in the kitchen staff should be wearing a mask and it should be covering their face. She said staff not wearing a mask appropriately around other staff or residents could lead to continued outbreak of Covid-19. <BR/>Review of a facility Employee Infection Control, Nutrition Services dated May 28, 2020 indicated, .anyone who enters the kitchen will have all hair restrained using bouffant caps, mesh or net, beard guard and clothing which covers body hair .<BR/>Review of a facility Competencies for Nutrition Services Employees checklist dated 7/2020 indicated, .Consistently uses hair restraints (and beard guards) properly .when indicated in the event of a respiratory or viral outbreak, wears a mask and other PPE as directed. SEE DIAGRAM pg. 6 .How to Wear a Medical Mask Safely .Do's .cover your mouth, nose, and chin .Don'ts .Do not wear mask only over mouth or nose .do not remove the mask to talk to someone .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate use of an antibiotic for 1 of 4 residents reviewed for antibiotic use. (Resident #29)<BR/>The facility failed to ensure Resident #29's urinalysis (is a test that examines the visual, chemical, and microscopic aspects of your urine) with a culture (checks urine for germs (microorganisms) that cause infections) was collected prior to antibiotics starting.<BR/>The facility failed to ensure Resident #29 Cefdinir (is used to treat bacterial infections in many different parts of the body) has an appropriate diagnosis for indication of use. <BR/>The facility failed to ensure Resident #29 was not treated with an antibiotic when lab work did not indicate a urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra). <BR/>This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections (happens when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them).<BR/>Findings included:<BR/>Record review of Resident #29's face sheet dated 10/30/23 indicated Resident #29 was 91-years-old male and admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic kidney disease (means your kidneys are damaged and can't filter blood the way they should), acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), and benign prostatic hyperplasia (is a condition in men in which the prostate gland is enlarged and not cancerous) with lower urinary tract symptoms. <BR/>Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated Resident #29 was usually understood and usually understood others. The MDS indicated Resident #29's BIMS score was 10 which indicated moderate cognitive impairment and required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and bathing. The MDS indicated Resident #29 had frequent urinary incontinence and always had bowel incontinence.<BR/>Record review of Resident #29's care plan dated 09/25/23 indicated use of antibiotic as evidence by Cefdinir 300mg capsule 1 capsule by mouth 2 times per day for 10 days (10/26/23). Intervention included use of antibiotics should be limited to confirmed or suspected bacterial infection. <BR/>Record review of Resident #29's hospice communication form received by Hospice RN dated 08/04/23 indicated Resident #29 had issues/symptoms of burning on urination/urgency. The hospice communication form indicated a new order for urinary analysis with culture and Cefdinir 300mg twice a day x 10 days.<BR/>Record review of Resident #29's MAR dated 08/01/23-08/31/23 indicated Cefdinir 300mg 2 capsule by mouth 2 times per day. Dx: congestive heart failure. Start date: 08/05/23. End date: 08/07/23. The MAR indicated Resident #29 received 2 days of the wrong dosage of Cefdinir. <BR/>Record review of Resident #29's MAR dated 08/01/23-08/31/23 indicated Cefdinir 300mg 1 capsule by mouth 2 times per day for 10 days. Dx: congestive heart failure. Start date: 08/07/23. End date: 08/17/23. The MAR indicated Resident #29 antibiotic should have been discontinued from the start date of 08/05/23 not 08/07/23. The MAR indicated Resident #29 received doses from 08/08/23-08/17/23. <BR/>Record review of Resident #29's nurse note, by RN R, dated 08/08/23 indicated .urine collected for urinalysis with culture and screen .urine yellow and cloudy .ready for pick up from lab . No other nurse notes for August 2023 noted.<BR/>Record review of Resident #29's UA with C&S, with collection date 08/09/23 at 5:22 a.m., received by lab 08/09/23 at 10:30 a.m. indicated no pathogens detected. <BR/>Record review of the facility's infection control log dated 08/01/23-08/31/23 indicated on .08/05/23 [Resident #29] .pathogens: normal flora/negative .infection category: urinary without catheter .related diagnosis: unspecified congestive heart failure .antibiotic: Yes .Disposition: Facility treatment successful .status: resolve .<BR/>Record review of Resident #29's urine culture dated 09/21/23 indicated .Klebsiella pneumoniae confirmed .positive extended-spectrum beta lactamase (ESBL) .these organisms are uniformly resistant to all .Multi-drug resistant (is a germ that is resistant to many antibiotics) . <BR/>During an interview on 11/02/23 at 3:04 p.m., the DON said the facility followed the McGreer criteria for their antibiotic stewardship program. She said she believed a resident had to meet 3 criteria to start antibiotic. She said Resident #29 had a couple of infection recently, urinary tract and cellulitis in his leg. She said sort of recalled Resident #29 being started on Cefdinir for a suspected UTI then the lab coming back negative. She said he could have stayed on the antibiotic for cellulitis, but she was not sure. She said she ADON P was the Infection Control Preventionist. <BR/>During an interview on 11/02/23 at 4:06 p.m., ADON P said she started July 2023 and was not certified to be the Infection Control Preventionist. She said she did not do the Antibiotic Stewardship Program. <BR/>Record review of a facility's Antibiotic Stewardship policy reviewed 01/21 indicated .widespread use of antibiotics has resulted in an increase in antibiotic-resistant infections .it is our policy to maintain an Antibiotic Stewardship Program to promote the appropriate use of antibiotics to treat infections .prescription record keeping .dose, duration, and indication of every antibiotic prescription MUST be documented in the medical record for every resident .<BR/>Record review of a facility's Infection Prevention and Control Surveillance policy revised 01/22 indicated .surveillance definition for urinary tract infection .for resident without an indwelling catheter .both criteria 1 and 2 must be present .at least 1 of the following sign or symptom sub criteria .acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate .fever or leukocytosis and at least 1 of the following localizing urinary tract sub criteria .in the absence of fever or leukocytosis, then 2 or more of the following localizing urinary tract sub criteria .one of the following microbiologic sub criteria .at least .of no more than 2 species of microorganisms in a voided urine sample .at least .of any number of organism in a specimen collected by in-and-out catheter .UTI should be diagnosed when there are localizing .signs and symptoms and a positive urine culture .urine specimens for culture should be processed as soon as possible, preferably within 1-2 hours .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not notify the physician of a significant change in the physical condition for 1 of 22 resident reviewed for notification of change. (Resident #151) <BR/>The facility did not notify the physician when Resident #151, who had a history of Acute Respiratory Failure with hypercapnia (too much carbon dioxide in the body), had an oxygen saturation of 88% on [DATE] at approximately 6:30 p.m., had difficulty breathing, and would not keep on their Bipap (non-invasive ventilation breathing support administered through a face mask) mask . The resident was found unresponsive at 11:10 p.m. and expired at the facility.<BR/>The facility failed to have a Physician Notification Policy.<BR/>These failures resulted in the identification of an Immediate Jeopardy (IJ) on [DATE] at 5:21 p.m. While the IJ was removed on [DATE] at 4:02 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures could place residents who experience a change of condition at risk for harm, deteriorating health or death.<BR/>Findings included:<BR/>Record review of a face sheet dated [DATE] indicated Resident #151 was [AGE] years old. Resident #151 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure with hypercapnia (high levels of carbon dioxide in the body), heart failure, and chronic obstructive pulmonary disease (chronic lung disease). <BR/>Record review of consolidated physician's orders dated [DATE] for Resident #151 indicated the resident was admitted on [DATE] to skilled care. An order dated [DATE] indicated Bipap as needed. As needed for SOB (shortness of breath), with naps. Notify provider with episodes of SOB . An order dated [DATE] indicated Bipap daily at bedtime . The orders indicated Resident #51 code status was full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). <BR/>Record review of the MDS dated [DATE] indicated Resident #151 usually understood others and was usually understood. The MDS indicated a BIMS was not conducted due to the resident be rarely to never understood. The MDS indicated Resident #151 required oxygen care. The MDS did not indicate the use of Bipap. <BR/>Record review of a care plan updated on [DATE] indicated Resident #151 had a care area for Breathing Pattern related to a diagnosis of chronic obstructive pulmonary disease. There was an intervention to administer medications, respiratory treatments, and oxygen as ordered. <BR/>Record review of an After Visit Summary for Resident #151 from the hospital dated [DATE] indicated, .Other Instructions .continue BIPAP PRN (as needed) for shortness of breath, lethargy, hypercapnia .Last vital signs recorded .BP 141/85 (blood pressure), Pulse 81, Temp 97.8 (oral), Resp 22, SpO2 100% (oxygen saturation). <BR/>Record review of hospital discharge records for Resident #151 with an admission date of [DATE] and a discharge date d on [DATE] indicated, .Pt was admitted for acute hypercapnic respiratory failure, altered mental status, and resolving pneumonia .Recommendations .Continue Bipap/Avaps PRN (as needed) for shortness of breath, lethargy, hypercapnia .<BR/>Record review of hospital records dated [DATE] indicate Resident #151 was evaluated in the emergency department. The reason for the visit was for chest pain and shortness of breath. The diagnosis was Atrial Fibrillation with rapid ventricular response (a cardiac rhythm when the rapid contractions of the atria make the ventricles beat to quickly. If the ventricles beat too fast, they cannot receive enough blood. So, they cannot meet the body's need for oxygenated blood).<BR/>Record review of vital signs for Resident #51 indicated on [DATE] at 5:59 p.m. a blood pressure of 117/59, a heart rate of 88, respirations of 18, a temperature of 97.8, and an oxygen saturation of 97%. On [DATE] at 12:26 p.m. a heart rate of 78, respirations of 18, and an oxygen saturation on 98%. On [DATE] at 3:01 p.m. a blood pressure of 136/80, a heart rate of 78, respirations of 18, an oxygen saturation of 98%. On [DATE] at 8:44 a.m. a heart rate of 78, respirations of 18, and oxygen saturation of 98%. On [DATE] at 1:36 p.m. a heart rate of 78, respirations of 19, and an oxygen saturation of 98%. On [DATE] at 1:07 p.m. a blood pressure of 142/70 and a temperature of 98.3. There were no further vital signs documented.<BR/>Record review of undated handwritten notes by LVN O indicated, at 18:30 p.m . Bipap on by nurse. The notes indicated at 8:50 p.m. went to pt. room, Bipap was off, pt had taken Bipap off, did explain to pt the need for keeping Bipap on, eyes closed, no response. The notes indicated at 10:25 p.m. went to pt. room, Bipap off, and was put back on pt. Bipap machine is working well. At 10.30 p.m. came to desk, called (family member) and explained to her that pt. will not keep Bipap on, that if pt's (family member) wanted to come and stay to help pt. with keeping Bipap on, it would be ok . At 11:10 p.m. Family member .here, nurse got up from desk and walked down to pt's room. Arrived in room, (family member) and I noticed pt not breathing and CPR (cardiopulmonary resuscitation) begin. At 11:23 p.m. CPR team arrived and CPR continued. There was one set of untimed vital signs that indicated pt pulse ox (oxygen saturation) was 88 then 90, B/P (blood pressure) 90/52, temp 96.2. The oxygen saturation, blood pressure and temperature were below Resident #151's baseline. Respirations or heart rate were not indicated. There was no documentation of the physician having been notified. <BR/>Record review of nurse's notes on the electronic medical record for Resident #151 indicated a note made my LVN O on [DATE] and electronically signed at 11:12 p.m., 1850 (6:50 p.m.) .Bipap was applied .pt appears to be resting well. A note made by LVN O on [DATE] and electronically signed 11:31 p.m. indicated 2050 (8:50 p.m.) pt. has taken Bipap off and explained to pt. that this is to help remove the CO2 (carbon dioxide) d/t pt. needs help to get ride of the bad oxygen, was still trying to take mask out of nurse's hand. A nurse's note made by LVN O on [DATE] and electronically signed at 12:10 a.m. indicated, a note for [DATE] 2225 (10:25 p.m.) Pt had taken mask off and was replaced back on and ask pt to not remove, this mask help with your breathing. A nurse's note made by the DON dated [DATE] and was electronically signed at 7:37 a.m. indicated on [DATE] 2230 (10:30 p.m.) family member .was called and informed pt continues to taking off Bipap mask and refuses to keep it on, did inform her that nurse will continue to go back and check and put mask back on as needed, did ask if pt (family member) wanted to stay due to pt noncompliance . A nurse's note made by the DON dated [DATE] and electronically signed at 7:32 a.m. indicated, on [DATE] 2310 (11:10 p.m.) family member .here, him and nurse walked to the pt room, pt. had Bipap slid off to the right side top of head and was not breathing, cpr was done immediately while pt. (family member was screaming at nurse why somebody was not down here sitting with him, 2313 (11:13 p.m.) CPR team with crash cart arrived and began assisting nurse with CPR, board hard surface placed under patient, pads on, continuing CPR 2318 (11:18 p.m.), analyzing, shock not advised, paramedics arrived 2329 (11:29 p.m.) taking over CPR in progress, firefighters arrived 2340 (11:40 p.m.), IV (intravenous access to body) started, intubated (when a tube inserted for venilation) 2345 (11:45 p.m.) . continue cpr, 2354 (11:54 p.m.) pulse check continue cpr, 2357 (11:57 p.m.) pulse check continue cpr, 2359 (11:59 p.m.) pulse check continue cpr, 2403 (12:03 a.m.) continued cpr, paramedic spoke to nurse and stated pt. PEA (pulseless electrical activity, a type of irregular heart rhythm, meaning it is a malfunction of the heart's electrical system) was not active and only there because of continued compressions, last pulse check 2406 (12:06 a.m.). Police arrived, and also assisted with cpr. EMS called time of death. Family was present. There were no nurse's notes indicating the physician had been notified of Resident #151's condition on [DATE]. <BR/>During an interview on [DATE] at 1:57 p.m., LVN O she was Resident #151's nurse the night of [DATE]. She said Resident #151 would not keep on his Bipap mask. She said she made notes on a piece of paper. She said when she came to work she checked on him right then. She said anytime she had a resident with a critical condition she checked on them first. She said she first checked on Resident #151 around 6:30 p.m. She said she took vital signs at this time. She said those vital signs were charted on the back of a handwritten note. She said she helped the aide clean him. She said she placed his Bipap mask back on him them. She said the aide reported to her that he had been taking his mask off that evening. She said she did call family and suggested that a family member might come sit with him to help keep his mask on. She said she walked in with the Family Member #2 and the resident was not breathing. She said the door was closed and no other staff were in the room. She said the mask was to the side of his head. She said she had previously taken care of the resident and he always has difficulty breathing. She said he could not breathe without some kind of assistance with his breathing. She said she did not call the physician at any time that evening . She said she did not notify the physician that Resident #151 would not keep on his Bipap mask. She said Resident #151 was not anxious and he did not need medication to calm him. She said she did not feel he needed medication so he would tolerate the Bipap better. She said she was checking on the resident every hour. She said she handwrote notes indicating when she had checked on him. She said at no time did staff sit with him to make sure he kept his mask on. She said, we just go in and do what we have to do and then leave. She said when she realized he was not breathing she checked his pulse and then started CPR. She said she only took one set of vital signs at 6:30 p.m. and this was documented on her handwritten note. She said she did not report the vital signs to the physician. She said at no time that evening did the resident open his eyes or talk to her. She said this was normal for him. She said she had had no specific trainings concerning the Bipap. She said she just knew how to use the Bipap from years of experience.<BR/>During an interview on [DATE] at 2:20 p.m., Corporate Nurse AA said she was looking for, but did not think the facility had a physician notification policy. <BR/>During an interview on [DATE] at 4:55 p.m., LVN O said she had only taken care of Resident #151 one previous shift. She said she was not that familiar with him. She said you could just tell he was critical. She said with CPR you check the airway, breaths, and circulations. She said the resident had no pulse. She said she did compressions in the middle of his sternum (the breastbone). She said she placed the heal of her hands in the middle of the sternum. <BR/>During an interview on [DATE] at 9:06 a.m., Attending Physician Z said he would expect nursing staff in the facility to make sure residents with shortness of breath or difficulty breathing were compliant in wearing their Bipap mask appropriately. He said he would expect staff to monitor the resident and send them to the ER for any acute changes. He said he would have expected staff to have contacted Nurse Practitioner K for symptoms or non-compliance in wearing the Bipap mask. When asked if the resident not wearing his BiPap mask could have contributed to Resident #151's death he said, oh yeah. He said from what little he knew about the resident he had multiple conditions that could have led to his death but not being compliant with wearing his BiPap could be part of it. He said non-compliance with not wearing his mask could affect everything.<BR/>During an interview on [DATE] at 9:25 a.m., Nurse Practitioner K said he would have expected staff to have contacted him for Resident #151 not wearing his mask or for increased shortness of breath. He said he had seen Resident #151 earlier in the day of [DATE] and the resident was a little short of breath. He said he told staff to call him for increased shortness of breath. He said he would have expected to have been notified for shortness of breath, not keeping his mask on and any acute changes. He said he might have tried a telehealth visit. He said he would have checked the resident's general condition. He said he probably would have had staff send the resident to the emergency room for further evaluation. <BR/>During an interview on [DATE] at 2:40 p.m., the DON said a change in condition could be acute shortness of breath, skin changes such as sweat and temperature change, and cyanosis (a bluish discoloration of the skin resulting from poor circulation). She said any change in condition would need to be reported immediately to the provider. She said on [DATE], the resident was not acting any different than he had. She said the nurse told her she did not see him as in distress.<BR/>During an interview on [DATE] at 10:54 a.m., the DON said she felt the nurse did not see Resident #151's vital signs and him taking his mask off as a change in condition. She said LVN O was a nurse a really long time. She said the resident had been fighting the mask and had been pulling it off. She said she did not feel the nurse recognized him as having a change in condition. She said when the resident was hypoxic (an absence of enough oxygen in the tissues to sustain bodily function. An oxygen saturation below 92% is considered hypoxic) the nurse should have checked the orders and notified the physician. The DON said she (the DON) had already discussed with the Nurse Practitioner K about the resident not keeping his mask on. She said he had advised that if Resident #151 would not keep the mask on to call family to the facility to keep the mask on. She said a provider not being notified for a change in condition could cause increased chance of harm. <BR/>During an interview on [DATE] at 1:13 p.m., the Administrator said if a nurse felt that a resident was critical and having difficulty breathing she would have expected this to have been reported to the physician by the nurse. She said abnormal vital signs for any resident should have been reported to a physician. She said staff were in regular contact with Nurse Practitioner K that night. She said she was not sure if a oxygen saturation of 88% was ever communicated to the provider. She said the resident was not enrolled in Hospice, but there were family members that wanted him placed on hospice. There was a family member that wanted him to be a full code and wanted everything done. The administrator said she discussed with the family member that the resident would not keep on his mask and the facility was unable to restrain him as he was in the hospital at the facility could not force him to wear a mask. She said the family member said he was not restrained in the hospital but was sedated. She said the facility could not chemically restrain him. She said a medication such as Ativan could not be ordered because Resident #151 was so fragile. <BR/>Review of a Change in Condition policy last revised on February 13, 2023 indicated, The primary goal of identifying Acute Changes of Condition (ACOCs) is to enable staff to evaluate and manage a patient at the community and avoid transfer to a hospital or emergency room (ER). To achieve this goal, the community's staff and practitioners must recognize an ACOC and identify it's nature, severity, and cause(s) changes in condition of the patient are determined by current and past medical conditions, medical orders, patient safety factors, and/or by assessments utilizing defined parameters .IMMEDIATE NOTIFICATION: Any symptom, sign, or apparent discomfort that is: acute or sudden in onset, and: a marked change (i.e. more severe) in relation to usually symptoms and sings, or Unrelieved by measures already prescribed . <BR/>Review of an article title Hypoxia by The Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/23063-hypoxia, and was accessed on [DATE] indicated, Hypoxia is low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin. Many chronic heart and lung conditions can put you at risk for hypoxia. Hypoxia can be life-threatening. If you are experiencing symptoms of hypoxia, call 911 or go to the nearest ER . The treatment for hypoxia depends on the underlying cause. The cause might be a one-time event or it could be an ongoing condition. Treatments might include: . BiLevel positive airway pressure (often known under the trade name BiPAP&reg;) . <BR/>The Administrator was notified of an IJ on [DATE] at 5:21 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on [DATE] at 1:40 p.m. and included the following:<BR/>Plan of Removal<BR/>Summary of Details which lead to outcomes <BR/>On [DATE], during annual survey initiated at the facility, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. F580 <BR/>The notification of the alleged immediate jeopardy states as follows: <BR/>F580-Physician Notification<BR/>The resident was a 79 y/o male, admitted on [DATE] with a diagnosis of Acute Respiratory failure with hypercapnia (to much carbon dioxide in the body). The resident was sent to the hospital on [DATE] and readmitted to the facility on [DATE].<BR/>The facility failed to notify the physician of a low oxygen saturation of 88% and that the resident would not keep his bipap on.<BR/>The facility failed to obtain and monitor the residents' vital signs.<BR/>The facility does not have a physician notification policy. <BR/>The facilities change of condition policy indicated to notify the physician when the resident is unrelieved by measures already prescribed.<BR/>o <BR/>How other residents with the potential to be affected by the same deficient practice will be identified; <BR/>o <BR/>Any resident with orders for bi-pap therapy and/or residents who have signs of respiratory distress<BR/>o <BR/>What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur; <BR/>o <BR/>The LVN was provided education by NP on [DATE]. Education includes: <BR/>a.) <BR/>Identification of change of condition.<BR/>b.) <BR/>Notification to provider for any change of condition.<BR/>c.) <BR/>Assessment and response to change of condition.<BR/>d.) <BR/>Increased monitoring at time of change of condition until recommendation received from physician.<BR/>e.) <BR/>Documentation of change of condition.<BR/>f.) <BR/>Ensuring physician orders are followed.<BR/>o <BR/>DON/ADON/MDS/WOUND NURSE were provided education by NP on [DATE]. <BR/>Education includes: <BR/>a) Identification of change of condition.<BR/>b) Notification to provider for any change of condition.<BR/>c)Assessment and response to change of condition.<BR/>d) Increased monitoring at time of change of condition until recommendation received from physician.<BR/>e) Documentation of change of condition.<BR/>f ) Ensuring physician orders are followed.<BR/>o <BR/>DON/ADON will provide education to all licensed staff prior to start of next scheduled work shift to include: starting 10/31 and reported to QA committee monthly x 3 months<BR/>a.) <BR/>Identification of change of condition.<BR/>b.) <BR/>Notification to provider for any change of condition.<BR/>c.) <BR/>Assessment and response to change of condition.<BR/>d.) <BR/>Increased monitoring at time of change of condition until recommendation received from physician. <BR/>e.) <BR/>Documentation of change of condition.<BR/>f.) <BR/>Notification to DON/Designee of change of condition.<BR/>g.) <BR/>Ensuring physician orders are followed. <BR/>o <BR/>All residents requiring bipap therapy will have standing orders written on eMAR with parameters to notify physician per guidance on parameters for notification from physician.<BR/>How the corrective action(s) will be monitored to ensure the deficient practice is being corrected and will not recur (i.e., what program will be put into place to monitor the continued effectiveness of the system changes); and <BR/>o <BR/> All new hire licensed staff are educated as above prior to completion of orientation.<BR/>o <BR/>All changes of condition will be communicated to DON/Designee and provider.<BR/>o <BR/>DON/Designee will review 24-hour reports and change of condition reports daily. <BR/>o <BR/>DON/Designee will review spo2 recordings for residents with bipap daily. <BR/>Involvement of Medical Director <BR/>The APRN Nurse Practitioner for Medical Director met with interdisciplinary team on [DATE]. <BR/>Involvement of QA <BR/>An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal. <BR/>Administrator will forward results of audits monthly to the QAPI Committee for review and/or action times three months. <BR/>Who is responsible for implementation of process? <BR/>The Director of Nursing/designee will be responsible for implementation of New Process. The New Process/ system will be started on [DATE] and no employee be able to return to work until they complete the Inservice. <BR/>Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on [DATE].<BR/>The surveyor verification of the Plan of Removal from [DATE] was as follows:<BR/>Record review of the current residents' electronic health records did not indicate any residents requiring breathing assistance with Bipap. Electronic health records were accessed from [DATE] - [DATE] . <BR/>Record review of a Training In-Service Form indicated an in-service was held on [DATE]. The in-service was present by a Nurse Practitioner. The in-service covered change of condition, changes in level of consciousness, oxygen saturation, CPR hand placement, notifying providers, notifying DON/Family, Increased monitoring with change of condition, and following physician's orders. A total of 24 staff members attended the in-service. The in-service included a signature of LVN O, the ADON, the MDS and the wound care nurse.<BR/>During an interview [DATE] at 2:00 p.m., the DON said the in-service training on [DATE] was verbal with mock CPR. She said staff completed a return demonstration on her. This in-service was completed on [DATE] at 8:00 p.m. <BR/>The DON said a change in condition would be acute shortness of breath, skin changes such as sweat and temperature change, cyanosis. She said any change in condition would need to be reported immediately to the provider. She said she held a mock code using several different scenarios and with people with different body sizes. She said she instructed to never leave a resident unattended that was in distress. She said all staff performed all CPR correctly. She said she instructed staff when patients come in with physician's orders to verify the orders are in and all equipment is in the room and orders are on the chart. She was able to accurately describe neglect of a resident. She said she educated staff on change of condition, changes in level of consciousness, oxygen saturation, CPR hand placement, notifying providers, notifying DON/Family, Increased monitoring with change of condition, and following physician's orders.<BR/>During an interview on [DATE] at 3:12 p.m., LVN O said she was in-serviced on identification of change of condition, notification to provider for any change of condition, assessment and response to change of condition., increased monitoring at time of change of condition until recommendation received from physician, documentation of change of condition and ensuring physician orders are followed. She was able to accurately describe how to do CPR and accurately describe neglect.<BR/>During interviews conducted from on [DATE] beginning at 2:00 p.m. through 4:02 p.m., 20 of 24 of nursing staff in-serviced (including staff across all shifts that were the DON, ADON, MDS Nurse, the Wound Care Nurse, CNAs, LVNs and RNs) were interviewed. All staff said they received education on change of condition and were able to verbalize understanding, changes in level of consciousness, oxygen saturation, CPR hand placement, notifying providers, notifying DON/Family, Increased monitoring with change of condition, and following physician's orders. <BR/>On [DATE] at 4:02 p.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 3 of 22 residents (Resident # 5, Resident #29, and Resident #361) reviewed for MDS assessment accuracy. <BR/>The facility failed to code Resident #5's use of oxygen on her MDS.<BR/>The facility failed to code Resident #29's use of oxygen and being on hospice services.<BR/>The facility failed to accurately reflect Resident #361 had a pressure ulcer on his admission MDS assessment. <BR/>These failures could place residents at risk for not receiving care and services to meet their needs.<BR/>Findings included:<BR/>1. Record review of Resident #5's face sheet dated 10/30/23 indicated Resident #5 was a [AGE] year-old female and admitted on [DATE] with diagnosis including cerebral ischemia (is the lack of blood supply to a region of the brain, resulting in a low supply of oxygen and nutrients) and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). <BR/>Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated Resident #5 was usually understood and usually had the ability to understand others. The MDS indicated Resident #5 had a BIMS score of 13 which indicated intact cognition and required supervision for transfer, limited assistance for bathing, and extensive assistance for bed mobility, dressing, toilet use, personal hygiene. The MDS did not indicated Resident #5 use of oxygen therapy. <BR/>Record review of Resident #5's care plan dated 06/21/23 indicated Resident #5 breathing pattern problem related to diagnosis of COPD related to oxygen 2 liter per minute inhalation every 12 hours and every 2 hours, oxygen use at home, and respiratory failure. Intervention included administer medications, respiratory treatments, and oxygen as ordered. <BR/>Record review of Resident #5's consolidated physician order dated 06/28/23 indicated oxygen 2 liters per minute inhalation every 2 shift via nasal cannula, oxygen saturation check (is the amount of oxygen that's circulating in your blood). <BR/>Record review of Resident #5's MAR date 09/01/23-09/30/23 indicated Oxygen 2 liters per minute inhalation every 2 shift via nasal cannula, oxygen saturation check. Dx: Chronic obstructive pulmonary disease. Start date: 06/28/23. No end date. The MAR indicated oxygen saturation documented every day for day and night shift. <BR/>2. Record review of Resident #29's face sheet dated 10/30/23 indicated Resident #29 was 91-years-old male and admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and dependence on supplemental oxygen. <BR/>Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated Resident #29 was usually understood and usually understood others. The MDS indicated Resident #29's BIMS score was 10 which indicated moderate cognitive impairment and required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and bathing. The MDS did not indicated use of oxygen therapy or hospice care. <BR/>Record review of Resident #29's care plan dated 11/11/22 indicated breathing pattern problem as evidence by respiratory failure (develops when the lungs can't get enough oxygen into the blood), oxygen liter per minute inhalation every 2 shift, and oxygen saturation every 2 shift. Intervention included administer medications, respiratory treatments, and oxygen as ordered.<BR/>Record review of Resident #29's care plan dated 05/15/23 indicated terminal prognosis related to end of life/palliative care as evidence by a hospice care service diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) and admit to hospice. Intervention included hospice has been initiated for additional resident and family support. <BR/>Record review of Resident #29's consolidated physician order dated 06/28/23 indicated oxygen liters per minute inhalation every 2 shift 2-4 liters. <BR/>Record review of Resident #29's MAR dated 08/01/23-08/31/23 indicated oxygen liters per minute inhalation every 2 shift 2-4 liters, Dx: Paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days). Start date 06/28/23. No end date. The MAR indicated use of oxygen 08/01/23-08/23/23 and 08/29/23-08/31/23. <BR/>Record review of Resident #29's Hospice Election Statement dated 05/03/23 indicated Resident #29 elected services with a local hospice company with a start of care date of 05/03/23. <BR/>During an interview on 11/02/23 at 1:30 p.m., RN LL said she was the MDS coordinator and had been in the position since March 2023. She said she used information from the resident's medical record to code their MDS. She said she could not only go by observation. She said Resident #29 was on oxygen and oxygen saturation were documented during his MDS assessment period. She said she somehow missed coding Resident #29 being on oxygen therapy. She said Resident #5 was also on oxygen during her MDS assessment period. She said when she viewed the MDS on her computer, oxygen therapy was coded. RN LL was asked to print another copy of Resident#5's MDS. RN LL provided a new copy of Resident #5's MDS and oxygen therapy was not coded. RN LL said recently the facility had experienced issues related to oxygen so that may be the issue with Resident #5's oxygen therapy not being coded on her MDS. She said during June 2023, when Resident #5's MDS was completed, she had a lot of people assisting her with MDSs. She said Resident #29 being on hospice services could not be coded on his August 2023 MDS because there were issues with hospice billing. She said the Regional MDS Consultant audited her submitted MDSs for accuracy. She said she did not know how often the Regional MDS Consultant audited the MDSs submitted. She said Resident #5 and Resident #29's information should have coded for accuracy assessment of the resident. She said she did not feel like having an inaccurate MDS assessment negatively affected the resident. She said the service was already done and captured. <BR/>On 11/02/23 at 2:10 p.m., RN LL provided an email to show proof the facility experienced issues coding oxygen on resident's MDSs. The email from the VP of Clinical Reimbursement dated 10/10/23 indicated .errors with respiratory treatment minute/days in Section O .if you have errors in Section O with Respiratory minutes and days you will need to dash those items in order to get the assessment to close .any resident you intend to claim respiratory minutes and days on between now and [DATE]st . The email addressed issues after Resident #5 and Resident #29's MDS assessment period and the issue were not related to respiratory treatment minutes and days. <BR/>During an interview on 11/02/23 at 2:30 p.m., the Hospice RN for Resident #29 said Resident #29 began services with the company 05/03/23. She said Resident #29 had an issue with getting a new Medicare number so billing was delayed but Resident #29 still received services and the facility still received payment. <BR/>3. Record review of Resident #361's face sheet dated 10/30/23 revealed Resident #361 was admitted to the facility initially on 2/17/17 and readmitted on [DATE] with diagnoses including lymphedema (swelling in an arm or leg caused by a blockage in the lymphatic system, part of the immune and circulatory systems), pneumonia (infection in lungs), weakness, abnormalities of gait and mobility, heart failure, and diabetes (high sugar levels in blood).<BR/>Record review of Resident #361's admission MDS dated [DATE] indicated Resident #361 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated Resident #361 was cognitively intact. Resident #361 required extensive assistance of 2 persons for most ADLs. Resident #361 was always incontinent of urine and frequently incontinent of bowel. The MDS said Resident #361 did not have pressure ulcers.<BR/>Record review of hospital records dated 8/3/23 prior to admitting to the facility revealed Resident #361 had a sacral decubital ulcer (wound caused from pressure to the lower back at the bottom of the spine) and was being treated with Santyl (ointment used to remove damaged tissue from skin ulcers).<BR/>During an interview on 11/02/23 at 9:46 AM, the MDS Coordinator said she had worked at the facility since March 2023. The MDS Coordinator said she was responsible for ensuring Resident #361's MDS was coded accurately. The MDS coordinator said when she codes a newly admitted resident, she uses the hospital records, the nurse's admission assessments, medication lists, physician orders, CNA and nurse documentation to aid in accurately coding the admission assessment. The MDS coordinator said a pressure wound to sacrum/coccyx should be included on MDS and care planned for treatment and prevention. The MDS coordinator said there were sometimes 200 or more pages in the hospital records, and she could miss something. The MDS coordinator said if the nurse's admission assessment/skin assessments were not completed then it hindered her in knowing what was going on with the resident on the day of admission. The MDS coordinator said it was important to complete the MDS assessment accurately to have the correct picture of the resident coded on the MDS.<BR/>During an interview on 11/02/23 at 10:52 AM, the ADM said if Resident #361 had a pressure ulcer at the time of the MDS assessment, then the pressure ulcer should have been included on the MDS assessment. The ADM said she expected the clinical staff to ensure the MDS was coded accurately. The ADM said the MDS Coordinator was responsible for the MDS assessments. The ADM said it was important to code the MDS accurately for billing and the staff would know what the resident required. <BR/>Record review of the facility's policy titled Resident Assessment dated 1/12/20 indicated . assess each resident's strengths, weaknesses, and care needs . it is the standard of care at this facility to conduct, initially and periodically, a comprehensive, accurate assessment of each resident's functional capacity utilizing the MDS according to the guidelines set forth in the Resident Assessment Instrument Manual .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed 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 one out of one resident (Resident #2) reviewed for PASRR.<BR/>The facility failed to submit NFSS forms timely for Resident #2. <BR/>These failures 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 include:<BR/>1. Record review of a face sheet dated10/03/2023 revealed Resident #2 was a [AGE] year-old female that admitted to the facility on [DATE] with the diagnoses of cerebral palsy (caused by abnormal brain development or damage to the developing brain that affects a person's ability to control his or her muscles), paranoid schizophrenia (stems from delusions-firmly held beliefs that persist despite evidence to the contrary-and hallucinations-seeing or hearing things that others do not), and muscle weakness.<BR/>Record review of Resident #2's quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 99, which indicated Resident #2 was cognitively impaired. Resident # 2 required extensive assistance for locomotion, bed mobility, bathing, and dressing. The MDS indicated Resident #2 was usually understood and usually understood others.<BR/>Record review of Resident #2's care plan dated 07/15/2023 stated Resident #2 was PASRR positive for the diagnosis of cerebral palsy and paranoid schizophrenia. Resident #2's ADL care plan indicated Resident #2 would have PT/OT evaluate and treat as needed to maintain or improve physical function.<BR/>Record review of the habilitation service plan (HSP) dated 06/12/2023, revealed Resident #2 was recommended to receive occupational therapy 5 times per week for 6 months to increase Resident #2's independence and safety with dressing and bathing.<BR/>The sign in sheet for the HSP, also dated 06/12/2023 indicated Resident #2, the PASRR Habilitation Coordinator, the social worker, the MDS Coordinator, and the Physical Therapy Assistant were present during the meeting and agreed on the recommendation.<BR/>Record review on an email correspondence dated 08/15/2023 between the PASRR Unit Program Specialist and the Administrator revealed the facility was informed and instructed in writing to submit a NFSS Request by a specific deadline but failed to do so. Also, the NFSS Request submittal by the NF was denied and there was not a follow up submittal to ensure the request was approved to provide specialized services for PASRR for the resident. The instructions included the following : Be sure your facility checks the status of the requests daily to ensure they are approved. Prompt attention should be given to the request if it has a pending denial status once it is submitted. This is a time sensitive status and can result in system generated denial if not followed up on by date noted by the reviewer in the request.<BR/>Review of Simple LTC portal (portal used to submit PASRR service requests) for Resident #2's OT Assessment reflected a note, dated 08/11/2023, NFSS form for OT was not submitted within 30 calendar days of the IDT meeting and it was form was not accepted.<BR/>During an interview on 10/04/2023 at 11:10 a.m., with the PASRR Habilitation Coordinator revealed the meeting on 06/11/2023 was the quarterly PASRR meeting mandated by the state. The PASRR Habilitation Coordinator stated it was decided in the meeting that Resident #2 would benefit from occupational therapy (OT) services and the process was initiated for Resident #2 to be evaluated and the paperwork to be submitted by the facility for approval for funding by the PASRR service group for the therapy. She stated the team present in the meeting decided it would be beneficial for her to have a reason to get out of bed every day and have therapy to look forward to. The PASRR Habilitation Coordinator stated after the meeting took place and she put her notes into the system it was up to the facility to complete the process.<BR/>During an interview on 10/04/2023 at 11:55 a.m., the PASRR Unit Program Specialist, stated her emails to the facility were self-explanatory and the facility failed to comply with the emails she sent. She stated it was important to file the NFSS form within 30 days after the IDT meeting and failure to do so may result in a resident not receiving needed rehabilitative services and could contribute to a decline in functional status. <BR/>During an interview with the MDS nurse 10/04/2023 at 2:00 pm, stated that she started she was unsure why the Simple LTC portal had not been checked daily to ensure Resident #2's OT request was followed up on. The MDS nurse stated it was important for the NFSS form to be completed 30 days after the IDT meeting. The MDS nurse stated that failure to submit the NFSS form within the timeframe may lead to residents not receiving services at the facility. <BR/>During an interview with the DON on 10/05/2023 at 12:20 p.m., stated she was unfamiliar with the process of PASRR and left it to the corporate MDS nurse to assist in those matters. <BR/>During an interview with the Administrator on 10/05/2023 at 1:40 p.m., stated she had received the emails from the PASRR specialist and a phone call. The Administrator stated the PASRR specialist called and said follow the instructions on the email and added no assistance with the process. The Administrator stated it was the right of Resident #2 to receive OT, but the Administrator did not feel Resident #2 had suffered any ill affect from having not received the services. <BR/>Policy related to PASRR services was requested 10/05/2023 at 10:00 a.m. and 1:00 p.m. by the Administrator and no policy was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a discharge summary that included but is not limited to, (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. and resident's follow up care and any post-discharge medical and non-medical services for 1. <BR/>(Residents #202) of four residents reviewed for discharge planning.<BR/>1. The facility failed to complete a recapitulation of Resident #202's stay.<BR/>2. The facility failed to ensure Resident #202 had a physician prescribed wheelchair, bedside commode, and shower transfer bench when he was discharged home alone.<BR/>This failure could place residents at risk of decreased socialization, depression, impaired skin integrity and increased fall risk.<BR/>Findings included:<BR/>1) Review of the face sheet for Resident #202 reflected the resident was a 68-year- old- male that admitted on [DATE] with the diagnoses of right femur fracture a break in the uppermost part of thighbone, next to the hip joint), arthritis, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). <BR/>Review of Resident #202's care plan dated 10/09/2023 reflected the following discharge care plan: Resident and/or representative will be assisted in planning for discharge to safest environment over the next 90 days. The intervention was listed as: educate and assist resident and/or representative to reach discharge goals and transfer to the community safely.<BR/>Record review of the recapitulation for Resident #202 revealed a blank recapitulation form.<BR/>Review of Resident #201's physician discharge noted written on 10/23/2023 by NP K revealed: .(Resident #202) was a [AGE] year-old male who had been in the rehabilitation facility after sustaining a distal right femur fracture with surgical fixation with an ORIF (surgery to fix fractured femur). He (Resident #202) had been actively participating with therapy services since his admission, but he was still noted to be non-weight bearing to his right lower extremity and was currently in a right leg immobilizer. He (Resident #201) had been wheelchair dependent since his admission. And to safely navigate in the community, at home, into perform his activities of daily living maintaining independence he will need a wheelchair, bedside commode, and tub transfer bench at the time of discharge to safely be able to meet his daily care needs. <BR/>Record review of Social Service note dated 10/24/2023 at 7:30 p.m. revealed, SW ordered DME through the DME company yesterday, 10-23-2023. DME ordered was wheelchair; tub transfer bench; and bedside Commode. SW requested the wheelchair be delivered to resident's room before discharge on [DATE], for use of transport home. Facility van driver provided transport home and resident arrived at his home around 1:30 p.m. SW received a call from resident stating his DME had not been delivered. SW called DME company and spoke to a lady who stated that she saw his DME was ordered yesterday, 10-23-23, but could not explain why it had not been delivered. SW requested that the lady call resident directly and coordinate delivery. This lady stated that she would call him immediately. SW received another phone call from resident around 3:30 p.m. stating that DME company called him because they do not take his insurance. DME company never notified SW that they could not fill the DME order. SW called the number given to resident, which was another DME company. At around 5:30 p.m., SW emailed the new DME company the order and asked if they could fill the physician's DME order and they replied via email that they will take care of it. SW called (Van Transport Tech) and requested he take resident a facility wheelchair to use until tomorrow, 10-25-23, and get his DME order filled and delivered to resident's home.<BR/>During an interview on 11/1/2023 at 4:50 p.m., Resident #202 stated the discharge from the facility had not gone smoothly. He stated on 10/23/2023 the facility van transport tech dropped him off at his apartment around 1:00 p.m. Resident #202 stated he transferred from the facility wheelchair to the couch and the transport left. Resident #202 stated he had no way to get to the bathroom, no way to get to his kitchen, and no way other than crawling to get out of his house. Resident #202 stated he had to urinate in a cup because he did not have a urinal or a way to the bathroom. Resident #202 stated he knew he was in trouble at that point and called a relative of his and they came over and filed a complaint with the facility for leaving him alone in an unsafe environment. Resident #202 stated a few hours later the facility transport driver came back with the facility wheelchair, and they allowed him to borrow it until his was delivered. Resident #202 stated his relative called the DME company and it turned out that no one had checked his insurance and they would be unable to provide him with any equipment. Resident #202 stated the next day around 3 p.m., the new DME company brought a wheelchair, bedside commode, and transfer bench. Resident #202 stated he had discussed with the SW prior to leaving he could not afford both the transfer bench and the bedside commode because of the copay they required. Resident #201 declined the bedside commode and transfer bench because he was asked to pay over $100 to keep them. Resident #202 stated his relative went to a local store and purchased a urinal for him and the facility came and got their wheelchair back that <BR/>evening.<BR/>During an interview on 11/02/2023 at 10:20 a.m., the SW stated she ordered the DME and was not aware the particular DME company they were using was not approved by Resident #202. The SW stated it was often the practice of the facility to wait until just before discharge to order DME so the most appropriate DME would be ordered. The SW stated she learned a valuable lesson from the situation with Resident #201 and would follow up with all DME companies to ensure they DME was delivered prior to discharge.<BR/>During an interview on 11/02/2023 at 2:45 p.m., the Administrator stated it was the facility policy to make sure the discharge summary and recapitulation was completed prior to the resident leaving the facility by the nurse discharging the resident, so they could have a copy with them when they went home. The Administrator stated it was the facilities policy to ensure DME was either delivered to the facility prior to discharge if the resident could not function in their home without it, or within a few hours of arrival at home in some cases. The Administrator stated in the case of Resident #202, the DME company had not informed the facility they were unable to accommodate the DME order prior to the resident discharging. The Administrator stated she had no problem leaving a wheelchair with the resident until he got his own DME delivered. The Administrator stated it was the job of the SW to ensure all the discharge items were taken care of for each resident.<BR/>Review of the facility's policy titled, Discharge Summary and Plan, revised April 2009, reflected, . 2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge .The discharge summary shall include a description of the resident's: a. Medically defined condition and prior medical history, b. Medical status measurement, c. Physical and mental functional status, d. Sensory and physical impairments, e. Nutritional status and requirements, f. Special treatments of procedures, g. Mental and psychosocial status, Discharge potential, i. Dental condition, j. Activities potential, k. Rehabilitation potential, l. Cognitive status, m. Drug therapy; .6. A copy of the post-discharge plan and summary will be provided to the resident and receiving facility, and a copy will be filed in the resident's medical records. <BR/>A policy for ordering DME was requested of the Administrator on 11/1/2023 at 4:15 p.m. and again on 11/2/2023 at 9:30 a.m. No policy was provided by the facility prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good grooming and personal hygiene for a resident who is unable to carry out activities of daily living were provided for 2 of 4 residents reviewed for activities daily living (Resident #2 and Resident #5)<BR/>The facility did not clean or trim the nails of Resident #2 and Resident #5. <BR/>The facility failed to promptly respond to Resident #2 and Resident #5's call lights who were ADL dependent.<BR/>These failures could place dependent residents at risk of poor hygiene, infections, injuries and unmet needs. <BR/>Findings included: <BR/>Record review of Resident #2 's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including respiratory failure, colon cancer, diabetes, and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred). <BR/>Record review of Resident #2's MDS dated [DATE] indicated Resident #2 made himself understood and usually understood others. The MDS indicated Resident #2 had moderately impaired cognitive function (BIMS of 10). The MDS indicated he had no behavior of rejecting care. The MDS indicated he required limited assistance with locomotion in his wheelchair, supervision only with toilet use and eating. The MDS indicated he required extensive assistance with dressing, personal hygiene and bathing. The MDS indicated bed mobility had only occurred once or twice during the 7 days look back period. The MDS indicated transfers and walking had not occurred during the 7 days look back period. <BR/>Record review of Resident #2's care plan dated 12/7/22 indicated his ADL dependency was not specifically addressed. <BR/>During an observation on 2/8/23 at 11:15 a.m. revealed Resident #2 laid in his bed. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/>During an interview and observation on 2/8/23 at 2:44 p.m. revealed Resident #2 sat in his bed. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/> Resident #2 said he had been at the facility approximately 2 months. He said no one had offered to trim and clean his nails since he had been at the facility.<BR/>During an observation and interview on 2/9/23 at 9:05 a.m. revealed Resident #2 sat in his wheelchair. His nails were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under several of the nails. CNA F was making his bed. CNA F said nail care was usually done on shower days by the CNAs. CNA F indicated she had just administered a shower to Resident #2. CNA F said nurses trimmed the nails of diabetic residents. <BR/>During an observation on 2/9/23 at 11:17 a.m. revealed Resident #2 was in therapy sitting in his wheelchair. CNA F stood at his side viewing his nails. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/>During an interview on 2/9/23 at 11:18 a.m., CNA F said she did not know if Resident #2 was a diabetic. CNA F said she cleaned Resident #2's nails in the shower by washing over the top of his hands but indicated she did not clean under his nails. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said she worked the hall on which Resident #2 resided on 2/8/23. RN C said there was no set schedule for diabetic nail care and nurses just performed the care as it needed to be done. RN C said no CNAs had reported to her that any diabetic resident needed nail care yesterday (2/8/23). RN C said Resident #2's nails were very thick and would have to be soaked before they could be cut. RN C said that might be why the nail care had not been performed. RN C said it was important to ensure nail care was completed to prevent infection. <BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she regularly worked the hall that Resident #2 resided on. CNA E said CNAs and nurses were responsible to ensure residents nails were cleaned and trimmed. CNA E said nurses performed nail care for diabetic residents. CNA E said there was no set schedule for CNAs to perform nail care and indicated she performed nail care when she saw it needed to be done. CNA E said if she saw nail care was needed for a diabetic resident, she would notify the nurse. CNA E said she could not remember if she notified RN C that nail care was needed for Resident #2. CNA E said it was important to ensure nail care was completed to maintain resident hygiene.<BR/>2. Record review of Resident #5's consolidated physician orders dated 2/10/23 indicated he was [AGE] years old admitted to facility on 1/16/23 with diagnoses including atherosclerotic heart disease (heart disease caused by the buildup of fats, cholesterol and other substances in and on the artery walls), and rheumatoid arthritis (chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility) and dementia. <BR/>Record review of Resident #5's MDS dated [DATE] indicated Resident #5 usually understood and usually made himself understood. The MDS indicated he had moderately impaired cognitive function (BIMS of 9). The MDS indicated he had no behavior of rejecting care. The MDs indicated transfers had only occurred once or twice during the 7 days look back period. The MDS indicated locomotion in his wheelchair had not occurred during the 7 days look back period. The MDS indicated he required limited assistance with walking in his room and eating. The MDS indicated he required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and bathing. <BR/>Record review of Resident #5's care plan revised on 2/1/23 indicated his ADL dependency was not specifically addressed.<BR/>During an observation and interview on 2/8/23 at 3:45 p.m. revealed Resident #5 laid in his bed. His nails were long (approximately 1/2 centimeter past the end of his fingers). There was a dark brown substance under several (more than 2 nails on each hand but less than 5 nails of each hand) nails to each hand. Resident #5 said he wanted his nails to be cleaned and trimmed. Resident #5 said he did not know when his nails were last cleaned and trimmed. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said she worked the hall on which Resident #5 resided on 2/8/23. RN C said CNAs were responsible to perform nail care for non-diabetic residents. RN C said there was no set schedule for CNAs to perform nail care and indicated CNAs were to perform the nail care as needed. RN C said it was important to ensure nail care was completed to prevent infection.<BR/>During an observation on 2/10/23 at 9:32 a.m. revealed Resident #5 laid in his bed. His nails were long (approximately 1/2 centimeter past the end of his fingers). There was a dark brown substance under several (more than 2 nails on each hand but less than 5 nails of each hand) nails to each hand. <BR/>During an interview on 2/10/23 at 10:28 a.m., CNA G said residents were to have their nails cleaned and trimmed on shower days by CNAs. CNA G said resident nails were to be cleaned and trimmed as needed in between shower days. CNA G said it was important to ensure nail care was done to avoid infection and unintentional injury (scratches and skin tears).<BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she regularly worked the hall that Resident #5 resided on. CNA E said CNAs and nurses were responsible to ensure residents nails were cleaned and trimmed. CNA E said nurses performed nail care for diabetic residents and CNAs performed nail care for non-diabetic residents. CNA E said there was no set schedule for CNAs to perform nail care and indicated she performed nail care when she saw it needed to be done. CNA E said she did not recall performing nail care for Resident #5 but indicated she would have cleaned and trimmed his nails if she noticed they were long and dirty. CNA E said it was important to ensure nail care was completed to maintain resident hygiene. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected CNAs to ensure nail care was completed for non-diabetic residents as it was needed. The DON said she expected nurses to perform nail care for diabetic residents as it was needed. The DON said it was important to ensure nail care was done to prevent unintentional injuries (such as scratches) and prevent infections. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected staff to ensure resident's nails were cleaned and trimmed. <BR/>Record review of the facility policy and procedure titled Bathing revised on 02/12/20 reflected, .Tasks commonly completed during the bathing process .Report abnormal findings to the nurse in charge .needs shall be discussed with the resident and responsible party during care plan meetings with the interdisciplinary team in order to identify and implement proper hygiene habits and promote resident rights and dignity The policy and procedure did not specifically address nail care. A policy and procedure for nail care was requested but not received. <BR/>3. During an observation on 2/8/23 at 2:44 p.m. revealed Resident #5 could be heard across the hall yelling Somebody come help me. <BR/>During an observation on 2/8/23 at 2:47 p.m. revealed Resident #2 pushed his call light in order to obtain assistance to get up.<BR/>During a continuous observation on 2/8/23 from 2:47 p.m. to 3:15 p.m. revealed Resident #5's call light dome remained lit up and the call light alarm was audible until 3:12 p.m. Resident #5 continued to yell intermittently for help from 2:47 p.m. to 3:15 p.m. Resident #2's call light dome remained lit up and the call light alarm was audible until 3:15 p.m. Resident #5's room was directly adjacent to Resident #2's room. <BR/>During an observation on 2/8/23 at 2:51 p.m., revealed Receptionist I walked by both Resident #2 and Resident #5's rooms as Resident #5 yelled out. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:52 p.m. revealed LVN J walked by both Resident #2 and Resident #5's rooms pushing a treatment cart. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:55 p.m. revealed Admissions Director K walked by both Resident #2 and Resident #5's rooms as Resident #5 yelled out Help. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:57 p.m. revealed an unidentified staff member in a khaki-colored polo pushed a red hand truck/ appliance dolly (tool to move heavy items) by both Resident #2 and Resident #5's rooms. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:58 p.m. revealed Housekeeper L stood in the hallway, 2 rooms down from Resident #2 and Resident #5's rooms. Housekeeper L stood in front of his housekeeping cart with his back toward the surveyor. His head was bent down as if he were looking at something in front of him. <BR/>During an observation on 2/8/23 at 3:02 p.m. revealed CNA H walked by both Resident #2 and Resident #5's rooms. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 3:12 p.m. revealed Maintenance Personnel M answered Resident # 5's call light. <BR/>During an observation on 2/8/23 at 3:15 p.m. revealed CNA H answered Resident #2's call light.<BR/>During an interview on 2/8/23 at 3:16 p.m., maintenance personnel M said answering call lights was everyone's (all staff's) responsibility. Maintenance Personnel M said he may not be able to get/do exactly what the resident requested/needed. Maintenance Personnel M said he could ensure there was not an emergency and notify the nurse of the resident request/need. Maintenance Personnel M said Resident #5 said he just wanted to go home. <BR/>During an interview on 2/8/23 at 3:17 p.m., CNA H said anyone could answer a call light. CNA H said even if the staff were not clinical, they can and should respond to a call light. CNA H said non-clinical staff should check on call lights because there could be an emergency, or the resident might have a simple request. CNA H said she did not immediately check on the call lights because she had just came onto her shift. CNA H said she should have checked on the call lights the first time she went by and notified the residents she would be right back. CNA H said Resident #2 needed help to get up. <BR/>During an interview on 2/8/23 at 3:18 p.m., Housekeeper L said he had worked at the facility since November 2022. Housekeeper L said he noticed the call lights going off but had not been given any instructions regarding call lights. Housekeeper L said he was not sure if he was supposed to answer call lights. <BR/>During an interview on 2/8/23 at 3:29 p.m., Admissions Director K said she had worked at the facility for approximately 3 years. Admissions Director K said any staff could check on a call light, but some residents call out or yell out like every 10 minutes. Admissions Director K said even for the residents that frequently call out she would still check on them. Admissions Director K said she was not sure if Resident #2 and Resident #5 were residents that called out frequently. Admissions Director K said staff had to respond to call lights because the resident might actually need help. Admissions Director K said she did see Resident #2 and Resident #5's call lights when she walked by. Admissions Director K said she did hear Resident #5 yell as she walked by his room. When asked why she did not respond to the call lights or Resident #5's yell for help Admissions Director K said I want to say in my heart of hearts it's because I didn't think they needed Admissions Director K stopped mid-sentence and then said but I can't say that. Admissions Director K then said there was no excuse for not having stopped and checked on Resident #2 and Resident #5's call lights. <BR/>During an interview on 2/8/23 at 3:35 p.m., LVN J said she did not remember walking by Resident #2 and Resident #5's rooms with her cart. LVN J said she certainly would have stopped and checked on the call lights had she noticed they were going off. LVN J said we (all staff) were responsible for answering call lights. <BR/>During an interview on 2/9/23 at 10:19 a.m., Receptionist I said she use to be a CNA and had worked at the facility for 2 &frac12; years. Receptionist I said all staff members were responsible for answering call lights. Receptionist I said it was important to respond to call lights because it could be an emergency. Receptionist I said if the request were something simple, non-clinical staff can assist them or notify the nurse. Receptionist I said she did not remember walking past Resident #2 and Resident #5's call lights yesterday (2/8/23). Receptionist I said she did not remember Resident #5 yelling out for help. Receptionist I said she would have answered the call lights had she noticed them going off. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said all staff clinical or not, were responsible for responding to resident call lights. The DON indicated it was unacceptable that call lights remained unanswered for over 20 minutes while multiple staff members walked by. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected all staff to respond to resident call lights in order to ensure resident needs were met. <BR/>Record review of the facility policy and procedure titled, Call Lights-Answering, revised on 02/12/20 reflected, Standard of Practice: The staff will provide an environment that helps meet the resident's needs by answering call lights appropriately. Procedures: (1) Respond to patients/resident's call lights and emergency lights in a timely manner . (5) If unable to complete the request, do not turn off the call light; the call light will remain on until the service is completed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 6 residents (Resident #27 and Resident #361) reviewed for pressure injury.<BR/>The facility failed to ensure Resident #27 low air loss mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings.<BR/>The facility failed to ensure Resident #27 had dressing on his back wounds. <BR/>The facility failed to ensure the WCN loosening Resident #27's dressing, before removing, from his heel wound to prevent bleeding. <BR/>The facility failed to ensure Resident #27 was turned and repositioned every 2 hours.<BR/>The facility failed to ensure Resident #27 was positioned correctly when using his positioning aides.<BR/>The facility failed to treat Resident #361's unstageable (the base of the wound was covered by a layer of dead tissue that was yellow, grey, green, brown, or black and unable to determine the stage of the wound) sacral pressure ulcer for 3 days after admission.<BR/>These failures could place residents at risk for deterioration of wound. <BR/>Findings included:<BR/>1. Record review of Resident #27's face sheet dated 10/30/23 indicated Resident #27 was a [AGE] year-old male and admitted on [DATE] with diagnoses including cerebral infarction ((also known as a stroke) refers to damage to tissues in the brain due to a loss of oxygen to the area), pressure ulcer of buttock (also known as bedsores, are an injury that breaks down the skin and underlying tissue), stage 3, skin changes and pain.<BR/>Record review of Resident #27's annual MDS assessment dated [DATE] indicated Resident #27 was usually understood and usually understood others. The MDS indicated Resident #27 had a BIMS score of 09 which indicated moderately impaired cognition and required limited assistance with dressing, extensive assistance with bed mobility, toilet use, personal hygiene, and bathing. The MDS indicated Resident #27 had 2 Stage 4 pressure ulcers and were present upon admission/entry or reentry. The MDS indicated Resident #27 had skin and ulcer/injury treatments of pressure reducing device for bed, nutrition or hydration intervention, pressure ulcer/injury care, application of ointments/medications other than to feet, and application of dressing to feet. The MDS indicated Resident #27 received an anticoagulant (are medicines that help prevent blood clots) for 3 days during the 7 days assessment period. <BR/>Record review of Resident #27's care plan dated 09/21/23 indicated anticoagulant/antiplatelet (medications that prevent blood clots from forming) related to diagnosis of atrial fibrillation (is an irregular and often very rapid heart rhythm) and history of cerebrovascular accident (stroke) as evidence by Apixaban (is used to prevent serious blood clots from forming due to a certain irregular heartbeat) 5mg tablet 1 tablet by mouth 2 times a day. Interventions included handle resident carefully when turning, positioning, or transferring and maintain pressure on skin tears, blood draws sites, and IV sites for at least five minutes. <BR/>Record review of Resident #27's care plan dated 10/24/23 indicated Resident #27 was at risk for/actual of skin breakdown related to skin failure and history of pressure injury as evidence by pressure reducing/redistribution mattress (redistribute a patient's weight so as to relieve pressure points), pressure ulcer risk: high score 10-12, confined to bed most of time, wound (pressure, diabetic or stasis), open lesions. Interventions assist resident to turn and reposition frequently, report refusals, off load heels, position resident properly; use pressure reducing or pressure relieving devices if indicated, and treatments and dressings as ordered per physician. <BR/>Record review of Resident #27's Consolidated Physician Orders dated 04/06/23 Pressure reducing/redistributing mattress, night shift. <BR/>Record review of Resident #27's Consolidated Physician Orders dated 06/02/23 Air Mattress to bed, every 2 shifts. Check every shift for function. <BR/>Record review of Resident #27's Consolidated Physician Orders dated 10/12/23 indicated cleanse wound on day shift, cleanse wound to left upper back with normal saline, pat dry, apply calcium alginate with silver (Assist with infection reduction. Primary dressing for wounds with moderate to heavy exudate (drainage)), cover with silicone bordered dressing (is highly conformable with a thin, low-profile edge to help minimize the rolling and lifting that can impact adhesion) daily.<BR/>Record review of Resident #27's Consolidated Physician Orders dated 10/27/23 indicated cleanse wound on day shift, right back with normal saline, pat dry, apply alginate calcium when blister breaks and cover with silicone foam bordered dressing daily.<BR/>Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated Pressure reducing/redistributing mattress, night shift. Diagnosis: Benign Prostate Hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty) with lower urinary tract symptoms. Start date: 04/06/23. Documentation noted every day, night shifts.<BR/>Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated Air Mattress to bed, every 2 shifts. Check every shift for function. Diagnosis: skin changes. Start date: 06/02/23. Documentation noted every day, 2 shifts. <BR/>Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated cleanse wound on day shift, cleanse wound to left upper back with normal saline, pat dry, apply calcium alginate with silver, cover with silicone bordered dressing daily. Diagnosis: skin changes. Start date: 10/12/23. Documentation noted 10/12/23-10/31/23 on day shift. <BR/>Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated cleanse wound on day shift, right back with normal saline, pat dry, apply alginate calcium when blister breaks and cover with silicone foam bordered dressing daily. Diagnosis: skin changes. Start dated: 10/27/23. Documentation noted 10/27/23-10/31/23 on day shift.<BR/>Record review of Resident #27's wound evaluation and management summary dated 10/25/23 indicated .wounds on his sacrum .left first finger .right lateral (outside of your foot) heel .right upper lateral foot .left upper back .left back .right back .stage 4 pressure wound (There is full-thickness skin loss extending through the fascia with considerable tissue loss) of the right, upper, lateral foot full thickness .2.4cmx1.8cmx0.2cm (Lx W x D) .at goal for wound progress .stage 4 pressure wound of the right, lateral heel, full thickness .3.4cm.3.4cmx0.1cm .stage 4 pressure wound sacrum full thickness .6.8cmx10cmx2cm .at goal .recommendation off-load wound .reposition per facility protocol .group-2 mattress .stage 3 pressure wound of the left upper back full thickness .1.2cmx0.9cmx0.1cm .improved evidence by decreased surface area .non-pressure wound of the left back partial thickness .9cmx2.5cmx0.1cm .abrasion/sheer .non-pressure wound of the right back .6cmx1.5cmxnot measurable cm .blister fluid filled .<BR/>Record review of Resident #27's wound evaluation and management summary dated 11/01/23 indicated .wounds on his right lateral heel .left upper back .sacrum .right upper lateral foot .left back .right back .left first finger . stage 4 pressure wound the right, upper, lateral foot full thickness .8cmx10cmx0.2cm .objective palliation .wound progress at goal . stage 4 pressure wound of the right, lateral heel, full thickness .3.5cmx4.0cmx0.1cm .wound progress at goal . stage 4 pressure wound sacrum full thickness .9cmx12.5cmx2.0cm .wound progress at goal . stage 3 pressure wound of the left upper back full thickness .19cmx12.5cmx0.1cm .wound progress at goal .unavoidable due to generalized decline .non-pressure wound of the left back .signoff-wounds has merged with another site on 11/01/23 . non-pressure wound of the right back .signoff-wounds has merged with another site on 11/01/23<BR/>Record review of the facility's weight log dated 10/04/23 indicated Resident #27 was 6'3 and 215.6 pounds. <BR/>During an interview and observation on 10/30/23 at 11:24 a.m., Resident #27 was on a bariatric (a person is classified as having obesity), low air loss mattress, lying on his back. Resident #27 feet were covered but appeared to be elevated. Resident #27 low air loss mattress setting was 50 pounds. Resident #27 said he had wounds on his right foot and bottom. He said he came to the facility with the wounds. Resident #27 said he did not feel like the staff turned him enough. <BR/>During an observation on 10/30/23 at 3:41 p.m., Resident #27 was lying on his back with head of his bed elevated. <BR/>During an observation on 10/31/23 at 9:46 a.m., Resident #27 was lying on his right side with an elongated, balloon shaped pillow in front of him. He said he did not know what the pillow was used for, and it had not been used before. Resident #27's low air loss mattress setting was on 50 pounds. <BR/>During an observation on 10/31/23 at 11:37 a.m., Resident #27 was lying on his right side with an elongated, balloon shaped pillow in front of him.<BR/>During an observation on 10/31/23 at 2:08 p.m., Resident #27 was lying on his left side and the low air loss mattress setting was on 50 pounds.<BR/>During an observation and interview on 10/31/23 at 3:02 p.m., Resident #27 was lying on his left side with triangular shaped positioning aide behind his back. When WCN NN removed the covers from Resident #27's legs, 2 small rectangular shaped positioning wedges were beneath his heels, but no pillow or wedge observed underneath the knees and Resident #27's calf was laying on the edge of the rectangular wedges which caused an indentation to his calf. During wound care provided by WCN NN, WCN NN removed a dressing from Resident #27's left heel. The dressing from Resident #27's left heel was slightly stuck to the skin and when removed, small amounts of frank blood dripped onto the positioning wedges. When Resident #27 was turned on his left side, one dressing was noted to the left side of his back but two other wounds were noted to the back without dressing. Resident #27's low air loss mattress setting was on 50 pounds. Resident #27 said he was 6'3 and 380 lbs. <BR/>During an observation on 11/01/23 at 3:08 p.m., Resident #27's low air loss mattress setting was on 300 pounds. <BR/>During an interview on 11/02/23 at 10:26 a.m., WCN NN said she started as the wound care nurse August 2023. She said everyone was responsible for checking the low air loss mattress settings. She said Resident #27's low air low mattress setting was on 50 pounds. She said when she went to do wound care with the wound care doctor today (11/02/23), they noticed the mattress looked low. She said she did not know how to unlock the bed settings, so the wound care doctor fixed the settings on Resident #27's bed. She said she thought the wound care doctor set the bed to 180 pounds. She said she only looked at the machine lights to make sure they were green, after the wound care doctor set the settings. She said she did not know why the wound care doctor set the low air loss mattress settings at 180 pounds because Resident #27 weighed more than 180 pounds. She said she normally tried to glance at the low air loss mattress machine when she did his daily dressings changes. She said she because there was no specific order on what weight to set the mattress settings on, she would look up the resident's weight to determine the settings. She said the floor nurses should check the mattress setting every shift to make sure it was working and on the right settings. She said the nurse's charted on the TAR every shift, they checked the mattress. She said correct inputted weight on the low air loss mattress was important to prevent wounds from happening and current wounds from getting worse. She said the wrong settings negatively affected the resident by worsening the wounds and be in pain. She said that could cause the need for pain medication and contributed to the slow healing of Resident #27's sacrum wounds. The WCN NN said CNAs were responsible for turning and repositioning residents every 2 hours when they made rounds. She said the hall nurse should ensure the CNAs were turning and repositioning residents every 2 hours. She said she did not know how the hall nurse monitored if every 2-hour turning happened. She said she looked into resident's rooms when she walked the halls to monitor turning and repositioning. She said turning and repositioning every 2 hours prevents further deterioration of wounds, removed pressure to prevent wounds, and reduced pressure on bony areas. She said she had not noticed Resident #27 not been tuned and repositioned every 2 hours. The WCN NN said she was responsible for dressing changes and wound care Monday-Friday and floor nurse did dressing changes on the weekend. She said the nurses were responsible for the resident's dressing staying on and changing the dressing when soiled. She said when she did Resident #27's wound care on Monday (10/30/23), he had 3 dressing to his back. She said no one notified her two of the dressing had fallen off on Tuesday (10/31/23) prior to the observed dressing change. She said the CNAs are supposed to let the nurses know when a dressing comes off. She said the wounds needed dressing to stop bacteria from getting in and help with healing. She said if no dressing is on the wounds, it could get infected and deteriorate. She said this would cause Resident #27 to need antibiotics and different treatment orders. She said she did not know if the CNAs had been instructed or in-serviced to notify nursing staff when wound dressing come off. The WCN NN said she did not know if CNAs had training on how to use and place positioning aides. She said she did not know if the positioning wedges came in different size and lengths since Resident #27 was tall and bariatric. She said she did not remember on Tuesday (10/31/23) during the dressing change if Resident #27 had a pillow underneath his knees. She said but Resident #27 should have a pillow underneath his knees to prevent pressure and give knee support. She said no knee support could cause blisters, wounds, and decreased range of motion. She said the facility was in the process of starting training on turning and repositioning. The WCN NN said Resident #27 was on a blood thinner and the Xeroform gauze dried out and stuck to the wound. She said she could have moistened the dressing to help prevent the wound from bleeding. She said Resident #27 being on a blood thinner cause him to bleed easier than other residents. <BR/>During an interview on 11/02/23 at 11:35 a.m., CNA H said she had been a CNA for 20 years but started back working at the facility around August 2023. She said she worked 6am-2pm shift on the 100-hall. She said she worked with Resident #27. She said resident were supposed to be turned every 2 hours to prevent skin break down and pressure sores. She said she knew how to correctly position resident using position aides and knew why it was important. She said pillows or position aides were important because they kept the skin from touching, prevented skin breakdown, and relieved pressure areas. She said she always found Resident #27 with a pillow underneath his knees. She said she let nurses know when wound dressing came off. She said Resident #27's back dressing normally stayed on, but his butt dressing came loose often. She said the wounds needed dressings because they were pressure sores, and they needed the dressing to heal. <BR/>During an interview on 11/02/23 at 2:06 p.m., LVN N said she had worked at the facility for 4 years and worked the 6am-6pm shift. She said she primarily worked the 300-hall and 400-hall but also worked the others hall too. She said residents should be turned. She said the resident should be turned and repositioned every 2 hours by the aides. She said LVN should check what position the resident are in throughout the day. She said if residents refused to be turned and repositioned, the aides needed to notify the nurse so it could be charted. She said turning and repositioning ensured resident did not develop wounds. LVN N said it was the nurse's responsibility to make sure the low air loss mattress was working every time you entered the room. She said all nurses should make sure the setting was on the correct weight by checking the weight in the computer system. She said the correct settings helped distribute the correct amount for the wounds and if the mattress is flat, it could cause more wounds or make current wounds worse. LVN N said all nurses should make sure dressings stayed on. She said if the wounds are left open, bacteria could be introduced and cause an infection. She said the infection could cause the resident to need antibiotics, develop sepsis (is a serious condition in which the body responds improperly to an infection) and c-diff ((also known as Clostridioides difficile or C. difficile) is a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon)), and death. <BR/>During an interview on 11/02/23 at 3:04 p.m., the DON said the CNAs should be turning and repositioning residents every 2 hours and as needed. She said LVNs and the DON should ensure it happened by making rounds. She said the facility used to have a system in place to have residents face a certain way a specific time of the day. She said that process did not work. She said she picked a different hall a week and monitored turning and repositioning. She said turning and repositioning was important to prevent skin breakdown. She said it was always uncomfortable to the resident to stay in the same position. The DON said the WCN was responsible for making sure low air loss mattress were on the right settings or weight. She said the WCN should at least be checking weekly, if not every time she was in the room doing dressing changes. She said unfortunately, CNAs can accidently change the setting and family members. She said the wrong setting could cause pressure and effect the resident's skin integrity. She said she did not know if the low air loss mattress being on the incorrect weight could cause pressure ulcer delayed healing. She said the floor nurse were responsible to make sure the low air loss mattress was working and on the ordered type of mattress. The DON said the WCN did dressing changes and the aides should notify the LVN when the dressing came off. She said the aides know to notify the nurses when a dressing comes off. She said wounds without ordered dressing risked infection and delayed healing. She said wound dressing were important for adequate healing. The DON said she did not know if all the aides knew how the use positioning aide/wedges. She said the facility had a large turnover in aides and was in the process of training the staff. She said pillow or wedge should be between or under the knees to provide support. She said correct use of positioning aides was important for comfort, proper body alignment, and reduced pressure wounds. <BR/>During an interview on 11/02/23 at 4:30 p.m., the WC MD said Resident #27 was under his care for several wounds. He said Resident #27 had recently been placed on hospice and his wound care was palliation, so not directly trying to heal the wounds. He said he had also clustered some wounds after his last visit (11/01/23) to decrease the amount of treatment needing to be performed. He said he vaguely remembered Resident #27 mattress setting being on the wrong weight. He said the low air loss mattress should be close the resident's weight and if tolerated, alternating every 15 minutes. He said Resident #27 was about 250 pounds so 50 pounds was far from what he needed. He said Resident #27 had a decline in health, decreasing the healing of his wounds. He said Resident #27 being on 50 pounds settings instead of about 250 pounds could feasibly have contributed to the increased size of the pressure and non-pressure wounds. He said he did not know the facility's policy on how often the low air loss mattress setting should be checked but they should be checked when wound care was provided. <BR/>2. Record review of Resident #361's face sheet dated 10/30/23 revealed Resident #361 was admitted to the facility initially on 2/17/17 and readmitted on [DATE] with diagnoses including lymphedema (swelling in an arm or leg caused by a blockage in the lymphatic system, part of the immune and circulatory systems), pneumonia (infection in lungs), weakness, abnormalities of gait and mobility, heart failure, and diabetes (high sugar levels in blood).<BR/>Record review of Resident #361's admission MDS dated [DATE] indicated Resident #361 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated Resident #361 was cognitively intact. Resident #361 required extensive assistance of 2 persons for most ADLs. Resident #361 was always incontinent of urine and frequently incontinent of bowel. The MDS said Resident #361 did not have pressure ulcers.<BR/>Record review of Resident #361's undated care plan revealed he was at risk for/actual skin breakdown with onset date of 8/07/23.<BR/>Record review of hospital records dated 8/3/23 revealed Resident #361 had a sacral decubital ulcer (wound caused from pressure to the lower back at the bottom of the spine) and was being treated with Santyl (ointment used to remove damaged tissue from skin ulcers).<BR/>Record review of Resident #361 's admission assessment revealed there was no documentation of an admission assessment upon admission.<BR/>Record review of Resident #361 's initial skin assessment revealed there was no documentation of an initial skin assessment completed.<BR/>Record review of Resident #361 's nurses' notes revealed there was no documentation until 8/18/23 and it did not address Resident #361 's pressure ulcer to his sacrum/coccyx.<BR/>Record review of Resident #361 's order summary report dated 10/31/23 revealed there was no orders to treat Resident #361 's pressure ulcer to his sacrum/coccyx until 8/07/23, however, the order did not match what APRN QQ had documented in his 8/07/23 note. The 8/07/23 order was to cleanse the coccyx wound every other day with wound cleanser, pat dry, apply medihoney, wet/dry dressing, and cover with mepilex.<BR/>Record review of Resident #361 's physician visit note dated 8/07/23 completed by APRN QQ revealed during the visit Resident #361 complained of pain to his coccyx. APRN QQ documented Resident #361 to have an unstageable sacral wound that covered his sacrum and his left and right buttocks. APRN QQ documented the wound to have slough and eschar to the wound base with serous drainage present. APRN QQ ordered wound care to cleanse the wound with wound cleanser, pat dry, apply Santyl to moist fluffed gauzes covering the entire wound, cover with dry gauze and secure with a silicone foam dressing every other day.<BR/>During an interview on 11/01/23 at 10:31 AM, APRN QQ said he did not recall being notified about Resident #361 's wound to his bottom upon his admission. APRN QQ said he would have expected the admitting nurse to notify him with abnormal findings for orders. APRN QQ said Resident #361 admitted on Friday 8/04/23 and he saw Resident #361 on Monday 8/07/23. APRN QQ said he remembered there was little mention of the pressure ulcer to Resident #361 's bottom in the hospital records during his review. APRN QQ said the wound was covered with slough (wet dead tissue) and eschar (dried out dead tissue) and he was unable to stage the pressure injury. APRN QQ said it was a pretty bad wound and he gave orders for wound care, and he made a referral for the wound care physician to see him that usually came to the facility on Wednesdays. APRN QQ said after the wound care physician saw Resident #361 and debrided the wound (cut away dead tissue), then they were able to see the extent of the wound. APRN QQ said the resident had osteomyelitis (bone infection) in his foot and he suspected that it could have come through the bone and settled in the sacrum/coccyx. APPRN QQ said he did an x-ray of the sacral area, and it was suspicious of osteomyelitis, then they decided it was best to send him to the hospital for further treatment. APRN QQ said depending on how the wound looked upon admission on [DATE], he most likely would have given the same orders and made a referral to wound care. APRN QQ said it was possible the wound could have deteriorated without appropriate care from 8/04/23 until 8/07/23, but unlikely that it would have deteriorated to the point of needing emergent intervention in that time frame.<BR/>During an interview on 11/01/23 at 11:18 AM, LVN KK had worked at the facility for six months and normally worked on 600 hall on the 6am-6pm shift. LVN KK said the nurse on the floor was primarily responsible for completing the admission assessment, obtaining and entering orders, initial skin assessments upon the resident's arrival/admission. LVN KK said the first nurse to lay eyes on resident was responsible for all the admission stuff. LVN KK said if a resident was admitted during the week, he preferred to have the wound care nurse go with him and do the skin assessment with him. LVN KK said by completing the admission assessment that included the skin assessment, it would find a pressure wound and it was important to find pressure wounds on admission, so it would show it was acquired at hospital and not at the facility. He would document LVN KK said if he found any new wounds during his skin assessment, he would notify the physician for orders, and he let wound care nurse and the DON know. LVN KK said the nurses were responsible for doing the wound care on the weekends if there was no treatment nurse on the weekend. LVN KK reviewed Resident 361's chart at surveyor request and he none of Resident #361's admission assessments, including the skin assessment was not completed upon admission and still did not show to be completed. LVN KK said it appeared there was no orders to treat the pressure ulcer to Resident #361's bottom until 8/07/23. LVN KK said he could not tell what nurse had admitted Resident #361 due to there was no notes documented.<BR/>During an interview on 11/01/23 at 11:49 AM, MD RR said he remembered Resident #361 and he had a really nasty coccyx wound. MD RR said he saw Resident #361 on 8/16/23 and that was the only time he saw him in August. MD RR said he debrided the wound and then staged it as a stage 4 pressure ulcer (extends to muscle, tendon, and bone). MD RR said he believed he received the referral to see Resident #361 on 8/16/23 and remembered APRN QQ asking him to see Resident #361. MD RR said any wound that did not receive the appropriate care over three days would most likely deteriorate. <BR/>During an interview on 11/01/23 at 11:57 AM, LVN NN said she began working at the facility sometime in August 2023. LVN NN said she did not recall seeing Resident #361 for wound care because he may have admitted before she began working at the facility as the wound care nurse. LVN NN said the nurses were responsible for completing the admission skin assessments and if she was at the facility, she would do them with the admitting nurse. <BR/>During an interview on 11/01/23 at 6/02 PM LVN O said she had worked at the facility for five years and normally worked the 600 hall on 6pm-6am shift. LVN O said on new resident admissions, the nurse had to complete a head-to-toe assessment to include weight, vital signs, assess lungs, heart, feet, and look at everywhere on their skin. LVN O said findings during the assessment should be documented in the admission assessment and skin assessment questionnaire. LVN O said if she found a pressure wound and did not have orders to treat it, then she would notify the physician for orders for treatment immediately. LVN O said Resident #361 did not admit to 600 hall, he was on the 100 hall when he came back from the hospital in August after his amputation. LVN O said she thought an agency nurse admitted him. LVN O said if a pressure ulcer did not receive appropriate care for three days, then the wound could get worse.<BR/>During an interview on 11/02/23 at 8:36 AM, ADON P said she had worked at the facility since 7/26/23. ADON P said she was responsible for reviewing the 24-hour reports, reviewing nurses' notes, making sure labs were done, along with making sure the nurses were doing what they were supposed to do and helping the DON and ADM. ADON P said she also reviewed new admissions to ensure all the medications were reconciled correctly and available. ADON P said the admitting nurse was responsible for completing the admission assessments and skin assessments as soon as possible, but within 24 hours. ADON P said there was no admission assessment documented on Resident #361 and there were only two nurses' notes on Resident #361. ADON P said if the admission assessment, skin assessments, nurse's notes or anything were not documented, it affected Resident #361's care. ADON P said if it was not documented, then it was not done. ADON P said not receiving needed care to Resident #361's pressure ulcer for three days could have negatively affected the healing of his wound.<BR/>During an interview on 11/02/23 at 10:05 AM, the DON said the admission assessment, skin assessment, medication review, orders, bed rail evaluation, consents, and baseline care plans should be completed by the admitting nurse. The DON said the admission assessments should be completed by the admitting nurse within 24 hours of admission. The DON said the documentation on Resident #361 was terrible and just awful due to there was no admission assessment with skin assessment and only two nurses' notes during Resident #361's 8/04/23-8/18/23 stay. The DON said she could not determine who the admitting nurse was that did not complete the admission and skin assessments on Resident #361, but she said she believed it had to be an agency nurse. The DON said she was responsible for making sure the nurses were completing the admission assessments. The DON said they had an admission audit form that was started by ADON P, and the DON was the second check. The DON said at time of Resident #361's admission, she did not have an ADON to help her and was having to work the floor frequently and at night and was not able to follow on things like she needed to. The DON said due to the admission assessments not being completed and Resident #361's pressure to his sacrum/coccyx was not discovered on admission, then his needed care was delayed and that was not good. The DON said not receiving care to Resident #361's sacrum/coccyx pressure ulcer could have negatively impacted the healing of the pressure ulcer, however, since it was not documented on his admission assessment, there was no way of determining how much or if any deterioration occurred to his pressure ulcer. <BR/>During an interview on 11/02/23 at 10:52 AM, the ADM said the receiving nurse would be responsible for completing an admission assessment and the DON or her designee checks over it. The ADM said if the admission assessment was not completed, then they could miss resident care needs. The ADM said a complete admission assessment should be completed to identify any resident issues and provide interventions to prevent decline. The ADM said she would have expected Resident #361 to have been provided care to his pressure ulcer to his coccyx to prevent further breakdown. <BR/>Record review of the facility's policy titled Prevention of Pressure Ulcers/Injuries dated July 2018 indicated . residents would receive care to maintain skin integrity and prevent pressure ulcers/injuries . residents will be repositioned on a routine basis based on the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide residents with limited range of motion appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion for 1 of 5 residents reviewed for range of motion. (Resident #1) <BR/>The facility did not provide restorative therapy for Resident #1's contractures.<BR/>This failure could place residents who had contractures at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being.<BR/>Findings included:<BR/>Record review of a face sheet dated 10/03/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), muscle spasms, and recurrent depressive disorders. <BR/>Record review of physician's orders dated 10/04/23 did not indicate an order for restorative therapy for Resident #1. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #1 was rarely to never understood. The MDS indicated a BIMS was not conducted due to Resident #1 being rarely to never understood. The MDS indicated Resident #1 was totally dependent on staff for all ADLs. The MDS indicated Resident #1 had Range of Motion impairment to both side of the upper and lower extremities. <BR/>Record review of a care plan last revised on 05/31/23 indicated Resident #1 had a self-care deficit. There was an intervention that indicated Resident #1 was a total assist with dressing, grooming, hygiene, and bathing. There was an intervention to provide assistance with self-care as needed. The care plan indicated Resident #1 had impaired mobility related to limited joint mobility. There were interventions for OT/PT (occupation therapy/physical therapy) screen and/or evaluation as needed. There was an intervention for RNA (restorative nurse aide) referral as needed. <BR/>Record review of a Therapy Screen of Resident #1 and was dated 09/08/23 indicated, Recommendations-Restorative Nursing Services are indicated . This was signed by the Rehabilitation Therapy Manager. <BR/>Record review of the electronic medical record access on 10/3/23, 10/04/23, and 10/05/23 did not indicated any restorative nursing documentation. <BR/>During an interview on 10/04/23 at 10:50 a.m., the DON said there were no recent restorative notes for Resident #1. She said he had not been receiving restorative therapy because the therapy was not ordered.<BR/>During an interview on 10/04/23 at 1:15 p.m., the Rehabilitation Therapy Manager said she has completed contracture screenings on Resident #1. She said she did not know if Restorative Therapy even required an order. She said she verbally tell the MDS Coordinator if she recommended someone for restorative therapy. She said the MDS Coordinator was over the Restorative Program. The Rehabilitation Therapy Manager said she had nothing to do with the Restorative Program and did not know how it worked.<BR/>During an interview on 10/04/23 at 1:25 p.m., the MDS Coordinator said one of her responsibilities was the restorative program. She said she met once a week with the Rehabilitation Therapy Manager. She said this was when she was made aware of each recommendation. She said she then initiated the restorative services for the residents. She said she did not know the Rehabilitation Therapy Manager had made a recommendation for Resident #1. I guess we need to get a better system. She said a negative outcome would depend on each resident's current level of care.<BR/>During an interview on 10/05/23 at 10:33 a.m., the DON said there was no documentation of Resident #1 receiving restorative therapy and he had not been receiving restorative therapy. She said someone not receiving recommended therapy could lead to a decrease in function.<BR/>During an interview on 10/05/23 at 11:50 a.m., the Administrator said the therapist was supposed to notify herself and the MDS Coordinator of any recommendation made during Therapy Screens. She said herself and the MDS Coordinator were not made aware of his restorative therapy recommendation. She said it was not communicated in a meeting. She said a resident not receiving therapy could cause continued physical decline and could prevent them from maintain current function.<BR/>Review of a Screening, Rehabilitation facility policy dated April, 2012 indicated, .the outcome of the screen may be to proceed with a physician's order to evaluate or that no additional rehabilitation services are required at that time .<BR/>An article titled Contractures and Splinting, https://www.advanced-healthcare.com/wp-content/uploads/2011/07/August-2014-Inservice.pdf, dated August 2014 indicated, . Contractures - Joint movement is similar to the hinge on a door. Regularly moving the door keeps it working properly, so the door opens and closes easily. When the door isn't moved regularly, the hinge may rust from lack of use, making the door harder to open and close. Similarly, the structures in and around the joints stretch, flex, and move all day long keeping them functional. If the joint is not moved, it shrinks, becomes stiff, and loses the ability to stretch and move. This causes changes in fluids that lubricate the inside of the joint. Movement squeezes and pushes the fluid around, lubricating the joint. When a joint stops moving, so does the fluid. Now both the outside and inside of the joint are immobile. Contractures are joint deformities caused by immobility. Keeping residents active and moving is the best way to prevent contractures .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 3 of 22 residents (Resident #6, Resident #7 and Resident #4) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #6 and Resident #7's oxygen tubing and humidifier bottles were dated per the facility's policy.<BR/>The facility failed to change Resident #6's oxygen tubing and humidifier bottle every Wednesday per the physician's orders. <BR/>The facility failed to change Resident #6 and Resident #7's nebulizer mask and tubing per the facility's policy.<BR/>The facility failed to ensure Resident #6 and Resident #7's nebulizer, mask and tubing were dated per the facility's policy.<BR/>The facility did not ensure Resident #4's suction canister was emptied when it was &frac34; full.<BR/>The facility failed to ensure Resident #4's suction device, tubing, and suction canister were not dated.<BR/>These failures could place residents at risk for of respiratory infections.<BR/>Findings included:<BR/>1.Record review of Resident #6's face sheet dated 2/8/23 revealed Resident #6 was an [AGE] year-old female, and was admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease- constriction of the airways and difficulty breathing), atrial fibrillation (irregular and often rapid heart rate that causes poor blood flow), orthostatic hypotension (type of low blood pressure that occurs when standing up from sitting of lying down), and pain. <BR/>Record review of Resident #6's quarterly MDS dated [DATE] revealed Resident #6 had a BIMS of 12, which indicated she was cognitively intact. Resident #6 required limited to extensive assistance of 1 person for most ADL's. Resident #6 required oxygen therapy.<BR/>Record review of the Resident #6's order summary report dated 2/08/23 revealed an order for oxygen at 2 LPM by a nasal cannula; albuterol sulfate 0.63 mg (milligrams) in 3 mL (milliliters) of solution for nebulization inhalation every four hours as needed for shortness of breath; and ipratropium 0.5 mg with 3 mg in 3 mL of solution for nebulization inhalation every six hours. Resident #6's orders revealed an order for oxygen canister/tubing change every Wednesday evening and date humidifier water and oxygen tubing weekly on Wednesday.<BR/>Record review of Resident #6's eTAR dated 2/08/23 revealed the oxygen/tubing change every Wednesday evening and change & date humidifier water and oxygen tubing weekly on Wednesday was not documented as completed on Wednesday 2/01/23. There was not a task on the eTAR related to changing Resident #6's nebulizer tubing or nebulizer mask.<BR/>Record review of Resident #6's nurses' notes with date range of 10/08/22-2/08/23 revealed there was no documentation the nurses changed Resident #6's oxygen tubing on 2/01/23 or her nebulizer tubing, or nebulizer mask every 48 hours per the facility's policy.<BR/>During an observation and interview on 2/08/23 at 2:00 PM with Resident #6 revealed she had a nebulizer machine (changes liquid medication to a mist) with nebulizer tubing and a mask attached and the tubing nor the mask were dated. The nebulizer with tubing and mask was stored in a bag that reflected the bag was issued 6/22/22. The resident said she received breathing treatments with the nebulizer machine and mask every six hours. Resident #6 was wearing her oxygen at the time of the observation. The oxygen tubing nor the humidifier bottle were dated. Resident #6 said when she left the room in her wheelchair, she had oxygen bottles and she stored her oxygen tubing and cannula in the bag hanging on the oxygen concentrator at her bedside. The bag did not have a date. Resident #6 said she thought the nurses changed her oxygen tubing and nebulizer mask and tubing every month. She did not know when her oxygen tubing and nebulizer mask and tubing were changed last.<BR/>2. Record review of Resident #7's face sheet dated 2/8/23 revealed Resident #7 was a [AGE] year-old female, and was admitted to the facility on [DATE] with diagnoses of heart failure, atrial fibrillation, cerebral atherosclerosis (arteries in the brain become hard, thick, and narrow due to the buildup of plaque or fatty deposits inside the artery walls, which decreases the blow to areas of the brain), kidney failure (kidneys lose the ability to remove waste and balance fluids in the body), spondylosis (age-related wear and tear of the spinal disks), and pain. <BR/>Record review of Resident #7's annual MDS dated [DATE] revealed Resident #7 had a BIMS of 9, which indicated she was moderately cognitively impaired. Resident #7 required supervision to limited assistance of 1 person for most ADL's. Resident #7 required oxygen therapy.<BR/>Record review of Resident #7's order summary report dated 2/08/23 revealed an order for oxygen at 2 LPM by a nasal cannula and ipratropium 0.5 mg with 3 mg in 3 mL of solution for nebulization inhalation three times daily. Resident #7's orders revealed an order to change and date the nebulizer mask/mouthpiece & tubing weekly on Wednesday's night shift. There was not an order related to changing the oxygen tubing.<BR/>Record review of Resident #7's eTAR dated 2/08/23 revealed the change of the nebulizer mask/mouthpiece, & tubing was not documented as completed on Wednesday 2/01/23.<BR/>During an observation and interview on 2/08/23 at 11:49 AM, revealed Resident #7 had oxygen tubing with a nasal cannula attached to a humidifier bottle and they were not dated. The nasal cannula was stored in a bag hanging on the oxygen concentrator and the bag reflected it was issued 6/22/22. Resident #7 said she used her oxygen at night and sometimes during the day when she was short of breath. Resident #7's nebulizer and mask were in a bag, but they were not dated. Resident #7 said she could not remember when her oxygen tubing or nebulizer tubing and mask had last been changed. <BR/>During an interview on 2/08/23 at 3:55 PM with the DON, she said it was a constant struggle trying to get the night shift to do what they were supposed to do. She said she had gone down and visited with Resident #6 and Resident #7 after she knew the surveyor had visited with them and she saw for herself that the oxygen tubing/humidifier bottles and nebulizer/mask were not dated. She said if the tubing/humidifier bottles and nebulizer/masks were not dated, along with no documentation of when they were changed, then they would not be able to determine how long the resident had had the equipment and it could lead to the residents developing respiratory infections. The DON said she was ultimately responsible to ensure the night shift was changing and dating the respiratory equipment per the physician's orders and the facility's policies.<BR/>During an interview on 2/08/23 at 4:13 PM with RN A, she said the night shift nurses were responsible for changing the oxygen tubing and nebulizers/masks on Wednesday nights. She said the oxygen tubing and nebulizer masks should be dated when changed and documented in the resident's chart. She said if the oxygen tubing and nebulizers/masks were not changed regularly they would become nasty and dirty and could cause the resident to develop a respiratory infection. She said she did not specifically check the respiratory equipment (oxygen tubing, nebulizer tubing & masks/mouthpieces) for dates, because night shift was responsible for changing and dating the equipment. She said she would change any respiratory equipment herself and date the equipment if she noticed anything did not look sanitary. <BR/>During an interview on 2/08/23 at 4:25 PM with the Administrator, who was also one of the Infection Preventionists, revealed she expected the oxygen tubing/humidifier bottles and nebulizer/masks to be labeled/dated and it should be documented in the eTAR per the physician's orders. She said she the oxygen tubing/humidifier bottles and nebulizer/masks should be changed per the facility's policies.<BR/>3. Record review of Resident #4's consolidated physician orders dated 2/10/23 indicated he was [AGE] years old and readmitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), colostomy (surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) status, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) status, dysphagia (difficulty swallowing), and shortness of breath. <BR/>Record review of Resident #4's MDS dated [DATE], indicated Resident #4 sometimes made himself understood and usually understood others. The MDS indicated Resident #4 had short-term and long-term memory problems. The MDS indicated Resident #4 had moderately impaired cognitive decision-making skills. The MDS indicated Resident had no behavior of rejecting care. <BR/>Record review of Resident #4's care plan revised on 1/20/23 indicated Resident #4 had increased secretions and an increased risk of aspiration. The care plan interventions included assess for the presence of dyspnea (difficult or labored breathing) and suction as needed. <BR/>During an observation on 2/8/23 at 11:00 a.m. revealed Resident #4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an observation on 2/8/23 at 1:00 p.m. revealed Resident # 4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an observation on 2/8/23 at 3:00 p.m. revealed Resident #4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an interview on 2/9/23 at 9:30 a.m., LVN B said she took care of Resident #4 regularly on the 6:00 a.m. to 6:00 p.m. shift. LVN B said she changed the suction canister and tubing yesterday (2/8/23) evening at approximately 5:00 p.m. when Resident #4's family member pointed out the suction canister was full. LVN B said she had not noticed that the canister was full yesterday during the morning or afternoon. LVN B said it was ultimately the nurse's responsibility but would expect CNAs to notify her if they (CNAs) noted the canister was full. LVN B said the canister and tubing should be dated and initialed. LVN B said the suction canister and tubing should be changed at least every week and as needed. LVN B clarified if the suction device was dropped on the floor the tubing and suction device would be changed. LVN B further clarified if the suction canister was &frac12; way full the canister should be changed. LVN B said the suction equipment will not suction properly if the canister is full. LVN B said she did not suction Resident #4 yesterday prior to 5:00 p.m. LVN B said if he (Resident #4) had needed to be suctioned, and the canister was full, she would have had to retrieve a suction canister before he could have been suctioned. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said suction tubing and suction canisters should be dated to ensure they (suction tubing and suction canisters) are changed weekly. RN C said suction canisters should be emptied before they are full because when full they will not work properly. RN C said a full suction canister could delay a resident receiving suction for a minute or two while staff retrieved another canister. <BR/>During an interview on 2/9/23 at 11:45 a.m., CNA D said she took care of Resident #4 regularly on the day shift. CNA D said nurses handled anything related to suction equipment. CNA D said she did not report the canister was full to the nurse on 2/8/23 because she did not notice it was full. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected staff to ensure suction equipment was dated and suction canisters were changed when the canister was &frac34; full. The DON said she expected nurses to check the level of the canister at least once a shift and when they were in the room providing other care tasks to ensure the canister would be ready for use if suction was needed with no delay in care. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected nurses to follow policy and procedure regarding suction equipment. <BR/>Record review of the facility policy and procedure titled, Respiratory Equipment Change Schedule, reviewed by facility administration on 01/12/22 reflected, Standard of Practice: The community will provide a schedule for changing disposable equipment at regular intervals as determined by manufacturer recommendations and local community standards. Procedures: . provide a schedule for changing disposable equipment at regular intervals as determined by manufacturer recommendations and local community standards . aerosol tubing and aerosol nebulizer to be changed every forty-eight hours . small volume medication nebulizers, place in clean paper bag, labeled with resident's name and leave a resident's bedside . (8) Suction Canister: .(b) Change or empty canister or collection when &frac34; full. (9) Suction tubing .(b) Change or empty canister or collection when &frac34; full .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 9 residents (Residents #2 and Resident #3) reviewed for infection control practices.1. The facility failed to ensure CNA A and CNA B did not contaminate Resident #2's clothing, draw pad, bedding, pillows, and feeding tube pole after performing incontinent care.2. The facility failed to ensure CNA A and CNA B donned (put on) a gown while performing incontinent care on Resident #2, who was on Enhanced Barrier Precautions (EBP).3. The facility failed to ensure LVN C donned a gown while disconnecting Resident #3's feeding tube, assessing feeding tube placement, and attempting to flush the feeding tube, and the resident was on Enhanced Barrier Precautions.These failures could place residents at risk for cross contamination, at an increased risk of infection, and the spread of infection.Findings included:1. Record review of Resident #2's face sheet dated 7/14/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #2 had diagnoses which included quadriplegia (inability to move upper or lower body), shortness of breath, and lack of coordination.Record review of Resident #2's quarterly MDS assessment dated [DATE], indicated he was unable to complete the BIMS score, which indicated he had cognitive impairment. The MDS indicated Resident #2 was dependent on staff for all ADLs. The MDS indicated Resident #2 had a feeding tube.Record review of Resident #2's Care Plan dated 7/14/25 indicated he had a care area/problem of infection control with intervention of Enhanced Barrier Precautions, gown and glove use during high-contact resident care activities, which included providing hygiene, changing briefs, and assisting with toileting.Record review of Resident #2's Physician Orders did not reflect an order for Enhanced Barrier Precautions.During an observation on 7/14/25 at 11:45 AM, Resident #2 was lying in bed with head of bed elevated with tube feeding being infused by an infusion device. There was a blue name tag on the outside of his room, a PPE cart and EBP sign just to the inside of his door in his room.During an observation on 7/14/25 beginning at 1:30 PM, CNA A and CNA B entered Resident #2's room and washed their hands and put on gloves. CNA A and CNA B positioned themselves on opposite sides of Resident #2's bed to perform incontinent care on Resident #2. CNA A pulled a male incontinent pad from between Resident #2's legs and placed it in the trash bag. CNA B was on the window side of Resident #2 and rolled resident toward her and held him on his side while CNA A cleansed the head of his penis with a wipe, then used another wipe to cleanse the shaft of the penis, then another 2 wipes to cleanse down each side of his inner thighs. CNA A then used the same gloves to reposition the resident's pillow, moved his feeding tube pole, placed one hand on his shoulder and one on his thigh and pulled him toward her without changing her gloves. CNA B then cleansed Resident #2's bottom with 3 wipes and went between his legs, there was no bowel movement present. Then CNA B and CNA A still wearing the same gloves used during incontinent care, repositioned Resident #2, stuffed a 3-sided body pillow all around Resident #2, used the draw pad under him to pull Resident #2 up in bed, pulled his gown down and then removed their gloves. Neither CNA A nor CNA B wore a gown during Resident #2's incontinent care. Resident #2 had a blue name tag outside his door, an EBP sign posted on the wall just inside his door along with a PPE cart with EBP supplies. During an interview on 7/14/25 at 1:50 PM, CNA A said she had worked at the facility since 2019 and normally worked the 6 AM to 2 PM shift. CNA A said staff should change gloves during incontinent care more times than she did on Resident #2. CNA A said she should have changed her gloves after cleaning Resident #2's front perineal (private) area and before touching multiple surfaces in his room. CNA A said it was a hygiene thing and cross-contamination and could give Resident #2 an infection. CNA A said it was an infection control issue and could cause skin irritation too. CNA A said she would know someone was on EBP if there was a bucket and a sign outside the resident's door. CNA A said staff had to suit up with gown, gloves, and mask if a resident was on EBP. CNA A said residents on EBP were the residents with something in their urine or bowel. CNA A said Resident #2 probably should be on EBP because he had a feeding tube. CNA A said she did not see the EBP sign or the bucket just inside Resident #2's room and did not know what EBP was. CNA A said she did not know why Resident #2 had a EBP sign and cart, because they did not use it. CNA A said she had been on Resident #2's hall since April 2025 and had not ever used a gown during Resident #2's care.During an interview on 7/14/25 at 1:56 PM, CNA B said she had worked at the facility since May of 2025 and normally worked the 2 PM -10 PM shift but picked up a 6 AM -2 PM on 7/14/25. CNA B said she should have changed her gloves after performing incontinent care on Resident #2 and before touching multiple surfaces in his room. CNA B said it was cross-contamination and could cause him an infection. CNA B said they should have worn gowns while performing incontinent care on Resident #2 because he had a feeding tube. CNA B said EBP was to protect the staff and the resident from cross-contamination. CNA B said not wearing a gown during incontinent care could spread infection. CNA B said she did not see the EBP cart or EBP sign that was just inside Resident #2's room.Record review of the facility's Nursing Services-Competency Evaluation for Skill/Procedure: Perineal Care without catheter of CNA A dated 5/21/25 had a check mark in the met column which indicated CNA A had performed the procedure of perineal care and met the performance criteria, which included discarding used supplies, removed gloves, and performed hand hygiene and applied new gloves and placed new brief and changed lines as needed and positioned resident comfortably, and gave table and call light. Record review of the facility's Nursing Services-Competency Evaluation for Skill/Procedure: Perineal Care without catheter of CNA B dated 5/30/25 had a check mark in the met column which indicated CNA B had performed the procedure of perineal care and met the performance criteria, which included discarding used supplies, removed gloves, and performed hand hygiene and applied new gloves and placed new brief and changed lines as needed and positioned resident comfortably, and gave table and call light. 2. Record review of Resident #3's face sheet dated 7/15/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #3 had diagnoses which included myotonic muscular dystrophy (genetic condition characterized by progressive muscle weakness and wasting), diabetes (high blood sugar), and gastrostomy (feeding tube).Record review of Resident #3's quarterly MDS assessment dated [DATE], indicated she had a BIMS of 10, which indicated she had moderate cognitive impairment. The MDS indicated Resident #3 required moderate to dependent on staff for most ADLs. The MDS indicated Resident #3 had a feeding tube.Record review of Resident #3's Care Plan dated 7/15/25 indicated she had a care area/problem of altered nutritional status: enteral feeding monitor. Resident #3 also had a care area/problem of Infection control with intervention of Enhanced Barrier Precautions, gown and glove use during high-contact resident care activities.Record review of Resident #3's Physician Orders dated 7/01/25 - 7/31/25 did not reveal an order for Enhanced Barrier Precautions.Record review of Resident #3's Medication Record dated 6/23/25 - 7/15/25 indicated Enhanced Barrier Precautions every shift.During an observation and interview on 7/15/25 at 9:53 AM, Resident #3 was lying in bed and had a feeding tube infusion device connected to her feeding tube and the alarm was going off that it had completed. Resident #3 said staff wear gloves when administering her feedings and medications through her feeding tube and when providing incontinent care, but the staff never wear gowns during her care. There was a blue name tag outside her door, a PPE cart just inside Resident #3's door, but there was no EBP sign posted.During an observation and interview on 7/15/25 beginning at 10:04 AM, LVN C entered Resident #3's room and put on gloves. LVN C then pulled back the Resident #3's covers to expose her feeding tube. LVN C unhooked the feeding tube, then placed her stethoscope on the resident's abdomen, and checked placement of the feeding tube with 60 cc of air. LVN C then attempted to flush the feeding tube with water and then begun rolling the feeding tube between her fingers as she was leaned against the resident's bed/bedding. LVN C did not wear a gown as part of EBP. LVN C said they often had difficulty flushing the resident's feeding tube. LVN C said she was going to have someone else come try to flush it. During an interview on 7/15/25 at 10:35 AM, LVN C said she had worked at the facility for approximately twelve years and normally worked on the day shift. LVN C said she would know a resident was on EBP because they should have a PPE box in their room. LVN C said the EBP was for residents that had urinary catheters, wounds, feeding tubes, or any openings that could introduce infection. LVN C said residents on EBP should also have a sign posted indicating they were on EBP. LVN C said if staff were in direct contact with the resident, they should suit up and I did not do it on Resident #3. LVN C said she should have also worn a gown with her gloves during Resident #3's care. LVN C said it was important to follow EBP due to the at-risk residents had ports of entry for infection and EBP protected both the resident and staff. LVN C said EBPs was so staff did not carry anything from one resident to another resident. LVN C said if staff did not follow the EBP, it could place the residents at a higher risk of infection.During an interview on 7/15/25 at 2:17 PM, the ADON said he was also the Infection Preventionist. The ADON said staff should change their gloves during incontinent care any time they were doing different tasks. The ADON said the staff should have changed their gloves and performed hand hygiene after cleaning the Resident #2's front perineal area and prior to touching any other surfaces in the resident's room. The ADON said then staff should have changed gloves and performed hand hygiene after cleaning the resident's back perineal area and prior to touching any other of the resident's surfaces to prevent cross-contamination. The ADON said it was important to perform hand hygiene and change gloves appropriately to prevent cross-contamination and prevent the spread of infection. The ADON said all staff were responsible for ensuring staff were following the infection control policy and procedures. The ADON said residents who were on EBP was indicated by the blue name tags outside the resident's door and a PPE cart inside the resident's room. The ADON said they do not use the EBP signs, but staff had been educated that the blue name tags were indicative of the resident being on EBP. The ADON said any resident who had an invasive device, such as urinary catheter, a feeding tube, dialysis access, wounds or anything that would increase the risk of infections from an outside source would be on EBP. The ADON said the purpose of EBP was to protect the resident from an outside source of infection from direct care contact. The ADON said the resident, who was on EBP, was at an increased risk of infection if staff did not wear gown and gloves during direct care. The ADON said staff could spread infection from one resident to another resident if they were not wearing a gown during direct care. During an interview on 7/15/25 at 2:45 PM, the DON said staff should know a resident was on EBP from the blue name tags outside the resident's door and a PPE cart inside the resident's room. The DON said they do not use the EBP signs and only used the blue name tags outside the resident's room. The DON said the reasons a resident would be on EBP would be anyone with a feeding tube, urinary catheter, wounds, and any other indwelling device. The DON said the purpose of EBP was almost a reversed precaution, to protect the resident from getting something from the staff due to the resident was at a higher risk of infection and cross-contamination. The DON said staff should have changed their gloves when going from a dirty surface to a clean surface. The DON said staff should wash or sanitize their hands prior to and post incontinent care. The DON said the Infection Preventionist and herself would be responsible for ensuring staff were following the infection control policy and procedures. The DON said staff could transfer any bad bugs anywhere they touched with their contaminated gloves. The DON said the resident had the potential of infection if staff were not following EBP and transferred germs or bacteria from one resident to another resident. During an interview on 7/15/25 at 4:10 PM, the ADM said he would expect staff to follow the facility's infection control policy and procedures and change gloves and perform hand hygiene per their policies. The ADM said he would expect the EBP to be followed to protect the residents from anything staff may have come in to contact with. The ADM said not changing gloves, performing hand hygiene, following the EBP could be a potential infection control issue.Requested an Infection Control policy on 7/15/25 at 5:00 PM from the facility's Regional Nurse and was provided a policy titled Infection Prevention, Control & Surveillance, which did not contain pertinent information. Record review of the facility's policy titled Perineal Care dated revised April 10, 2023 indicated . staff would provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection . procedure . perform hand hygiene. Apply clean gloves . 5. Perineal care for a male resident . d. wash tip of penis . f. cleanse the shaft of the penis . 6. observe perineal area . 8. Turn resident to clean all areas of buttocks . 9. Dispose of gloves and used supplies and perform hand hygiene . 10. Apply new gloves and place new brief . 11. Position resident comfortably . Record review of the facility's policy titled Hand Hygiene for Staff and Residents dated revised February 2025 indicated . purpose . to reduce the spread of infection with proper hand hygiene . hand hygiene was the most important component for preventing the spread of infection . hand hygiene was done . before . before resident contact . after . contact with soiled or contaminated articles, such as articles that were contaminated with body fluids . resident contact . contact with contaminated object or source where there was a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds . toileting or assisting others with toileting .Record review of the facility's policy titled Enhanced Barrier Precautions dated revised March 2025 indicated . many residents in nursing homes were at increased risk of becoming colonized and developing infections with multi-drug-resistant organisms (MDROs) . facility utilized Enhanced Barrier Precautions (EBP) as a strategy to decrease transmission of CDC-targeted and epidemiologically important MDROs when Contact Precautions do not apply . indications . wounds and/or indwelling medical devices . indwelling medical devices include central lines . urinary catheters, feeding tubes . high contact resident care activities . providing hygiene . changing briefs or assisting with toileting . device care or use . feeding tube . communication . indicate the residents who were on EBP by subtle means, such as an alternate color of the resident's name badge on door .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pest for one (room [ROOM NUMBER]) of 6 rooms reviewed for pests.<BR/>The facility failed to treat room [ROOM NUMBER] for roaches. <BR/>These failures placed residents at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.<BR/>Findings included:<BR/>During an observation on 10/31/23 at 9:30 a.m. surveyor spotted approximately 10-15 roaches near some boxes stored on the floor of room [ROOM NUMBER]. There were food crumbs on the floor, stacked boxes with personal belongings of the resident, and large roaches were visible when the boxes were disturbed. <BR/>During an interview on 10/31/23 at 9:38 a.m. with the Maintenance Supervisor he stated the facility is contracted with a Pest Control company who comes out once a month to the facility to inspect and spray for pests. He stated currently the facility does not have a pest control issue. He stated that there had not been a roach infestation in the building since 2022. He stated that he has not seen any roaches in the building while doing his daily rounds. He stated that in the past they had issues with roaches in the building. He stated that during Covid (2020 to 2022) their previous pest control company did not want to come out and spray due to Covid. He stated when the current Pest Control company took over it knocked out the problem they had with roaches as they started spraying rooms. He stated that the Pest Control company took over January of 2022. He stated the Pest Control company comes out once a month to spray currently. He stated that none of the residents have told him they have seen roaches in their room or the building. <BR/>During an interview and Observation on 10/31/23 at 10:01 a.m. with the Maintenance Supervisor he stated that he can now see the roaches in room [ROOM NUMBER] and where they are hidden. He stated that he will call his man at pest control services to bring out some roach traps. He stated he was unaware of the infestation. <BR/>During an interview with the Housekeeping Supervisor on 10/31/23 at 10:04 a.m. he stated that his staff are trained to report pests in the building. He stated residents whose family leave food in their rooms sometimes have pests. He stated if food is left out there is a higher likelihood that pests will enter the room. He stated they encourage family to store food in Tupperware. He stated Resident # 68 (room [ROOM NUMBER]) had lots of food stored in his room. He stated Resident # 68 is the kind of person who screams and kicks when someone touches his belongings.<BR/>During an interview on 10/31/23 at 10:15 a.m. with Housekeeper Y he stated that he knew there were roaches in room [ROOM NUMBER]. He stated he did not report to the Housekeeping Supervisor or anyone else that he knew there were roaches in the room. He stated he started seeing them yesterday. He stated that it was in Resident #68's room. He stated that he was trained by the Housekeeping Supervisor to report when he saw pests in the building including roaches. He stated he did not report the roaches because he did not have time to. <BR/>During an interview on 11/1/23 at 11:12 a.m. with the Administrator she stated that Resident # 68 had some roaches in his room. She stated that they tried to place his food into a container, but he won't put his food away after he has had a snack. She stated that he is a snacker but also doesn't clean up after himself. She stated that staff will now start entering his room and placing his snacks in containers and cleaning up after him. She stated that they also laid traps that are safe to be around the residents.<BR/>Record review of an undated facility policy titled Pest Control revealed that This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . Garbage and trash are not permitted to accumulate and are removed from the facility daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Residents #1) reviewed for resident rights.<BR/>CNA E did not sit as she assisted Resident #1 with dining. <BR/>CNA E did not refrain from talking on her cell phone while she assisted Resident #1 with dining. <BR/>The facility did not ensure Resident #1 was clothed in his personal clothing. <BR/>These failures could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth.<BR/>Findings included:<BR/>Record review of Resident #1's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including Hemiplegia or hemiparesis (hemiplegia refers to a severe or complete loss of strength, whereas hemiparesis refers to a relatively mild loss of strength) following cerebral infarction (stroke) affecting the left non-dominant side, type II diabetes, shortness of breath, nausea/ vomiting, and depression. <BR/>Record review of Resident #1's MDS dated [DATE] indicated Resident #1 was usually understood and usually understood others. The MDS indicated Resident #1 had severe cognitive impairment (BIMS of 5). The MDS indicated he had no behavior of rejecting care during the 7 days look back period. The MDS indicated he required extensive assistance with bed mobility, transfers, locomotion in his wheelchair, dressings, eating, toilet use, and personal hygiene. The MDS indicated Resident #1 was completely dependent on staff for bathing. The MDS indicated Resident #1 was always incontinent of bowel and bladder. <BR/>Record review of Resident #1's care plan revised on 11/15/22 indicated Resident #1 had a self-care deficit. The care plan interventions included to give the resident as many choices as possible about care and provide assistance with self-care as needed. <BR/>During an observation on 2/8/23 at 11:10 a.m. revealed Resident #1 laid in his bed wearing a hospital gown. <BR/>During an observation on 2/8/23 at 12:45 p.m. revealed the door to Resident # 1's door was open. CNA E stood at Resident #1's bedside. CNA E said loudly Well what are you going to then?. A few moments later CNA E again said, Well what are you going to then? and then said I gotta go. The surveyor entered the room. CNA E continued to stand at Resident #1's bedside and fed him several bites from his food tray. <BR/>During an observation and interview on 2/8/23 at 2:50 p.m. revealed Resident #1 laid in his bed wearing a hospital gown. Resident #1 said he did not want to wear a hospital gown. Resident #1 said his family member had brought him some clothes and pointed at the armoire. There were multiple personal clothing items hanging in the armoire. Resident #1 said he guessed he had to wear the gown because that was what they (facility staff) put on him. Resident #1 could not say how long he had been wearing the hospital gown or who had placed the hospital gown on him. Resident #1 said CNA E talked on the phone while she fed him today (2/8/23) and felt it was rude. <BR/>During an interview on 2/10/23 at 10:28 a.m., CNA G said there was no reason for a resident to have been in a hospital gown. CNA G said the facility had clothes that were donated for resident use if a resident did not have any personal clothes available. CNA G said if a resident did not want to wear a hospital gown and was placed in hospital gown, it could take away the resident's dignity. CNA G said CNAs should not stand while feeding a resident because it could cause the resident to feel intimidated. CNA G said another reason CNAs should not stand while feeding a resident was to ensure the resident did not have any signs of aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). CNA G said under no circumstance should a CNA take a personal phone call while he/she administered resident care. CNA G said to take a personal call during the administration of patient care was not only disrespectful but would also divert attention away from the resident. <BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she should not have stood while feeding Resident #1. CNA E said she should have sat at Resident #1's bedside while she assisted him with eating because it was more respectful than standing. CNA E said she stood while she fed Resident #1 because she was in a hurry. CNA E said she did not notice Resident #1 was wearing a hospital gown and indicated he should have been wearing his personal clothes. CNA E said she should not have taken the personal call while she assisted Resident #1 but did so because she had a family situation. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected staff to sit while they assisted residents with eating in order to promote respect and safety. The DON said it was not acceptable for a resident to be in a hospital gown and to do so (place a resident in a hospital gown) could affect the resident's dignity. The DON said it was not acceptable for staff to have taken a phone call while assisting a resident. The DON said she expected staff to go to the break room or their car if they had to take a phone call. The DON said a staff member taking a phone call in front of a resident was a dignity issue and could also confuse the resident. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected staff to ensure residents were clothed in their personal clothing if it was the resident's preference. The Administrator said she expected staff to ensure respect and dignity were provided to residents. The Administrator indicated taking personal phone calls during resident care activities and standing while feeding a resident did not promote respect and dignity.<BR/>Record review of the undated facility policy and procedure titled, Exercise of Rights reflected, Policy Statement- Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to our facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good grooming and personal hygiene for a resident who is unable to carry out activities of daily living were provided for 2 of 4 residents reviewed for activities daily living (Resident #2 and Resident #5)<BR/>The facility did not clean or trim the nails of Resident #2 and Resident #5. <BR/>The facility failed to promptly respond to Resident #2 and Resident #5's call lights who were ADL dependent.<BR/>These failures could place dependent residents at risk of poor hygiene, infections, injuries and unmet needs. <BR/>Findings included: <BR/>Record review of Resident #2 's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including respiratory failure, colon cancer, diabetes, and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred). <BR/>Record review of Resident #2's MDS dated [DATE] indicated Resident #2 made himself understood and usually understood others. The MDS indicated Resident #2 had moderately impaired cognitive function (BIMS of 10). The MDS indicated he had no behavior of rejecting care. The MDS indicated he required limited assistance with locomotion in his wheelchair, supervision only with toilet use and eating. The MDS indicated he required extensive assistance with dressing, personal hygiene and bathing. The MDS indicated bed mobility had only occurred once or twice during the 7 days look back period. The MDS indicated transfers and walking had not occurred during the 7 days look back period. <BR/>Record review of Resident #2's care plan dated 12/7/22 indicated his ADL dependency was not specifically addressed. <BR/>During an observation on 2/8/23 at 11:15 a.m. revealed Resident #2 laid in his bed. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/>During an interview and observation on 2/8/23 at 2:44 p.m. revealed Resident #2 sat in his bed. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/> Resident #2 said he had been at the facility approximately 2 months. He said no one had offered to trim and clean his nails since he had been at the facility.<BR/>During an observation and interview on 2/9/23 at 9:05 a.m. revealed Resident #2 sat in his wheelchair. His nails were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under several of the nails. CNA F was making his bed. CNA F said nail care was usually done on shower days by the CNAs. CNA F indicated she had just administered a shower to Resident #2. CNA F said nurses trimmed the nails of diabetic residents. <BR/>During an observation on 2/9/23 at 11:17 a.m. revealed Resident #2 was in therapy sitting in his wheelchair. CNA F stood at his side viewing his nails. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/>During an interview on 2/9/23 at 11:18 a.m., CNA F said she did not know if Resident #2 was a diabetic. CNA F said she cleaned Resident #2's nails in the shower by washing over the top of his hands but indicated she did not clean under his nails. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said she worked the hall on which Resident #2 resided on 2/8/23. RN C said there was no set schedule for diabetic nail care and nurses just performed the care as it needed to be done. RN C said no CNAs had reported to her that any diabetic resident needed nail care yesterday (2/8/23). RN C said Resident #2's nails were very thick and would have to be soaked before they could be cut. RN C said that might be why the nail care had not been performed. RN C said it was important to ensure nail care was completed to prevent infection. <BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she regularly worked the hall that Resident #2 resided on. CNA E said CNAs and nurses were responsible to ensure residents nails were cleaned and trimmed. CNA E said nurses performed nail care for diabetic residents. CNA E said there was no set schedule for CNAs to perform nail care and indicated she performed nail care when she saw it needed to be done. CNA E said if she saw nail care was needed for a diabetic resident, she would notify the nurse. CNA E said she could not remember if she notified RN C that nail care was needed for Resident #2. CNA E said it was important to ensure nail care was completed to maintain resident hygiene.<BR/>2. Record review of Resident #5's consolidated physician orders dated 2/10/23 indicated he was [AGE] years old admitted to facility on 1/16/23 with diagnoses including atherosclerotic heart disease (heart disease caused by the buildup of fats, cholesterol and other substances in and on the artery walls), and rheumatoid arthritis (chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility) and dementia. <BR/>Record review of Resident #5's MDS dated [DATE] indicated Resident #5 usually understood and usually made himself understood. The MDS indicated he had moderately impaired cognitive function (BIMS of 9). The MDS indicated he had no behavior of rejecting care. The MDs indicated transfers had only occurred once or twice during the 7 days look back period. The MDS indicated locomotion in his wheelchair had not occurred during the 7 days look back period. The MDS indicated he required limited assistance with walking in his room and eating. The MDS indicated he required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and bathing. <BR/>Record review of Resident #5's care plan revised on 2/1/23 indicated his ADL dependency was not specifically addressed.<BR/>During an observation and interview on 2/8/23 at 3:45 p.m. revealed Resident #5 laid in his bed. His nails were long (approximately 1/2 centimeter past the end of his fingers). There was a dark brown substance under several (more than 2 nails on each hand but less than 5 nails of each hand) nails to each hand. Resident #5 said he wanted his nails to be cleaned and trimmed. Resident #5 said he did not know when his nails were last cleaned and trimmed. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said she worked the hall on which Resident #5 resided on 2/8/23. RN C said CNAs were responsible to perform nail care for non-diabetic residents. RN C said there was no set schedule for CNAs to perform nail care and indicated CNAs were to perform the nail care as needed. RN C said it was important to ensure nail care was completed to prevent infection.<BR/>During an observation on 2/10/23 at 9:32 a.m. revealed Resident #5 laid in his bed. His nails were long (approximately 1/2 centimeter past the end of his fingers). There was a dark brown substance under several (more than 2 nails on each hand but less than 5 nails of each hand) nails to each hand. <BR/>During an interview on 2/10/23 at 10:28 a.m., CNA G said residents were to have their nails cleaned and trimmed on shower days by CNAs. CNA G said resident nails were to be cleaned and trimmed as needed in between shower days. CNA G said it was important to ensure nail care was done to avoid infection and unintentional injury (scratches and skin tears).<BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she regularly worked the hall that Resident #5 resided on. CNA E said CNAs and nurses were responsible to ensure residents nails were cleaned and trimmed. CNA E said nurses performed nail care for diabetic residents and CNAs performed nail care for non-diabetic residents. CNA E said there was no set schedule for CNAs to perform nail care and indicated she performed nail care when she saw it needed to be done. CNA E said she did not recall performing nail care for Resident #5 but indicated she would have cleaned and trimmed his nails if she noticed they were long and dirty. CNA E said it was important to ensure nail care was completed to maintain resident hygiene. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected CNAs to ensure nail care was completed for non-diabetic residents as it was needed. The DON said she expected nurses to perform nail care for diabetic residents as it was needed. The DON said it was important to ensure nail care was done to prevent unintentional injuries (such as scratches) and prevent infections. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected staff to ensure resident's nails were cleaned and trimmed. <BR/>Record review of the facility policy and procedure titled Bathing revised on 02/12/20 reflected, .Tasks commonly completed during the bathing process .Report abnormal findings to the nurse in charge .needs shall be discussed with the resident and responsible party during care plan meetings with the interdisciplinary team in order to identify and implement proper hygiene habits and promote resident rights and dignity The policy and procedure did not specifically address nail care. A policy and procedure for nail care was requested but not received. <BR/>3. During an observation on 2/8/23 at 2:44 p.m. revealed Resident #5 could be heard across the hall yelling Somebody come help me. <BR/>During an observation on 2/8/23 at 2:47 p.m. revealed Resident #2 pushed his call light in order to obtain assistance to get up.<BR/>During a continuous observation on 2/8/23 from 2:47 p.m. to 3:15 p.m. revealed Resident #5's call light dome remained lit up and the call light alarm was audible until 3:12 p.m. Resident #5 continued to yell intermittently for help from 2:47 p.m. to 3:15 p.m. Resident #2's call light dome remained lit up and the call light alarm was audible until 3:15 p.m. Resident #5's room was directly adjacent to Resident #2's room. <BR/>During an observation on 2/8/23 at 2:51 p.m., revealed Receptionist I walked by both Resident #2 and Resident #5's rooms as Resident #5 yelled out. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:52 p.m. revealed LVN J walked by both Resident #2 and Resident #5's rooms pushing a treatment cart. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:55 p.m. revealed Admissions Director K walked by both Resident #2 and Resident #5's rooms as Resident #5 yelled out Help. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:57 p.m. revealed an unidentified staff member in a khaki-colored polo pushed a red hand truck/ appliance dolly (tool to move heavy items) by both Resident #2 and Resident #5's rooms. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:58 p.m. revealed Housekeeper L stood in the hallway, 2 rooms down from Resident #2 and Resident #5's rooms. Housekeeper L stood in front of his housekeeping cart with his back toward the surveyor. His head was bent down as if he were looking at something in front of him. <BR/>During an observation on 2/8/23 at 3:02 p.m. revealed CNA H walked by both Resident #2 and Resident #5's rooms. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 3:12 p.m. revealed Maintenance Personnel M answered Resident # 5's call light. <BR/>During an observation on 2/8/23 at 3:15 p.m. revealed CNA H answered Resident #2's call light.<BR/>During an interview on 2/8/23 at 3:16 p.m., maintenance personnel M said answering call lights was everyone's (all staff's) responsibility. Maintenance Personnel M said he may not be able to get/do exactly what the resident requested/needed. Maintenance Personnel M said he could ensure there was not an emergency and notify the nurse of the resident request/need. Maintenance Personnel M said Resident #5 said he just wanted to go home. <BR/>During an interview on 2/8/23 at 3:17 p.m., CNA H said anyone could answer a call light. CNA H said even if the staff were not clinical, they can and should respond to a call light. CNA H said non-clinical staff should check on call lights because there could be an emergency, or the resident might have a simple request. CNA H said she did not immediately check on the call lights because she had just came onto her shift. CNA H said she should have checked on the call lights the first time she went by and notified the residents she would be right back. CNA H said Resident #2 needed help to get up. <BR/>During an interview on 2/8/23 at 3:18 p.m., Housekeeper L said he had worked at the facility since November 2022. Housekeeper L said he noticed the call lights going off but had not been given any instructions regarding call lights. Housekeeper L said he was not sure if he was supposed to answer call lights. <BR/>During an interview on 2/8/23 at 3:29 p.m., Admissions Director K said she had worked at the facility for approximately 3 years. Admissions Director K said any staff could check on a call light, but some residents call out or yell out like every 10 minutes. Admissions Director K said even for the residents that frequently call out she would still check on them. Admissions Director K said she was not sure if Resident #2 and Resident #5 were residents that called out frequently. Admissions Director K said staff had to respond to call lights because the resident might actually need help. Admissions Director K said she did see Resident #2 and Resident #5's call lights when she walked by. Admissions Director K said she did hear Resident #5 yell as she walked by his room. When asked why she did not respond to the call lights or Resident #5's yell for help Admissions Director K said I want to say in my heart of hearts it's because I didn't think they needed Admissions Director K stopped mid-sentence and then said but I can't say that. Admissions Director K then said there was no excuse for not having stopped and checked on Resident #2 and Resident #5's call lights. <BR/>During an interview on 2/8/23 at 3:35 p.m., LVN J said she did not remember walking by Resident #2 and Resident #5's rooms with her cart. LVN J said she certainly would have stopped and checked on the call lights had she noticed they were going off. LVN J said we (all staff) were responsible for answering call lights. <BR/>During an interview on 2/9/23 at 10:19 a.m., Receptionist I said she use to be a CNA and had worked at the facility for 2 &frac12; years. Receptionist I said all staff members were responsible for answering call lights. Receptionist I said it was important to respond to call lights because it could be an emergency. Receptionist I said if the request were something simple, non-clinical staff can assist them or notify the nurse. Receptionist I said she did not remember walking past Resident #2 and Resident #5's call lights yesterday (2/8/23). Receptionist I said she did not remember Resident #5 yelling out for help. Receptionist I said she would have answered the call lights had she noticed them going off. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said all staff clinical or not, were responsible for responding to resident call lights. The DON indicated it was unacceptable that call lights remained unanswered for over 20 minutes while multiple staff members walked by. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected all staff to respond to resident call lights in order to ensure resident needs were met. <BR/>Record review of the facility policy and procedure titled, Call Lights-Answering, revised on 02/12/20 reflected, Standard of Practice: The staff will provide an environment that helps meet the resident's needs by answering call lights appropriately. Procedures: (1) Respond to patients/resident's call lights and emergency lights in a timely manner . (5) If unable to complete the request, do not turn off the call light; the call light will remain on until the service is completed .

Based on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 2 of 4 (600 Hall Nurse/Medication and the Treatment Cart) medication carts and 1 of 2 (LVN G) nurses observed for medication storage.<BR/>The facility did not ensure the medication carts were secured and unable to be accessed by unauthorized personnel. <BR/>The facility failed to ensure medications were not left at the nurse's station unattended.<BR/>These failures could place residents at risk for not receiving drugs and biologicals as needed, medications being used passed their effective or expiration date, and a drug diversion.<BR/>Findings include:<BR/>1. During an observation on 11/29/23 at 2:13 p.m. a Nurse/Medication cart on the 600 hall was unattended and unlocked. The MDS nurse, an LVN, and 2 other people walked by the unlocked cart and did not lock it while the surveyor was standing at the nurse's station.<BR/>During an observation on 11/29/23 at 2:15 p.m. LVN G walked up and locked the unattended and unlocked medication cart. <BR/>2. During an observation on 11/30/23 at 10:45 a.m. 13 medication cards and multiple IV medications sitting on the nurse's station in the rehab unit unattended.<BR/>During an interview on 11/30/23 at 10:52 am LVN G said the medication cards were sitting on the nurse's station because he was getting ready to discharge a resident. LVN G said the IV medications had recently been delivered and he had not had time to put them up. LVN G said he left the medications unattended when he went to show someone in the medication room something on the stat lock box. LVN G said someone could have taken any of the medication while they were unattended.<BR/>3. During an observation on 11/30/23 at 3:07 p.m. the treatment cart was unlocked and unattended. The Maintenance Supervisor and a CNA were both observed walking in the hallway past the treatment cart. <BR/>During an interview on 11/30/23 at 3:08 p.m. the Wound Care Nurse said she left her cart unlocked and unattended because she went outside to tell the charge nurse something about a resident. The Wound Care Nurse said she did not usually leave her treatment cart unlocked, unattended, and in the middle of the hall. The Treatment Nurse said it was important not to leave the treatment cart unlocked and unattended, so no one got into it and harmed themselves.<BR/>During an interview on 12/01/23 at 10:42 a.m. LVN D said when walking away from the medication cart it should be locked. LVN D said the medication carts should never be left unattended and unlocked. LVN D said medications should not be left out in the open and unattended including at the nurse's station. LVN D the importance of ensuring the medication carts were locked and medications were not left unattended was so no one took any of the medications thinking they were candy. <BR/>During an interview on 12/01/23 at 10:46 a.m. RN E said medication carts should be locked when left unattended. RN E said medication should never be left out in the open and unattended including at the nurse's station. RN E said the importance of locking med carts and not leaving medications unattended was to prevent medication from going missing. <BR/>During an interview on 12/01/23 at 11:28 a.m. the DON said she expected staff to lock the medication carts if they were leaving them unattended. The DON said medications should not be left unattended. The DON said the importance of locking medication carts when they were left unattended and not leaving medications unattended at the nurse's station was so residents did not get medications that were not theirs and to prevent drug diversions. <BR/>During an interview on 12/01/23 at 12:17 p.m. the Administrator said she expected staff to lock medication carts when they were left unattended and to ensure all medications were secured. The Administrator said medications should not be left unattended at the nurse's station. The Administrator said the importance of locking unattended medication carts and not leaving medications unattended was safety of the residents. <BR/>Record review of the facility's Medication Storage policy dated 1/2023 indicated, Medications and biologicals are stored properly, following manufacturer's or provided pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible to only licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed to access the medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or not attended by persons with authorized access .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 9 residents (Residents #2 and Resident #3) reviewed for infection control practices.1. The facility failed to ensure CNA A and CNA B did not contaminate Resident #2's clothing, draw pad, bedding, pillows, and feeding tube pole after performing incontinent care.2. The facility failed to ensure CNA A and CNA B donned (put on) a gown while performing incontinent care on Resident #2, who was on Enhanced Barrier Precautions (EBP).3. The facility failed to ensure LVN C donned a gown while disconnecting Resident #3's feeding tube, assessing feeding tube placement, and attempting to flush the feeding tube, and the resident was on Enhanced Barrier Precautions.These failures could place residents at risk for cross contamination, at an increased risk of infection, and the spread of infection.Findings included:1. Record review of Resident #2's face sheet dated 7/14/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #2 had diagnoses which included quadriplegia (inability to move upper or lower body), shortness of breath, and lack of coordination.Record review of Resident #2's quarterly MDS assessment dated [DATE], indicated he was unable to complete the BIMS score, which indicated he had cognitive impairment. The MDS indicated Resident #2 was dependent on staff for all ADLs. The MDS indicated Resident #2 had a feeding tube.Record review of Resident #2's Care Plan dated 7/14/25 indicated he had a care area/problem of infection control with intervention of Enhanced Barrier Precautions, gown and glove use during high-contact resident care activities, which included providing hygiene, changing briefs, and assisting with toileting.Record review of Resident #2's Physician Orders did not reflect an order for Enhanced Barrier Precautions.During an observation on 7/14/25 at 11:45 AM, Resident #2 was lying in bed with head of bed elevated with tube feeding being infused by an infusion device. There was a blue name tag on the outside of his room, a PPE cart and EBP sign just to the inside of his door in his room.During an observation on 7/14/25 beginning at 1:30 PM, CNA A and CNA B entered Resident #2's room and washed their hands and put on gloves. CNA A and CNA B positioned themselves on opposite sides of Resident #2's bed to perform incontinent care on Resident #2. CNA A pulled a male incontinent pad from between Resident #2's legs and placed it in the trash bag. CNA B was on the window side of Resident #2 and rolled resident toward her and held him on his side while CNA A cleansed the head of his penis with a wipe, then used another wipe to cleanse the shaft of the penis, then another 2 wipes to cleanse down each side of his inner thighs. CNA A then used the same gloves to reposition the resident's pillow, moved his feeding tube pole, placed one hand on his shoulder and one on his thigh and pulled him toward her without changing her gloves. CNA B then cleansed Resident #2's bottom with 3 wipes and went between his legs, there was no bowel movement present. Then CNA B and CNA A still wearing the same gloves used during incontinent care, repositioned Resident #2, stuffed a 3-sided body pillow all around Resident #2, used the draw pad under him to pull Resident #2 up in bed, pulled his gown down and then removed their gloves. Neither CNA A nor CNA B wore a gown during Resident #2's incontinent care. Resident #2 had a blue name tag outside his door, an EBP sign posted on the wall just inside his door along with a PPE cart with EBP supplies. During an interview on 7/14/25 at 1:50 PM, CNA A said she had worked at the facility since 2019 and normally worked the 6 AM to 2 PM shift. CNA A said staff should change gloves during incontinent care more times than she did on Resident #2. CNA A said she should have changed her gloves after cleaning Resident #2's front perineal (private) area and before touching multiple surfaces in his room. CNA A said it was a hygiene thing and cross-contamination and could give Resident #2 an infection. CNA A said it was an infection control issue and could cause skin irritation too. CNA A said she would know someone was on EBP if there was a bucket and a sign outside the resident's door. CNA A said staff had to suit up with gown, gloves, and mask if a resident was on EBP. CNA A said residents on EBP were the residents with something in their urine or bowel. CNA A said Resident #2 probably should be on EBP because he had a feeding tube. CNA A said she did not see the EBP sign or the bucket just inside Resident #2's room and did not know what EBP was. CNA A said she did not know why Resident #2 had a EBP sign and cart, because they did not use it. CNA A said she had been on Resident #2's hall since April 2025 and had not ever used a gown during Resident #2's care.During an interview on 7/14/25 at 1:56 PM, CNA B said she had worked at the facility since May of 2025 and normally worked the 2 PM -10 PM shift but picked up a 6 AM -2 PM on 7/14/25. CNA B said she should have changed her gloves after performing incontinent care on Resident #2 and before touching multiple surfaces in his room. CNA B said it was cross-contamination and could cause him an infection. CNA B said they should have worn gowns while performing incontinent care on Resident #2 because he had a feeding tube. CNA B said EBP was to protect the staff and the resident from cross-contamination. CNA B said not wearing a gown during incontinent care could spread infection. CNA B said she did not see the EBP cart or EBP sign that was just inside Resident #2's room.Record review of the facility's Nursing Services-Competency Evaluation for Skill/Procedure: Perineal Care without catheter of CNA A dated 5/21/25 had a check mark in the met column which indicated CNA A had performed the procedure of perineal care and met the performance criteria, which included discarding used supplies, removed gloves, and performed hand hygiene and applied new gloves and placed new brief and changed lines as needed and positioned resident comfortably, and gave table and call light. Record review of the facility's Nursing Services-Competency Evaluation for Skill/Procedure: Perineal Care without catheter of CNA B dated 5/30/25 had a check mark in the met column which indicated CNA B had performed the procedure of perineal care and met the performance criteria, which included discarding used supplies, removed gloves, and performed hand hygiene and applied new gloves and placed new brief and changed lines as needed and positioned resident comfortably, and gave table and call light. 2. Record review of Resident #3's face sheet dated 7/15/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #3 had diagnoses which included myotonic muscular dystrophy (genetic condition characterized by progressive muscle weakness and wasting), diabetes (high blood sugar), and gastrostomy (feeding tube).Record review of Resident #3's quarterly MDS assessment dated [DATE], indicated she had a BIMS of 10, which indicated she had moderate cognitive impairment. The MDS indicated Resident #3 required moderate to dependent on staff for most ADLs. The MDS indicated Resident #3 had a feeding tube.Record review of Resident #3's Care Plan dated 7/15/25 indicated she had a care area/problem of altered nutritional status: enteral feeding monitor. Resident #3 also had a care area/problem of Infection control with intervention of Enhanced Barrier Precautions, gown and glove use during high-contact resident care activities.Record review of Resident #3's Physician Orders dated 7/01/25 - 7/31/25 did not reveal an order for Enhanced Barrier Precautions.Record review of Resident #3's Medication Record dated 6/23/25 - 7/15/25 indicated Enhanced Barrier Precautions every shift.During an observation and interview on 7/15/25 at 9:53 AM, Resident #3 was lying in bed and had a feeding tube infusion device connected to her feeding tube and the alarm was going off that it had completed. Resident #3 said staff wear gloves when administering her feedings and medications through her feeding tube and when providing incontinent care, but the staff never wear gowns during her care. There was a blue name tag outside her door, a PPE cart just inside Resident #3's door, but there was no EBP sign posted.During an observation and interview on 7/15/25 beginning at 10:04 AM, LVN C entered Resident #3's room and put on gloves. LVN C then pulled back the Resident #3's covers to expose her feeding tube. LVN C unhooked the feeding tube, then placed her stethoscope on the resident's abdomen, and checked placement of the feeding tube with 60 cc of air. LVN C then attempted to flush the feeding tube with water and then begun rolling the feeding tube between her fingers as she was leaned against the resident's bed/bedding. LVN C did not wear a gown as part of EBP. LVN C said they often had difficulty flushing the resident's feeding tube. LVN C said she was going to have someone else come try to flush it. During an interview on 7/15/25 at 10:35 AM, LVN C said she had worked at the facility for approximately twelve years and normally worked on the day shift. LVN C said she would know a resident was on EBP because they should have a PPE box in their room. LVN C said the EBP was for residents that had urinary catheters, wounds, feeding tubes, or any openings that could introduce infection. LVN C said residents on EBP should also have a sign posted indicating they were on EBP. LVN C said if staff were in direct contact with the resident, they should suit up and I did not do it on Resident #3. LVN C said she should have also worn a gown with her gloves during Resident #3's care. LVN C said it was important to follow EBP due to the at-risk residents had ports of entry for infection and EBP protected both the resident and staff. LVN C said EBPs was so staff did not carry anything from one resident to another resident. LVN C said if staff did not follow the EBP, it could place the residents at a higher risk of infection.During an interview on 7/15/25 at 2:17 PM, the ADON said he was also the Infection Preventionist. The ADON said staff should change their gloves during incontinent care any time they were doing different tasks. The ADON said the staff should have changed their gloves and performed hand hygiene after cleaning the Resident #2's front perineal area and prior to touching any other surfaces in the resident's room. The ADON said then staff should have changed gloves and performed hand hygiene after cleaning the resident's back perineal area and prior to touching any other of the resident's surfaces to prevent cross-contamination. The ADON said it was important to perform hand hygiene and change gloves appropriately to prevent cross-contamination and prevent the spread of infection. The ADON said all staff were responsible for ensuring staff were following the infection control policy and procedures. The ADON said residents who were on EBP was indicated by the blue name tags outside the resident's door and a PPE cart inside the resident's room. The ADON said they do not use the EBP signs, but staff had been educated that the blue name tags were indicative of the resident being on EBP. The ADON said any resident who had an invasive device, such as urinary catheter, a feeding tube, dialysis access, wounds or anything that would increase the risk of infections from an outside source would be on EBP. The ADON said the purpose of EBP was to protect the resident from an outside source of infection from direct care contact. The ADON said the resident, who was on EBP, was at an increased risk of infection if staff did not wear gown and gloves during direct care. The ADON said staff could spread infection from one resident to another resident if they were not wearing a gown during direct care. During an interview on 7/15/25 at 2:45 PM, the DON said staff should know a resident was on EBP from the blue name tags outside the resident's door and a PPE cart inside the resident's room. The DON said they do not use the EBP signs and only used the blue name tags outside the resident's room. The DON said the reasons a resident would be on EBP would be anyone with a feeding tube, urinary catheter, wounds, and any other indwelling device. The DON said the purpose of EBP was almost a reversed precaution, to protect the resident from getting something from the staff due to the resident was at a higher risk of infection and cross-contamination. The DON said staff should have changed their gloves when going from a dirty surface to a clean surface. The DON said staff should wash or sanitize their hands prior to and post incontinent care. The DON said the Infection Preventionist and herself would be responsible for ensuring staff were following the infection control policy and procedures. The DON said staff could transfer any bad bugs anywhere they touched with their contaminated gloves. The DON said the resident had the potential of infection if staff were not following EBP and transferred germs or bacteria from one resident to another resident. During an interview on 7/15/25 at 4:10 PM, the ADM said he would expect staff to follow the facility's infection control policy and procedures and change gloves and perform hand hygiene per their policies. The ADM said he would expect the EBP to be followed to protect the residents from anything staff may have come in to contact with. The ADM said not changing gloves, performing hand hygiene, following the EBP could be a potential infection control issue.Requested an Infection Control policy on 7/15/25 at 5:00 PM from the facility's Regional Nurse and was provided a policy titled Infection Prevention, Control & Surveillance, which did not contain pertinent information. Record review of the facility's policy titled Perineal Care dated revised April 10, 2023 indicated . staff would provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection . procedure . perform hand hygiene. Apply clean gloves . 5. Perineal care for a male resident . d. wash tip of penis . f. cleanse the shaft of the penis . 6. observe perineal area . 8. Turn resident to clean all areas of buttocks . 9. Dispose of gloves and used supplies and perform hand hygiene . 10. Apply new gloves and place new brief . 11. Position resident comfortably . Record review of the facility's policy titled Hand Hygiene for Staff and Residents dated revised February 2025 indicated . purpose . to reduce the spread of infection with proper hand hygiene . hand hygiene was the most important component for preventing the spread of infection . hand hygiene was done . before . before resident contact . after . contact with soiled or contaminated articles, such as articles that were contaminated with body fluids . resident contact . contact with contaminated object or source where there was a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds . toileting or assisting others with toileting .Record review of the facility's policy titled Enhanced Barrier Precautions dated revised March 2025 indicated . many residents in nursing homes were at increased risk of becoming colonized and developing infections with multi-drug-resistant organisms (MDROs) . facility utilized Enhanced Barrier Precautions (EBP) as a strategy to decrease transmission of CDC-targeted and epidemiologically important MDROs when Contact Precautions do not apply . indications . wounds and/or indwelling medical devices . indwelling medical devices include central lines . urinary catheters, feeding tubes . high contact resident care activities . providing hygiene . changing briefs or assisting with toileting . device care or use . feeding tube . communication . indicate the residents who were on EBP by subtle means, such as an alternate color of the resident's name badge on door .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Residents #1) reviewed for resident rights.<BR/>CNA E did not sit as she assisted Resident #1 with dining. <BR/>CNA E did not refrain from talking on her cell phone while she assisted Resident #1 with dining. <BR/>The facility did not ensure Resident #1 was clothed in his personal clothing. <BR/>These failures could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth.<BR/>Findings included:<BR/>Record review of Resident #1's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including Hemiplegia or hemiparesis (hemiplegia refers to a severe or complete loss of strength, whereas hemiparesis refers to a relatively mild loss of strength) following cerebral infarction (stroke) affecting the left non-dominant side, type II diabetes, shortness of breath, nausea/ vomiting, and depression. <BR/>Record review of Resident #1's MDS dated [DATE] indicated Resident #1 was usually understood and usually understood others. The MDS indicated Resident #1 had severe cognitive impairment (BIMS of 5). The MDS indicated he had no behavior of rejecting care during the 7 days look back period. The MDS indicated he required extensive assistance with bed mobility, transfers, locomotion in his wheelchair, dressings, eating, toilet use, and personal hygiene. The MDS indicated Resident #1 was completely dependent on staff for bathing. The MDS indicated Resident #1 was always incontinent of bowel and bladder. <BR/>Record review of Resident #1's care plan revised on 11/15/22 indicated Resident #1 had a self-care deficit. The care plan interventions included to give the resident as many choices as possible about care and provide assistance with self-care as needed. <BR/>During an observation on 2/8/23 at 11:10 a.m. revealed Resident #1 laid in his bed wearing a hospital gown. <BR/>During an observation on 2/8/23 at 12:45 p.m. revealed the door to Resident # 1's door was open. CNA E stood at Resident #1's bedside. CNA E said loudly Well what are you going to then?. A few moments later CNA E again said, Well what are you going to then? and then said I gotta go. The surveyor entered the room. CNA E continued to stand at Resident #1's bedside and fed him several bites from his food tray. <BR/>During an observation and interview on 2/8/23 at 2:50 p.m. revealed Resident #1 laid in his bed wearing a hospital gown. Resident #1 said he did not want to wear a hospital gown. Resident #1 said his family member had brought him some clothes and pointed at the armoire. There were multiple personal clothing items hanging in the armoire. Resident #1 said he guessed he had to wear the gown because that was what they (facility staff) put on him. Resident #1 could not say how long he had been wearing the hospital gown or who had placed the hospital gown on him. Resident #1 said CNA E talked on the phone while she fed him today (2/8/23) and felt it was rude. <BR/>During an interview on 2/10/23 at 10:28 a.m., CNA G said there was no reason for a resident to have been in a hospital gown. CNA G said the facility had clothes that were donated for resident use if a resident did not have any personal clothes available. CNA G said if a resident did not want to wear a hospital gown and was placed in hospital gown, it could take away the resident's dignity. CNA G said CNAs should not stand while feeding a resident because it could cause the resident to feel intimidated. CNA G said another reason CNAs should not stand while feeding a resident was to ensure the resident did not have any signs of aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). CNA G said under no circumstance should a CNA take a personal phone call while he/she administered resident care. CNA G said to take a personal call during the administration of patient care was not only disrespectful but would also divert attention away from the resident. <BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she should not have stood while feeding Resident #1. CNA E said she should have sat at Resident #1's bedside while she assisted him with eating because it was more respectful than standing. CNA E said she stood while she fed Resident #1 because she was in a hurry. CNA E said she did not notice Resident #1 was wearing a hospital gown and indicated he should have been wearing his personal clothes. CNA E said she should not have taken the personal call while she assisted Resident #1 but did so because she had a family situation. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected staff to sit while they assisted residents with eating in order to promote respect and safety. The DON said it was not acceptable for a resident to be in a hospital gown and to do so (place a resident in a hospital gown) could affect the resident's dignity. The DON said it was not acceptable for staff to have taken a phone call while assisting a resident. The DON said she expected staff to go to the break room or their car if they had to take a phone call. The DON said a staff member taking a phone call in front of a resident was a dignity issue and could also confuse the resident. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected staff to ensure residents were clothed in their personal clothing if it was the resident's preference. The Administrator said she expected staff to ensure respect and dignity were provided to residents. The Administrator indicated taking personal phone calls during resident care activities and standing while feeding a resident did not promote respect and dignity.<BR/>Record review of the undated facility policy and procedure titled, Exercise of Rights reflected, Policy Statement- Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to our facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote resident self-determination through support of family choice for 1 of 6 residents reviewed for resident rights. (Resident #1)<BR/>The facility did not place Resident #1's tennis shoes on his feet daily per family requested. <BR/>This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life. <BR/>Findings included: <BR/>Record review of a face sheet dated 10/03/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), muscle spasms, and recurrent depressive disorders. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #1 was rarely to never understood. The MDS indicated a BIMS was not conducted due to Resident #1 being rarely to never understood. The MDS indicated Resident #1 was totally dependent on staff for all ADLs including dressing. <BR/>Record review of a care plan last revised on 05/31/23 indicated Resident #1 had a self-care deficit. There was an intervention that indicated Resident #1 was a total assist with dressing, grooming, hygiene, and bathing. The care plan indicated Resident #1 wished to have a representative involved in care decisions. <BR/>Record review of nurse's notes from 9/22/23 to 10/03/23 did not indicate Resident #1 had refused to wear his tennis shoes daily. <BR/>During an observation on 10/3/23 at 8:13 a.m. Resident #1 was resting in bed. There was a sign hanging on the window beside the resident's bed that indicated, 8-5-2023, Please turn (Resident #1's) feeding off from 2:00 pm til 4:00 p.m. daily. It's down time per the doctor. Please put his tennis shoes on during his down time for the 2 hours. We are trying to help prevent foot drop. Thank You.<BR/>During an observation on 10/3/23 at 3:24 p.m., Resident #1 was resting in bed. The resident did not have on tennis shoes. He only had socks on his feet. The sign was still hanging beside the bed. <BR/>During an interview on 10/03/23 at 5:05 p.m., a family member of Resident #1 said they wanted the resident to wear his tennis shoes between 2 p.m. and 4 p.m. The family member said they had placed the sign on the window requesting for his tennis shoes to be placed on him each day. She said he never had on his tennis shoes. <BR/>During an observation on 10/4/23 at 2:20 p.m., Resident #1 resting bed. Feet propped up on a pillow. There were socks on his feet. He did not have on tennis shoes. The resident's feeding was disconnected and was on down time.<BR/>During an observation on 10/4/23 at 3:15 p.m., Resident #1 resting in bed. Feet propped up on a pillow. There were socks on his feet. He did not have on tennis shoes. The resident's feeding was disconnected and was on down time. <BR/>During an interview on 10/04/23 at 3:44 p.m., CNA A said she had never noticed the sign hanging on the window requesting for Resident #1 to have his tennis shoes on from 2 p.m. to 4 p.m. She said she had never seen Resident #1 with tennis shoes on his feet. <BR/>During an interview on 10/05/23 at 8:40 a.m., CNA B said a family member did request for Resident #1 to have his tennis shoes on daily. She said there had been times when Resident #1 had shaken his head and did not want them on. She said Resident #1's refusals were not charted that she was aware of. <BR/>During an interview on 10/5/2023 at 8:52 a.m., CNA C said she had never seen Resident #1 with his tennis shoes on and she was not aware his family wanted him to wear his tennis shoes. She said she normally did not take care of Resident #1. She said she just helped the aide that took care of him.<BR/>During an interview on 10/5/2023 at 9:32 a.m., LVN D said she had not witnessed Resident #1 ever having on his tennis shoes and she had just noticed the sign on 10/5/23. <BR/>During an interview 10/5/2023 at 10:33 a.m., the DON said she wished that nursing staff would put tennis shoes on Resident #1. She said Resident #1 did not like wearing the tennis shoes and refused to wear them. She said she would have expected any refusals to have been documented in the nurse's notes.<BR/>During an interview on 10/05/23 at 11:50 a.m., the Administrator said she would want the family to better communicate that they wanted tennis shoes on Resident #1. She said she would want the family's preferences to be honored as long as they were safe for the resident. She said any refusals should have been documented in the nurse's progress notes.<BR/>Review of a Resident Right's policy last revised on August 14, 2022 indicated, .The staff will abide by and protect resident rights in accordance with state and federal guidelines . Staff will abide by resident rights as outlined within CMS State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities (Rev. 11-22-17) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed 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 one out of one resident (Resident #2) reviewed for PASRR.<BR/>The facility failed to submit NFSS forms timely for Resident #2. <BR/>These failures 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 include:<BR/>1. Record review of a face sheet dated10/03/2023 revealed Resident #2 was a [AGE] year-old female that admitted to the facility on [DATE] with the diagnoses of cerebral palsy (caused by abnormal brain development or damage to the developing brain that affects a person's ability to control his or her muscles), paranoid schizophrenia (stems from delusions-firmly held beliefs that persist despite evidence to the contrary-and hallucinations-seeing or hearing things that others do not), and muscle weakness.<BR/>Record review of Resident #2's quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 99, which indicated Resident #2 was cognitively impaired. Resident # 2 required extensive assistance for locomotion, bed mobility, bathing, and dressing. The MDS indicated Resident #2 was usually understood and usually understood others.<BR/>Record review of Resident #2's care plan dated 07/15/2023 stated Resident #2 was PASRR positive for the diagnosis of cerebral palsy and paranoid schizophrenia. Resident #2's ADL care plan indicated Resident #2 would have PT/OT evaluate and treat as needed to maintain or improve physical function.<BR/>Record review of the habilitation service plan (HSP) dated 06/12/2023, revealed Resident #2 was recommended to receive occupational therapy 5 times per week for 6 months to increase Resident #2's independence and safety with dressing and bathing.<BR/>The sign in sheet for the HSP, also dated 06/12/2023 indicated Resident #2, the PASRR Habilitation Coordinator, the social worker, the MDS Coordinator, and the Physical Therapy Assistant were present during the meeting and agreed on the recommendation.<BR/>Record review on an email correspondence dated 08/15/2023 between the PASRR Unit Program Specialist and the Administrator revealed the facility was informed and instructed in writing to submit a NFSS Request by a specific deadline but failed to do so. Also, the NFSS Request submittal by the NF was denied and there was not a follow up submittal to ensure the request was approved to provide specialized services for PASRR for the resident. The instructions included the following : Be sure your facility checks the status of the requests daily to ensure they are approved. Prompt attention should be given to the request if it has a pending denial status once it is submitted. This is a time sensitive status and can result in system generated denial if not followed up on by date noted by the reviewer in the request.<BR/>Review of Simple LTC portal (portal used to submit PASRR service requests) for Resident #2's OT Assessment reflected a note, dated 08/11/2023, NFSS form for OT was not submitted within 30 calendar days of the IDT meeting and it was form was not accepted.<BR/>During an interview on 10/04/2023 at 11:10 a.m., with the PASRR Habilitation Coordinator revealed the meeting on 06/11/2023 was the quarterly PASRR meeting mandated by the state. The PASRR Habilitation Coordinator stated it was decided in the meeting that Resident #2 would benefit from occupational therapy (OT) services and the process was initiated for Resident #2 to be evaluated and the paperwork to be submitted by the facility for approval for funding by the PASRR service group for the therapy. She stated the team present in the meeting decided it would be beneficial for her to have a reason to get out of bed every day and have therapy to look forward to. The PASRR Habilitation Coordinator stated after the meeting took place and she put her notes into the system it was up to the facility to complete the process.<BR/>During an interview on 10/04/2023 at 11:55 a.m., the PASRR Unit Program Specialist, stated her emails to the facility were self-explanatory and the facility failed to comply with the emails she sent. She stated it was important to file the NFSS form within 30 days after the IDT meeting and failure to do so may result in a resident not receiving needed rehabilitative services and could contribute to a decline in functional status. <BR/>During an interview with the MDS nurse 10/04/2023 at 2:00 pm, stated that she started she was unsure why the Simple LTC portal had not been checked daily to ensure Resident #2's OT request was followed up on. The MDS nurse stated it was important for the NFSS form to be completed 30 days after the IDT meeting. The MDS nurse stated that failure to submit the NFSS form within the timeframe may lead to residents not receiving services at the facility. <BR/>During an interview with the DON on 10/05/2023 at 12:20 p.m., stated she was unfamiliar with the process of PASRR and left it to the corporate MDS nurse to assist in those matters. <BR/>During an interview with the Administrator on 10/05/2023 at 1:40 p.m., stated she had received the emails from the PASRR specialist and a phone call. The Administrator stated the PASRR specialist called and said follow the instructions on the email and added no assistance with the process. The Administrator stated it was the right of Resident #2 to receive OT, but the Administrator did not feel Resident #2 had suffered any ill affect from having not received the services. <BR/>Policy related to PASRR services was requested 10/05/2023 at 10:00 a.m. and 1:00 p.m. by the Administrator and no policy was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good grooming and personal hygiene for a resident who is unable to carry out activities of daily living were provided for 2 of 4 residents reviewed for activities daily living (Resident #2 and Resident #5)<BR/>The facility did not clean or trim the nails of Resident #2 and Resident #5. <BR/>The facility failed to promptly respond to Resident #2 and Resident #5's call lights who were ADL dependent.<BR/>These failures could place dependent residents at risk of poor hygiene, infections, injuries and unmet needs. <BR/>Findings included: <BR/>Record review of Resident #2 's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including respiratory failure, colon cancer, diabetes, and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred). <BR/>Record review of Resident #2's MDS dated [DATE] indicated Resident #2 made himself understood and usually understood others. The MDS indicated Resident #2 had moderately impaired cognitive function (BIMS of 10). The MDS indicated he had no behavior of rejecting care. The MDS indicated he required limited assistance with locomotion in his wheelchair, supervision only with toilet use and eating. The MDS indicated he required extensive assistance with dressing, personal hygiene and bathing. The MDS indicated bed mobility had only occurred once or twice during the 7 days look back period. The MDS indicated transfers and walking had not occurred during the 7 days look back period. <BR/>Record review of Resident #2's care plan dated 12/7/22 indicated his ADL dependency was not specifically addressed. <BR/>During an observation on 2/8/23 at 11:15 a.m. revealed Resident #2 laid in his bed. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/>During an interview and observation on 2/8/23 at 2:44 p.m. revealed Resident #2 sat in his bed. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/> Resident #2 said he had been at the facility approximately 2 months. He said no one had offered to trim and clean his nails since he had been at the facility.<BR/>During an observation and interview on 2/9/23 at 9:05 a.m. revealed Resident #2 sat in his wheelchair. His nails were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under several of the nails. CNA F was making his bed. CNA F said nail care was usually done on shower days by the CNAs. CNA F indicated she had just administered a shower to Resident #2. CNA F said nurses trimmed the nails of diabetic residents. <BR/>During an observation on 2/9/23 at 11:17 a.m. revealed Resident #2 was in therapy sitting in his wheelchair. CNA F stood at his side viewing his nails. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/>During an interview on 2/9/23 at 11:18 a.m., CNA F said she did not know if Resident #2 was a diabetic. CNA F said she cleaned Resident #2's nails in the shower by washing over the top of his hands but indicated she did not clean under his nails. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said she worked the hall on which Resident #2 resided on 2/8/23. RN C said there was no set schedule for diabetic nail care and nurses just performed the care as it needed to be done. RN C said no CNAs had reported to her that any diabetic resident needed nail care yesterday (2/8/23). RN C said Resident #2's nails were very thick and would have to be soaked before they could be cut. RN C said that might be why the nail care had not been performed. RN C said it was important to ensure nail care was completed to prevent infection. <BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she regularly worked the hall that Resident #2 resided on. CNA E said CNAs and nurses were responsible to ensure residents nails were cleaned and trimmed. CNA E said nurses performed nail care for diabetic residents. CNA E said there was no set schedule for CNAs to perform nail care and indicated she performed nail care when she saw it needed to be done. CNA E said if she saw nail care was needed for a diabetic resident, she would notify the nurse. CNA E said she could not remember if she notified RN C that nail care was needed for Resident #2. CNA E said it was important to ensure nail care was completed to maintain resident hygiene.<BR/>2. Record review of Resident #5's consolidated physician orders dated 2/10/23 indicated he was [AGE] years old admitted to facility on 1/16/23 with diagnoses including atherosclerotic heart disease (heart disease caused by the buildup of fats, cholesterol and other substances in and on the artery walls), and rheumatoid arthritis (chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility) and dementia. <BR/>Record review of Resident #5's MDS dated [DATE] indicated Resident #5 usually understood and usually made himself understood. The MDS indicated he had moderately impaired cognitive function (BIMS of 9). The MDS indicated he had no behavior of rejecting care. The MDs indicated transfers had only occurred once or twice during the 7 days look back period. The MDS indicated locomotion in his wheelchair had not occurred during the 7 days look back period. The MDS indicated he required limited assistance with walking in his room and eating. The MDS indicated he required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and bathing. <BR/>Record review of Resident #5's care plan revised on 2/1/23 indicated his ADL dependency was not specifically addressed.<BR/>During an observation and interview on 2/8/23 at 3:45 p.m. revealed Resident #5 laid in his bed. His nails were long (approximately 1/2 centimeter past the end of his fingers). There was a dark brown substance under several (more than 2 nails on each hand but less than 5 nails of each hand) nails to each hand. Resident #5 said he wanted his nails to be cleaned and trimmed. Resident #5 said he did not know when his nails were last cleaned and trimmed. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said she worked the hall on which Resident #5 resided on 2/8/23. RN C said CNAs were responsible to perform nail care for non-diabetic residents. RN C said there was no set schedule for CNAs to perform nail care and indicated CNAs were to perform the nail care as needed. RN C said it was important to ensure nail care was completed to prevent infection.<BR/>During an observation on 2/10/23 at 9:32 a.m. revealed Resident #5 laid in his bed. His nails were long (approximately 1/2 centimeter past the end of his fingers). There was a dark brown substance under several (more than 2 nails on each hand but less than 5 nails of each hand) nails to each hand. <BR/>During an interview on 2/10/23 at 10:28 a.m., CNA G said residents were to have their nails cleaned and trimmed on shower days by CNAs. CNA G said resident nails were to be cleaned and trimmed as needed in between shower days. CNA G said it was important to ensure nail care was done to avoid infection and unintentional injury (scratches and skin tears).<BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she regularly worked the hall that Resident #5 resided on. CNA E said CNAs and nurses were responsible to ensure residents nails were cleaned and trimmed. CNA E said nurses performed nail care for diabetic residents and CNAs performed nail care for non-diabetic residents. CNA E said there was no set schedule for CNAs to perform nail care and indicated she performed nail care when she saw it needed to be done. CNA E said she did not recall performing nail care for Resident #5 but indicated she would have cleaned and trimmed his nails if she noticed they were long and dirty. CNA E said it was important to ensure nail care was completed to maintain resident hygiene. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected CNAs to ensure nail care was completed for non-diabetic residents as it was needed. The DON said she expected nurses to perform nail care for diabetic residents as it was needed. The DON said it was important to ensure nail care was done to prevent unintentional injuries (such as scratches) and prevent infections. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected staff to ensure resident's nails were cleaned and trimmed. <BR/>Record review of the facility policy and procedure titled Bathing revised on 02/12/20 reflected, .Tasks commonly completed during the bathing process .Report abnormal findings to the nurse in charge .needs shall be discussed with the resident and responsible party during care plan meetings with the interdisciplinary team in order to identify and implement proper hygiene habits and promote resident rights and dignity The policy and procedure did not specifically address nail care. A policy and procedure for nail care was requested but not received. <BR/>3. During an observation on 2/8/23 at 2:44 p.m. revealed Resident #5 could be heard across the hall yelling Somebody come help me. <BR/>During an observation on 2/8/23 at 2:47 p.m. revealed Resident #2 pushed his call light in order to obtain assistance to get up.<BR/>During a continuous observation on 2/8/23 from 2:47 p.m. to 3:15 p.m. revealed Resident #5's call light dome remained lit up and the call light alarm was audible until 3:12 p.m. Resident #5 continued to yell intermittently for help from 2:47 p.m. to 3:15 p.m. Resident #2's call light dome remained lit up and the call light alarm was audible until 3:15 p.m. Resident #5's room was directly adjacent to Resident #2's room. <BR/>During an observation on 2/8/23 at 2:51 p.m., revealed Receptionist I walked by both Resident #2 and Resident #5's rooms as Resident #5 yelled out. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:52 p.m. revealed LVN J walked by both Resident #2 and Resident #5's rooms pushing a treatment cart. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:55 p.m. revealed Admissions Director K walked by both Resident #2 and Resident #5's rooms as Resident #5 yelled out Help. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:57 p.m. revealed an unidentified staff member in a khaki-colored polo pushed a red hand truck/ appliance dolly (tool to move heavy items) by both Resident #2 and Resident #5's rooms. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:58 p.m. revealed Housekeeper L stood in the hallway, 2 rooms down from Resident #2 and Resident #5's rooms. Housekeeper L stood in front of his housekeeping cart with his back toward the surveyor. His head was bent down as if he were looking at something in front of him. <BR/>During an observation on 2/8/23 at 3:02 p.m. revealed CNA H walked by both Resident #2 and Resident #5's rooms. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 3:12 p.m. revealed Maintenance Personnel M answered Resident # 5's call light. <BR/>During an observation on 2/8/23 at 3:15 p.m. revealed CNA H answered Resident #2's call light.<BR/>During an interview on 2/8/23 at 3:16 p.m., maintenance personnel M said answering call lights was everyone's (all staff's) responsibility. Maintenance Personnel M said he may not be able to get/do exactly what the resident requested/needed. Maintenance Personnel M said he could ensure there was not an emergency and notify the nurse of the resident request/need. Maintenance Personnel M said Resident #5 said he just wanted to go home. <BR/>During an interview on 2/8/23 at 3:17 p.m., CNA H said anyone could answer a call light. CNA H said even if the staff were not clinical, they can and should respond to a call light. CNA H said non-clinical staff should check on call lights because there could be an emergency, or the resident might have a simple request. CNA H said she did not immediately check on the call lights because she had just came onto her shift. CNA H said she should have checked on the call lights the first time she went by and notified the residents she would be right back. CNA H said Resident #2 needed help to get up. <BR/>During an interview on 2/8/23 at 3:18 p.m., Housekeeper L said he had worked at the facility since November 2022. Housekeeper L said he noticed the call lights going off but had not been given any instructions regarding call lights. Housekeeper L said he was not sure if he was supposed to answer call lights. <BR/>During an interview on 2/8/23 at 3:29 p.m., Admissions Director K said she had worked at the facility for approximately 3 years. Admissions Director K said any staff could check on a call light, but some residents call out or yell out like every 10 minutes. Admissions Director K said even for the residents that frequently call out she would still check on them. Admissions Director K said she was not sure if Resident #2 and Resident #5 were residents that called out frequently. Admissions Director K said staff had to respond to call lights because the resident might actually need help. Admissions Director K said she did see Resident #2 and Resident #5's call lights when she walked by. Admissions Director K said she did hear Resident #5 yell as she walked by his room. When asked why she did not respond to the call lights or Resident #5's yell for help Admissions Director K said I want to say in my heart of hearts it's because I didn't think they needed Admissions Director K stopped mid-sentence and then said but I can't say that. Admissions Director K then said there was no excuse for not having stopped and checked on Resident #2 and Resident #5's call lights. <BR/>During an interview on 2/8/23 at 3:35 p.m., LVN J said she did not remember walking by Resident #2 and Resident #5's rooms with her cart. LVN J said she certainly would have stopped and checked on the call lights had she noticed they were going off. LVN J said we (all staff) were responsible for answering call lights. <BR/>During an interview on 2/9/23 at 10:19 a.m., Receptionist I said she use to be a CNA and had worked at the facility for 2 &frac12; years. Receptionist I said all staff members were responsible for answering call lights. Receptionist I said it was important to respond to call lights because it could be an emergency. Receptionist I said if the request were something simple, non-clinical staff can assist them or notify the nurse. Receptionist I said she did not remember walking past Resident #2 and Resident #5's call lights yesterday (2/8/23). Receptionist I said she did not remember Resident #5 yelling out for help. Receptionist I said she would have answered the call lights had she noticed them going off. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said all staff clinical or not, were responsible for responding to resident call lights. The DON indicated it was unacceptable that call lights remained unanswered for over 20 minutes while multiple staff members walked by. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected all staff to respond to resident call lights in order to ensure resident needs were met. <BR/>Record review of the facility policy and procedure titled, Call Lights-Answering, revised on 02/12/20 reflected, Standard of Practice: The staff will provide an environment that helps meet the resident's needs by answering call lights appropriately. Procedures: (1) Respond to patients/resident's call lights and emergency lights in a timely manner . (5) If unable to complete the request, do not turn off the call light; the call light will remain on until the service is completed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide residents with limited range of motion appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion for 1 of 5 residents reviewed for range of motion. (Resident #1) <BR/>The facility did not provide restorative therapy for Resident #1's contractures.<BR/>This failure could place residents who had contractures at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being.<BR/>Findings included:<BR/>Record review of a face sheet dated 10/03/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), muscle spasms, and recurrent depressive disorders. <BR/>Record review of physician's orders dated 10/04/23 did not indicate an order for restorative therapy for Resident #1. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #1 was rarely to never understood. The MDS indicated a BIMS was not conducted due to Resident #1 being rarely to never understood. The MDS indicated Resident #1 was totally dependent on staff for all ADLs. The MDS indicated Resident #1 had Range of Motion impairment to both side of the upper and lower extremities. <BR/>Record review of a care plan last revised on 05/31/23 indicated Resident #1 had a self-care deficit. There was an intervention that indicated Resident #1 was a total assist with dressing, grooming, hygiene, and bathing. There was an intervention to provide assistance with self-care as needed. The care plan indicated Resident #1 had impaired mobility related to limited joint mobility. There were interventions for OT/PT (occupation therapy/physical therapy) screen and/or evaluation as needed. There was an intervention for RNA (restorative nurse aide) referral as needed. <BR/>Record review of a Therapy Screen of Resident #1 and was dated 09/08/23 indicated, Recommendations-Restorative Nursing Services are indicated . This was signed by the Rehabilitation Therapy Manager. <BR/>Record review of the electronic medical record access on 10/3/23, 10/04/23, and 10/05/23 did not indicated any restorative nursing documentation. <BR/>During an interview on 10/04/23 at 10:50 a.m., the DON said there were no recent restorative notes for Resident #1. She said he had not been receiving restorative therapy because the therapy was not ordered.<BR/>During an interview on 10/04/23 at 1:15 p.m., the Rehabilitation Therapy Manager said she has completed contracture screenings on Resident #1. She said she did not know if Restorative Therapy even required an order. She said she verbally tell the MDS Coordinator if she recommended someone for restorative therapy. She said the MDS Coordinator was over the Restorative Program. The Rehabilitation Therapy Manager said she had nothing to do with the Restorative Program and did not know how it worked.<BR/>During an interview on 10/04/23 at 1:25 p.m., the MDS Coordinator said one of her responsibilities was the restorative program. She said she met once a week with the Rehabilitation Therapy Manager. She said this was when she was made aware of each recommendation. She said she then initiated the restorative services for the residents. She said she did not know the Rehabilitation Therapy Manager had made a recommendation for Resident #1. I guess we need to get a better system. She said a negative outcome would depend on each resident's current level of care.<BR/>During an interview on 10/05/23 at 10:33 a.m., the DON said there was no documentation of Resident #1 receiving restorative therapy and he had not been receiving restorative therapy. She said someone not receiving recommended therapy could lead to a decrease in function.<BR/>During an interview on 10/05/23 at 11:50 a.m., the Administrator said the therapist was supposed to notify herself and the MDS Coordinator of any recommendation made during Therapy Screens. She said herself and the MDS Coordinator were not made aware of his restorative therapy recommendation. She said it was not communicated in a meeting. She said a resident not receiving therapy could cause continued physical decline and could prevent them from maintain current function.<BR/>Review of a Screening, Rehabilitation facility policy dated April, 2012 indicated, .the outcome of the screen may be to proceed with a physician's order to evaluate or that no additional rehabilitation services are required at that time .<BR/>An article titled Contractures and Splinting, https://www.advanced-healthcare.com/wp-content/uploads/2011/07/August-2014-Inservice.pdf, dated August 2014 indicated, . Contractures - Joint movement is similar to the hinge on a door. Regularly moving the door keeps it working properly, so the door opens and closes easily. When the door isn't moved regularly, the hinge may rust from lack of use, making the door harder to open and close. Similarly, the structures in and around the joints stretch, flex, and move all day long keeping them functional. If the joint is not moved, it shrinks, becomes stiff, and loses the ability to stretch and move. This causes changes in fluids that lubricate the inside of the joint. Movement squeezes and pushes the fluid around, lubricating the joint. When a joint stops moving, so does the fluid. Now both the outside and inside of the joint are immobile. Contractures are joint deformities caused by immobility. Keeping residents active and moving is the best way to prevent contractures .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 3 of 22 residents (Resident #6, Resident #7 and Resident #4) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #6 and Resident #7's oxygen tubing and humidifier bottles were dated per the facility's policy.<BR/>The facility failed to change Resident #6's oxygen tubing and humidifier bottle every Wednesday per the physician's orders. <BR/>The facility failed to change Resident #6 and Resident #7's nebulizer mask and tubing per the facility's policy.<BR/>The facility failed to ensure Resident #6 and Resident #7's nebulizer, mask and tubing were dated per the facility's policy.<BR/>The facility did not ensure Resident #4's suction canister was emptied when it was &frac34; full.<BR/>The facility failed to ensure Resident #4's suction device, tubing, and suction canister were not dated.<BR/>These failures could place residents at risk for of respiratory infections.<BR/>Findings included:<BR/>1.Record review of Resident #6's face sheet dated 2/8/23 revealed Resident #6 was an [AGE] year-old female, and was admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease- constriction of the airways and difficulty breathing), atrial fibrillation (irregular and often rapid heart rate that causes poor blood flow), orthostatic hypotension (type of low blood pressure that occurs when standing up from sitting of lying down), and pain. <BR/>Record review of Resident #6's quarterly MDS dated [DATE] revealed Resident #6 had a BIMS of 12, which indicated she was cognitively intact. Resident #6 required limited to extensive assistance of 1 person for most ADL's. Resident #6 required oxygen therapy.<BR/>Record review of the Resident #6's order summary report dated 2/08/23 revealed an order for oxygen at 2 LPM by a nasal cannula; albuterol sulfate 0.63 mg (milligrams) in 3 mL (milliliters) of solution for nebulization inhalation every four hours as needed for shortness of breath; and ipratropium 0.5 mg with 3 mg in 3 mL of solution for nebulization inhalation every six hours. Resident #6's orders revealed an order for oxygen canister/tubing change every Wednesday evening and date humidifier water and oxygen tubing weekly on Wednesday.<BR/>Record review of Resident #6's eTAR dated 2/08/23 revealed the oxygen/tubing change every Wednesday evening and change & date humidifier water and oxygen tubing weekly on Wednesday was not documented as completed on Wednesday 2/01/23. There was not a task on the eTAR related to changing Resident #6's nebulizer tubing or nebulizer mask.<BR/>Record review of Resident #6's nurses' notes with date range of 10/08/22-2/08/23 revealed there was no documentation the nurses changed Resident #6's oxygen tubing on 2/01/23 or her nebulizer tubing, or nebulizer mask every 48 hours per the facility's policy.<BR/>During an observation and interview on 2/08/23 at 2:00 PM with Resident #6 revealed she had a nebulizer machine (changes liquid medication to a mist) with nebulizer tubing and a mask attached and the tubing nor the mask were dated. The nebulizer with tubing and mask was stored in a bag that reflected the bag was issued 6/22/22. The resident said she received breathing treatments with the nebulizer machine and mask every six hours. Resident #6 was wearing her oxygen at the time of the observation. The oxygen tubing nor the humidifier bottle were dated. Resident #6 said when she left the room in her wheelchair, she had oxygen bottles and she stored her oxygen tubing and cannula in the bag hanging on the oxygen concentrator at her bedside. The bag did not have a date. Resident #6 said she thought the nurses changed her oxygen tubing and nebulizer mask and tubing every month. She did not know when her oxygen tubing and nebulizer mask and tubing were changed last.<BR/>2. Record review of Resident #7's face sheet dated 2/8/23 revealed Resident #7 was a [AGE] year-old female, and was admitted to the facility on [DATE] with diagnoses of heart failure, atrial fibrillation, cerebral atherosclerosis (arteries in the brain become hard, thick, and narrow due to the buildup of plaque or fatty deposits inside the artery walls, which decreases the blow to areas of the brain), kidney failure (kidneys lose the ability to remove waste and balance fluids in the body), spondylosis (age-related wear and tear of the spinal disks), and pain. <BR/>Record review of Resident #7's annual MDS dated [DATE] revealed Resident #7 had a BIMS of 9, which indicated she was moderately cognitively impaired. Resident #7 required supervision to limited assistance of 1 person for most ADL's. Resident #7 required oxygen therapy.<BR/>Record review of Resident #7's order summary report dated 2/08/23 revealed an order for oxygen at 2 LPM by a nasal cannula and ipratropium 0.5 mg with 3 mg in 3 mL of solution for nebulization inhalation three times daily. Resident #7's orders revealed an order to change and date the nebulizer mask/mouthpiece & tubing weekly on Wednesday's night shift. There was not an order related to changing the oxygen tubing.<BR/>Record review of Resident #7's eTAR dated 2/08/23 revealed the change of the nebulizer mask/mouthpiece, & tubing was not documented as completed on Wednesday 2/01/23.<BR/>During an observation and interview on 2/08/23 at 11:49 AM, revealed Resident #7 had oxygen tubing with a nasal cannula attached to a humidifier bottle and they were not dated. The nasal cannula was stored in a bag hanging on the oxygen concentrator and the bag reflected it was issued 6/22/22. Resident #7 said she used her oxygen at night and sometimes during the day when she was short of breath. Resident #7's nebulizer and mask were in a bag, but they were not dated. Resident #7 said she could not remember when her oxygen tubing or nebulizer tubing and mask had last been changed. <BR/>During an interview on 2/08/23 at 3:55 PM with the DON, she said it was a constant struggle trying to get the night shift to do what they were supposed to do. She said she had gone down and visited with Resident #6 and Resident #7 after she knew the surveyor had visited with them and she saw for herself that the oxygen tubing/humidifier bottles and nebulizer/mask were not dated. She said if the tubing/humidifier bottles and nebulizer/masks were not dated, along with no documentation of when they were changed, then they would not be able to determine how long the resident had had the equipment and it could lead to the residents developing respiratory infections. The DON said she was ultimately responsible to ensure the night shift was changing and dating the respiratory equipment per the physician's orders and the facility's policies.<BR/>During an interview on 2/08/23 at 4:13 PM with RN A, she said the night shift nurses were responsible for changing the oxygen tubing and nebulizers/masks on Wednesday nights. She said the oxygen tubing and nebulizer masks should be dated when changed and documented in the resident's chart. She said if the oxygen tubing and nebulizers/masks were not changed regularly they would become nasty and dirty and could cause the resident to develop a respiratory infection. She said she did not specifically check the respiratory equipment (oxygen tubing, nebulizer tubing & masks/mouthpieces) for dates, because night shift was responsible for changing and dating the equipment. She said she would change any respiratory equipment herself and date the equipment if she noticed anything did not look sanitary. <BR/>During an interview on 2/08/23 at 4:25 PM with the Administrator, who was also one of the Infection Preventionists, revealed she expected the oxygen tubing/humidifier bottles and nebulizer/masks to be labeled/dated and it should be documented in the eTAR per the physician's orders. She said she the oxygen tubing/humidifier bottles and nebulizer/masks should be changed per the facility's policies.<BR/>3. Record review of Resident #4's consolidated physician orders dated 2/10/23 indicated he was [AGE] years old and readmitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), colostomy (surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) status, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) status, dysphagia (difficulty swallowing), and shortness of breath. <BR/>Record review of Resident #4's MDS dated [DATE], indicated Resident #4 sometimes made himself understood and usually understood others. The MDS indicated Resident #4 had short-term and long-term memory problems. The MDS indicated Resident #4 had moderately impaired cognitive decision-making skills. The MDS indicated Resident had no behavior of rejecting care. <BR/>Record review of Resident #4's care plan revised on 1/20/23 indicated Resident #4 had increased secretions and an increased risk of aspiration. The care plan interventions included assess for the presence of dyspnea (difficult or labored breathing) and suction as needed. <BR/>During an observation on 2/8/23 at 11:00 a.m. revealed Resident #4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an observation on 2/8/23 at 1:00 p.m. revealed Resident # 4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an observation on 2/8/23 at 3:00 p.m. revealed Resident #4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an interview on 2/9/23 at 9:30 a.m., LVN B said she took care of Resident #4 regularly on the 6:00 a.m. to 6:00 p.m. shift. LVN B said she changed the suction canister and tubing yesterday (2/8/23) evening at approximately 5:00 p.m. when Resident #4's family member pointed out the suction canister was full. LVN B said she had not noticed that the canister was full yesterday during the morning or afternoon. LVN B said it was ultimately the nurse's responsibility but would expect CNAs to notify her if they (CNAs) noted the canister was full. LVN B said the canister and tubing should be dated and initialed. LVN B said the suction canister and tubing should be changed at least every week and as needed. LVN B clarified if the suction device was dropped on the floor the tubing and suction device would be changed. LVN B further clarified if the suction canister was &frac12; way full the canister should be changed. LVN B said the suction equipment will not suction properly if the canister is full. LVN B said she did not suction Resident #4 yesterday prior to 5:00 p.m. LVN B said if he (Resident #4) had needed to be suctioned, and the canister was full, she would have had to retrieve a suction canister before he could have been suctioned. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said suction tubing and suction canisters should be dated to ensure they (suction tubing and suction canisters) are changed weekly. RN C said suction canisters should be emptied before they are full because when full they will not work properly. RN C said a full suction canister could delay a resident receiving suction for a minute or two while staff retrieved another canister. <BR/>During an interview on 2/9/23 at 11:45 a.m., CNA D said she took care of Resident #4 regularly on the day shift. CNA D said nurses handled anything related to suction equipment. CNA D said she did not report the canister was full to the nurse on 2/8/23 because she did not notice it was full. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected staff to ensure suction equipment was dated and suction canisters were changed when the canister was &frac34; full. The DON said she expected nurses to check the level of the canister at least once a shift and when they were in the room providing other care tasks to ensure the canister would be ready for use if suction was needed with no delay in care. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected nurses to follow policy and procedure regarding suction equipment. <BR/>Record review of the facility policy and procedure titled, Respiratory Equipment Change Schedule, reviewed by facility administration on 01/12/22 reflected, Standard of Practice: The community will provide a schedule for changing disposable equipment at regular intervals as determined by manufacturer recommendations and local community standards. Procedures: . provide a schedule for changing disposable equipment at regular intervals as determined by manufacturer recommendations and local community standards . aerosol tubing and aerosol nebulizer to be changed every forty-eight hours . small volume medication nebulizers, place in clean paper bag, labeled with resident's name and leave a resident's bedside . (8) Suction Canister: .(b) Change or empty canister or collection when &frac34; full. (9) Suction tubing .(b) Change or empty canister or collection when &frac34; full .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good grooming and personal hygiene for a resident who is unable to carry out activities of daily living were provided for 2 of 4 residents reviewed for activities daily living (Resident #2 and Resident #5)<BR/>The facility did not clean or trim the nails of Resident #2 and Resident #5. <BR/>The facility failed to promptly respond to Resident #2 and Resident #5's call lights who were ADL dependent.<BR/>These failures could place dependent residents at risk of poor hygiene, infections, injuries and unmet needs. <BR/>Findings included: <BR/>Record review of Resident #2 's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including respiratory failure, colon cancer, diabetes, and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred). <BR/>Record review of Resident #2's MDS dated [DATE] indicated Resident #2 made himself understood and usually understood others. The MDS indicated Resident #2 had moderately impaired cognitive function (BIMS of 10). The MDS indicated he had no behavior of rejecting care. The MDS indicated he required limited assistance with locomotion in his wheelchair, supervision only with toilet use and eating. The MDS indicated he required extensive assistance with dressing, personal hygiene and bathing. The MDS indicated bed mobility had only occurred once or twice during the 7 days look back period. The MDS indicated transfers and walking had not occurred during the 7 days look back period. <BR/>Record review of Resident #2's care plan dated 12/7/22 indicated his ADL dependency was not specifically addressed. <BR/>During an observation on 2/8/23 at 11:15 a.m. revealed Resident #2 laid in his bed. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/>During an interview and observation on 2/8/23 at 2:44 p.m. revealed Resident #2 sat in his bed. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/> Resident #2 said he had been at the facility approximately 2 months. He said no one had offered to trim and clean his nails since he had been at the facility.<BR/>During an observation and interview on 2/9/23 at 9:05 a.m. revealed Resident #2 sat in his wheelchair. His nails were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under several of the nails. CNA F was making his bed. CNA F said nail care was usually done on shower days by the CNAs. CNA F indicated she had just administered a shower to Resident #2. CNA F said nurses trimmed the nails of diabetic residents. <BR/>During an observation on 2/9/23 at 11:17 a.m. revealed Resident #2 was in therapy sitting in his wheelchair. CNA F stood at his side viewing his nails. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/>During an interview on 2/9/23 at 11:18 a.m., CNA F said she did not know if Resident #2 was a diabetic. CNA F said she cleaned Resident #2's nails in the shower by washing over the top of his hands but indicated she did not clean under his nails. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said she worked the hall on which Resident #2 resided on 2/8/23. RN C said there was no set schedule for diabetic nail care and nurses just performed the care as it needed to be done. RN C said no CNAs had reported to her that any diabetic resident needed nail care yesterday (2/8/23). RN C said Resident #2's nails were very thick and would have to be soaked before they could be cut. RN C said that might be why the nail care had not been performed. RN C said it was important to ensure nail care was completed to prevent infection. <BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she regularly worked the hall that Resident #2 resided on. CNA E said CNAs and nurses were responsible to ensure residents nails were cleaned and trimmed. CNA E said nurses performed nail care for diabetic residents. CNA E said there was no set schedule for CNAs to perform nail care and indicated she performed nail care when she saw it needed to be done. CNA E said if she saw nail care was needed for a diabetic resident, she would notify the nurse. CNA E said she could not remember if she notified RN C that nail care was needed for Resident #2. CNA E said it was important to ensure nail care was completed to maintain resident hygiene.<BR/>2. Record review of Resident #5's consolidated physician orders dated 2/10/23 indicated he was [AGE] years old admitted to facility on 1/16/23 with diagnoses including atherosclerotic heart disease (heart disease caused by the buildup of fats, cholesterol and other substances in and on the artery walls), and rheumatoid arthritis (chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility) and dementia. <BR/>Record review of Resident #5's MDS dated [DATE] indicated Resident #5 usually understood and usually made himself understood. The MDS indicated he had moderately impaired cognitive function (BIMS of 9). The MDS indicated he had no behavior of rejecting care. The MDs indicated transfers had only occurred once or twice during the 7 days look back period. The MDS indicated locomotion in his wheelchair had not occurred during the 7 days look back period. The MDS indicated he required limited assistance with walking in his room and eating. The MDS indicated he required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and bathing. <BR/>Record review of Resident #5's care plan revised on 2/1/23 indicated his ADL dependency was not specifically addressed.<BR/>During an observation and interview on 2/8/23 at 3:45 p.m. revealed Resident #5 laid in his bed. His nails were long (approximately 1/2 centimeter past the end of his fingers). There was a dark brown substance under several (more than 2 nails on each hand but less than 5 nails of each hand) nails to each hand. Resident #5 said he wanted his nails to be cleaned and trimmed. Resident #5 said he did not know when his nails were last cleaned and trimmed. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said she worked the hall on which Resident #5 resided on 2/8/23. RN C said CNAs were responsible to perform nail care for non-diabetic residents. RN C said there was no set schedule for CNAs to perform nail care and indicated CNAs were to perform the nail care as needed. RN C said it was important to ensure nail care was completed to prevent infection.<BR/>During an observation on 2/10/23 at 9:32 a.m. revealed Resident #5 laid in his bed. His nails were long (approximately 1/2 centimeter past the end of his fingers). There was a dark brown substance under several (more than 2 nails on each hand but less than 5 nails of each hand) nails to each hand. <BR/>During an interview on 2/10/23 at 10:28 a.m., CNA G said residents were to have their nails cleaned and trimmed on shower days by CNAs. CNA G said resident nails were to be cleaned and trimmed as needed in between shower days. CNA G said it was important to ensure nail care was done to avoid infection and unintentional injury (scratches and skin tears).<BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she regularly worked the hall that Resident #5 resided on. CNA E said CNAs and nurses were responsible to ensure residents nails were cleaned and trimmed. CNA E said nurses performed nail care for diabetic residents and CNAs performed nail care for non-diabetic residents. CNA E said there was no set schedule for CNAs to perform nail care and indicated she performed nail care when she saw it needed to be done. CNA E said she did not recall performing nail care for Resident #5 but indicated she would have cleaned and trimmed his nails if she noticed they were long and dirty. CNA E said it was important to ensure nail care was completed to maintain resident hygiene. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected CNAs to ensure nail care was completed for non-diabetic residents as it was needed. The DON said she expected nurses to perform nail care for diabetic residents as it was needed. The DON said it was important to ensure nail care was done to prevent unintentional injuries (such as scratches) and prevent infections. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected staff to ensure resident's nails were cleaned and trimmed. <BR/>Record review of the facility policy and procedure titled Bathing revised on 02/12/20 reflected, .Tasks commonly completed during the bathing process .Report abnormal findings to the nurse in charge .needs shall be discussed with the resident and responsible party during care plan meetings with the interdisciplinary team in order to identify and implement proper hygiene habits and promote resident rights and dignity The policy and procedure did not specifically address nail care. A policy and procedure for nail care was requested but not received. <BR/>3. During an observation on 2/8/23 at 2:44 p.m. revealed Resident #5 could be heard across the hall yelling Somebody come help me. <BR/>During an observation on 2/8/23 at 2:47 p.m. revealed Resident #2 pushed his call light in order to obtain assistance to get up.<BR/>During a continuous observation on 2/8/23 from 2:47 p.m. to 3:15 p.m. revealed Resident #5's call light dome remained lit up and the call light alarm was audible until 3:12 p.m. Resident #5 continued to yell intermittently for help from 2:47 p.m. to 3:15 p.m. Resident #2's call light dome remained lit up and the call light alarm was audible until 3:15 p.m. Resident #5's room was directly adjacent to Resident #2's room. <BR/>During an observation on 2/8/23 at 2:51 p.m., revealed Receptionist I walked by both Resident #2 and Resident #5's rooms as Resident #5 yelled out. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:52 p.m. revealed LVN J walked by both Resident #2 and Resident #5's rooms pushing a treatment cart. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:55 p.m. revealed Admissions Director K walked by both Resident #2 and Resident #5's rooms as Resident #5 yelled out Help. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:57 p.m. revealed an unidentified staff member in a khaki-colored polo pushed a red hand truck/ appliance dolly (tool to move heavy items) by both Resident #2 and Resident #5's rooms. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:58 p.m. revealed Housekeeper L stood in the hallway, 2 rooms down from Resident #2 and Resident #5's rooms. Housekeeper L stood in front of his housekeeping cart with his back toward the surveyor. His head was bent down as if he were looking at something in front of him. <BR/>During an observation on 2/8/23 at 3:02 p.m. revealed CNA H walked by both Resident #2 and Resident #5's rooms. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 3:12 p.m. revealed Maintenance Personnel M answered Resident # 5's call light. <BR/>During an observation on 2/8/23 at 3:15 p.m. revealed CNA H answered Resident #2's call light.<BR/>During an interview on 2/8/23 at 3:16 p.m., maintenance personnel M said answering call lights was everyone's (all staff's) responsibility. Maintenance Personnel M said he may not be able to get/do exactly what the resident requested/needed. Maintenance Personnel M said he could ensure there was not an emergency and notify the nurse of the resident request/need. Maintenance Personnel M said Resident #5 said he just wanted to go home. <BR/>During an interview on 2/8/23 at 3:17 p.m., CNA H said anyone could answer a call light. CNA H said even if the staff were not clinical, they can and should respond to a call light. CNA H said non-clinical staff should check on call lights because there could be an emergency, or the resident might have a simple request. CNA H said she did not immediately check on the call lights because she had just came onto her shift. CNA H said she should have checked on the call lights the first time she went by and notified the residents she would be right back. CNA H said Resident #2 needed help to get up. <BR/>During an interview on 2/8/23 at 3:18 p.m., Housekeeper L said he had worked at the facility since November 2022. Housekeeper L said he noticed the call lights going off but had not been given any instructions regarding call lights. Housekeeper L said he was not sure if he was supposed to answer call lights. <BR/>During an interview on 2/8/23 at 3:29 p.m., Admissions Director K said she had worked at the facility for approximately 3 years. Admissions Director K said any staff could check on a call light, but some residents call out or yell out like every 10 minutes. Admissions Director K said even for the residents that frequently call out she would still check on them. Admissions Director K said she was not sure if Resident #2 and Resident #5 were residents that called out frequently. Admissions Director K said staff had to respond to call lights because the resident might actually need help. Admissions Director K said she did see Resident #2 and Resident #5's call lights when she walked by. Admissions Director K said she did hear Resident #5 yell as she walked by his room. When asked why she did not respond to the call lights or Resident #5's yell for help Admissions Director K said I want to say in my heart of hearts it's because I didn't think they needed Admissions Director K stopped mid-sentence and then said but I can't say that. Admissions Director K then said there was no excuse for not having stopped and checked on Resident #2 and Resident #5's call lights. <BR/>During an interview on 2/8/23 at 3:35 p.m., LVN J said she did not remember walking by Resident #2 and Resident #5's rooms with her cart. LVN J said she certainly would have stopped and checked on the call lights had she noticed they were going off. LVN J said we (all staff) were responsible for answering call lights. <BR/>During an interview on 2/9/23 at 10:19 a.m., Receptionist I said she use to be a CNA and had worked at the facility for 2 &frac12; years. Receptionist I said all staff members were responsible for answering call lights. Receptionist I said it was important to respond to call lights because it could be an emergency. Receptionist I said if the request were something simple, non-clinical staff can assist them or notify the nurse. Receptionist I said she did not remember walking past Resident #2 and Resident #5's call lights yesterday (2/8/23). Receptionist I said she did not remember Resident #5 yelling out for help. Receptionist I said she would have answered the call lights had she noticed them going off. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said all staff clinical or not, were responsible for responding to resident call lights. The DON indicated it was unacceptable that call lights remained unanswered for over 20 minutes while multiple staff members walked by. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected all staff to respond to resident call lights in order to ensure resident needs were met. <BR/>Record review of the facility policy and procedure titled, Call Lights-Answering, revised on 02/12/20 reflected, Standard of Practice: The staff will provide an environment that helps meet the resident's needs by answering call lights appropriately. Procedures: (1) Respond to patients/resident's call lights and emergency lights in a timely manner . (5) If unable to complete the request, do not turn off the call light; the call light will remain on until the service is completed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 5 (Resident #1) residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 was taken to his vascular surgeon appointment for evaluation of his impaired blood circulation (flow) to his lower extremities (legs).<BR/>This failure could place residents at risk for not receiving appropriate care and treatment to prevent complications such as infections, gangrene, and amputation (removal).<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 05/13/23, revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses which included heart failure (the heart muscle does not pump blood as well as it should to meet the body's needs for blood and oxygen), diabetes ( high blood sugar in the blood) with neuropathy (weakness, numbness, and pain from nerve damage usually in hands and feet), end stage renal disease (kidneys unable to filter toxins from the body), dependent on dialysis (dialysis filters toxins from the body), partial amputation of penis (removal of part of the penis), Fournier gangrene (necrotic-dead tissue-infection of penis) and atherosclerotic heart disease (buildup of fats in the heart vessels causing obstruction of blood flow).<BR/>Record review of Resident #1's MDS admission assessment dated [DATE] revealed he had a BIMS score of 15, which indicated his cognition was intact. Resident #1 required limited assistance of one person with most ADL's but required total assistance for locomotion on and off the unit and extensive assistance of one person with bathing. The MDS assessment revealed Resident #1 had 2 unstageable pressure ulcers and was receiving dressings to his feet.<BR/>Record review of Resident #1's care plan dated 5/13/23 revealed he was at risk for skin breakdown with actual pressure ulcers, diabetic ulcer, and surgical wound. Resident #1 had cardiovascular disease with interventions to assess for changes in lower extremity (legs) edema or cold extremities.<BR/>Record review of Resident #1's Consolidated Order report dated 5/17/23 revealed he was receiving wound care treatments to left posterior calf, left heel, left great toe, right posterior calf, right heel, right ankle, and penis.<BR/>Record review of Resident #1's Doppler study of right extremity arteries (measures blood flow of lower leg) dated 4/24/23 revealed: 1) he had no flow visualized in the posterior tibial artery (PTA-supplies blood to the back of the lower leg), likely occlusion; 2) blood flow velocity (rate) was decreased in the arteries below the knee, likely mild peripheral arterial disease.<BR/>Record review of Resident #1's Doppler study of left extremity arteries dated 4/28/23 revealed he had moderate to severely diminished flow in the posterior tibial artery and anterior tibial artery (ATA-supplies blood to the front of the lower leg).<BR/>Record review of Resident #1's Nurses Notes dated 4/26/23 revealed LVN E received a call from the vascular surgeon's office with an appointment for Resident #1 on May 12, 2023, at 9:30 AM. LVN E documented she notified the resident's family member , the facility driver, and the nurse practitioner of the appointment.<BR/>Record review of Resident #1's Nurses Notes dated 5/12/23 revealed LVN D said she was informed by the SW that Resident #1 had missed his appointment with the vascular surgeon and the appointment was not on the VD calendar book. LVN D documented the appointment was rescheduled to 5/19/23 at 8:00 AM, the appointment was placed on the VD calendar book, and the family was notified of the new appointment.<BR/>Record review of the facility's VD calendar book for 5/12/23 revealed Resident #1 was not listed on the calendar for an appointment with the vascular surgeon. There was documentation in the VD calendar book for Resident #1 to have an appointment with the vascular surgeon on 5/19/23 at 8:00 AM.<BR/>During an interview on 5/13/23 at 12:43 PM, Resident #1's representative said she had called the SW the morning of 5/12/23 to remind the facility of Resident #1's appointment with the vascular surgeon to make sure he was ready to go. Resident #1's representative said the SW worker said they would make sure Resident #1 made it to his appointment. Resident #1 said she called back that afternoon and found out Resident #1 was not on the van schedule, and he did not make it to his appointment that was at 9:30 AM. <BR/>During an observation and interview on 5/13/23 at 3:35 PM, Resident #1 was lying in bed. Resident #1 said he had gone to dialysis and had been back for a little while. Resident # 1 said he did not remember if he had an appointment with a vascular surgeon on 5/12/23 or if he had missed an appointment. <BR/>During an interview on 5/13/23 at 3:39 PM, LVN A said she had worked at the facility for ten years. LVN A said when she was notified a resident had an appointment, she would let the family know and the VD know, and she would write it down on the VD calendar book, plus she would put the appointment on the nurses' 24-hour report. LVN A said the VD would usually notify the family prior to the appointment to remind the family of the time of the appointment, so a family member could meet the resident at the appointment. LVN A said if a family member was not able to go with the resident, then the facility would arrange for a staff member to go with the resident to the appointment. LVN A said the nurse was responsible for ensuring the resident's appointment was written in the VD book and the VD checked the VD book daily. LVN A said if an appointment was not written in the VD book, the appointment could be missed if the nurse did not catch it from the 24-hour report.<BR/>During an interview on 5/13/23 at 3:55 PM, LVN B said once she was notified a resident had an appointment, she would write the appointment in the VD calendar book. LVN B said the nurses were responsible for ensuring residents made it to their scheduled appointments. LVN B said they utilize a 24-hour report and report off to the next shift until the appointment was completed. LVN B said if the appointments were not written in the VD calendar book, then it would be a problem and most likely the appointment would be missed if the appointment had not been communicated to staff in another way. LVN B said it could be detrimental to a resident with circulation issues if they missed an appointment with a vascular surgeon, depending on the severity of circulation issue and health status, the resident could lose their leg or life, if it got that bad.<BR/>During an interview on 5/13/23 at 4:44 PM, CNA G said she had worked at the facility for five years and she had worked on the 100 hall on 5/12/23. CNA G said the nurse notified the CNAs the day before a resident had an appointment and the morning of the appointment to let them know to have the resident ready to go to the appointments. CNA G said she relied on the nurse to tell her who had appointments, but sometimes the VD would let her know of resident's upcoming appointments. CNA G said she was not told Resident #1 had an appointment on 5/12/23 until around 11:00 AM and it was already too late, and the nurse had to reschedule his appointment. <BR/>During an attempted phone interview on 5/13/23 at 5:01 PM, LVN E did not answer the phone and a voicemail was left. LVN E did not return the call.<BR/>During a phone interview on 5/13/23 at 5:08 PM, LVN D said when she was notified of a resident having an appointment, she would write the appointment in the VD calendar book, would put it on the 24-hour report, and would write a nurse's note related to the appointment. LVN D said the VD calendar book was always open at the nurse's station and she checked it daily, so she could relay to the CNAs and oncoming staff of the resident's upcoming appointments. LVN D said she was not aware Resident #1 had an appointment with the vascular surgeon until about noon on 5/12/23. LVN D said the SW told her Resident #1 had an appointment with the vascular surgeon at 2:00 PM on 5/12/23 and she went and told the CNAs to get him ready to go to his appointment. LVN D said a short time later the SW came back and said the appointment was at 9:30 AM 5/12/23 and he had already missed it. LVN D said she immediately called the vascular surgeon's office to reschedule the appointment, but the soonest they could reschedule the appointment was for 5/19/23 at 8:00 AM. LVN D said Resident #1 had circulatory problems and was going to the vascular surgeon for a consult for surgery. LVN D said Resident #1's 5/12/23 appointment was not on her 24-hour report, and it was not on the VD calendar book. LVN D said resident's appointments had to be written in the VD calendar book or no one would know the resident had an appointment. LVN D said it was the responsibility of the nurse's, CNAs, and the VD to ensure residents made it to their scheduled appointments.<BR/>During an interview on 5/13/23 at 5:20 PM, RN F said she used to be the DON at the facility until a year ago, but she had been back at the facility since March 2023 as the MDS Coordinator. RN F said she occasionally worked on the floor if needed. RN F said the nurses, the CNAs, and the VD were responsible for ensuring residents made it to their appointments. RN F said the appointments should be written down in the VD calendar book and the appointment should be on the 24-hour report to communicate to oncoming staff. RN F said the VD checked the VD calendar book daily and would often remind the nurses of the upcoming appointments to find out if family or staff would be going to the appointment with the resident. RN F said if the appointment was not written in the VD calendar book, there was the potential the resident would not make it to the appointment if it had not been communicated in another way. RN F said missing an appointment with the vascular surgeon, depending on the status of the circulation issue, it could delay the treatment of the resident.<BR/>During a phone interview on 5/13/2023 at 5:32 PM, the VD said the nurses were supposed to notify him and write the appointments in the VD calendar book. The VD said he looked at the VD calendar book multiple times daily and called family to remind them of upcoming appointments or the staff coordinator if a staff member would need to go with the resident. The VD said he also reminded the nurses of upcoming appointments to get the details of the appointment. The VD said he did not recall being told Resident #1 had an appointment on 5/12/23 at 9:30 AM. The VD said if the appointment was not written in the VD calendar book, he would not know about it. The VD said he was told on 5/12/23 at about 2:00 PM Resident #1 had an appointment earlier that morning and had missed it, but the VD said he did not know anything about the appointment. The VD said if the appointment was not in the calendar book, he would not have a clue about the appointment.<BR/>During an interview on 5/13/2023 at 5:40 PM, the Administrator said the nurses were responsible for writing the appointments on the VD calendar, putting it on the 24-hour report, and documenting it in the nurses' notes. The Administrator said it was the nurses' responsibility to ensure the resident was ready to go to their appointments, along with the CNA, and the VD, but she was ultimately responsible. The Administrator said they discuss upcoming appointments in their daily stand-up clinical meetings. The Administrator said it was not common for them to miss a resident's appointment because they utilize the 24-hour reports, the VD calendar book, and the daily clinical stand-up meetings. The Administrator said she was told about noon on 5/12/23 of Resident #1 having an appointment with the vascular surgeon at 2:00 PM that day, so she arranged transportation through their alternate transport company and then found out the appointment was for that morning and had already been missed. The Administrator said Resident #1 was a complex resident with many health issues. The Administrator said if Resident #1 had an appointment scheduled with the vascular surgeon, she would have expected the staff to ensure he made it to his appointment as scheduled.<BR/>During a phone interview on 5/13/2023 at 5:47 PM, the SW said Resident #1's family member called her on 5/12/23 at 12:19 PM (per her call log) to remind them of the resident's 2:00 PM appointment with the vascular surgeon. The SW said she checked the VD calendar book, and it was not written on the calendar. The SW said she told the Administrator she did not know how they missed not putting his appointment on the VD calendar book, but Resident #1 had an appointment with the vascular surgeon at 2:00 PM. The SW said the Administrator arranged alternate transportation for him to go at 2:00 PM. The SW said Resident #1's family member called her back at 12:27 PM (per her call log) and said she had called the vascular surgeon's office and the appointment was for 9:30 AM and he had already missed the appointment. The SW said the nurse on duty 5/12/23 called the vascular surgeon's office and rescheduled the appointment for the earliest date of 5/19/23 at 8:00 AM. The SW said she made sure the appointment was put on the VD calendar book and on the 24-hour report.<BR/>Record review of the facility's policy titled, Non-pressure Wounds : Arterial Insufficiency ulcers (Also known as Arterial Ischemic Wounds dated July 2018, revealed . arterial insufficiency ulcers were managed in accordance with professional guidelines . arterial insufficiency may be known as PAD or Peripheral Arterial Disease . common traits of PAD were narrowing and hardening of vessels and reduced blood flow and loss of elasticity and ability to constrict and dilate in response to tissue need for oxygen . more common in people with diabetes . ulceration that occurs as the result of arterial occlusive disease when non-pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis (death) . arterial/ischemic ulcers may be present with moderate to severe peripheral vascular disease . arterial ulcer usually occurred in the distal portion of the lower extremity and may be over the ankle or bony areas of the foot . increased susceptibility to infection on arterial wounds . management of arterial ulcerations were a complicated process . medical involvement and diagnostic procedures such as arterial flow studies, vascular surgeon consultation . were integral parts of management . re-establish vascular channels with by-pass surgery . medications to support blood flow . anticoagulants (blood thinner) . vasodilator (dilates vessels) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good grooming and personal hygiene for a resident who is unable to carry out activities of daily living were provided for 2 of 4 residents reviewed for activities daily living (Resident #2 and Resident #5)<BR/>The facility did not clean or trim the nails of Resident #2 and Resident #5. <BR/>The facility failed to promptly respond to Resident #2 and Resident #5's call lights who were ADL dependent.<BR/>These failures could place dependent residents at risk of poor hygiene, infections, injuries and unmet needs. <BR/>Findings included: <BR/>Record review of Resident #2 's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including respiratory failure, colon cancer, diabetes, and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred). <BR/>Record review of Resident #2's MDS dated [DATE] indicated Resident #2 made himself understood and usually understood others. The MDS indicated Resident #2 had moderately impaired cognitive function (BIMS of 10). The MDS indicated he had no behavior of rejecting care. The MDS indicated he required limited assistance with locomotion in his wheelchair, supervision only with toilet use and eating. The MDS indicated he required extensive assistance with dressing, personal hygiene and bathing. The MDS indicated bed mobility had only occurred once or twice during the 7 days look back period. The MDS indicated transfers and walking had not occurred during the 7 days look back period. <BR/>Record review of Resident #2's care plan dated 12/7/22 indicated his ADL dependency was not specifically addressed. <BR/>During an observation on 2/8/23 at 11:15 a.m. revealed Resident #2 laid in his bed. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/>During an interview and observation on 2/8/23 at 2:44 p.m. revealed Resident #2 sat in his bed. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/> Resident #2 said he had been at the facility approximately 2 months. He said no one had offered to trim and clean his nails since he had been at the facility.<BR/>During an observation and interview on 2/9/23 at 9:05 a.m. revealed Resident #2 sat in his wheelchair. His nails were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under several of the nails. CNA F was making his bed. CNA F said nail care was usually done on shower days by the CNAs. CNA F indicated she had just administered a shower to Resident #2. CNA F said nurses trimmed the nails of diabetic residents. <BR/>During an observation on 2/9/23 at 11:17 a.m. revealed Resident #2 was in therapy sitting in his wheelchair. CNA F stood at his side viewing his nails. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/>During an interview on 2/9/23 at 11:18 a.m., CNA F said she did not know if Resident #2 was a diabetic. CNA F said she cleaned Resident #2's nails in the shower by washing over the top of his hands but indicated she did not clean under his nails. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said she worked the hall on which Resident #2 resided on 2/8/23. RN C said there was no set schedule for diabetic nail care and nurses just performed the care as it needed to be done. RN C said no CNAs had reported to her that any diabetic resident needed nail care yesterday (2/8/23). RN C said Resident #2's nails were very thick and would have to be soaked before they could be cut. RN C said that might be why the nail care had not been performed. RN C said it was important to ensure nail care was completed to prevent infection. <BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she regularly worked the hall that Resident #2 resided on. CNA E said CNAs and nurses were responsible to ensure residents nails were cleaned and trimmed. CNA E said nurses performed nail care for diabetic residents. CNA E said there was no set schedule for CNAs to perform nail care and indicated she performed nail care when she saw it needed to be done. CNA E said if she saw nail care was needed for a diabetic resident, she would notify the nurse. CNA E said she could not remember if she notified RN C that nail care was needed for Resident #2. CNA E said it was important to ensure nail care was completed to maintain resident hygiene.<BR/>2. Record review of Resident #5's consolidated physician orders dated 2/10/23 indicated he was [AGE] years old admitted to facility on 1/16/23 with diagnoses including atherosclerotic heart disease (heart disease caused by the buildup of fats, cholesterol and other substances in and on the artery walls), and rheumatoid arthritis (chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility) and dementia. <BR/>Record review of Resident #5's MDS dated [DATE] indicated Resident #5 usually understood and usually made himself understood. The MDS indicated he had moderately impaired cognitive function (BIMS of 9). The MDS indicated he had no behavior of rejecting care. The MDs indicated transfers had only occurred once or twice during the 7 days look back period. The MDS indicated locomotion in his wheelchair had not occurred during the 7 days look back period. The MDS indicated he required limited assistance with walking in his room and eating. The MDS indicated he required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and bathing. <BR/>Record review of Resident #5's care plan revised on 2/1/23 indicated his ADL dependency was not specifically addressed.<BR/>During an observation and interview on 2/8/23 at 3:45 p.m. revealed Resident #5 laid in his bed. His nails were long (approximately 1/2 centimeter past the end of his fingers). There was a dark brown substance under several (more than 2 nails on each hand but less than 5 nails of each hand) nails to each hand. Resident #5 said he wanted his nails to be cleaned and trimmed. Resident #5 said he did not know when his nails were last cleaned and trimmed. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said she worked the hall on which Resident #5 resided on 2/8/23. RN C said CNAs were responsible to perform nail care for non-diabetic residents. RN C said there was no set schedule for CNAs to perform nail care and indicated CNAs were to perform the nail care as needed. RN C said it was important to ensure nail care was completed to prevent infection.<BR/>During an observation on 2/10/23 at 9:32 a.m. revealed Resident #5 laid in his bed. His nails were long (approximately 1/2 centimeter past the end of his fingers). There was a dark brown substance under several (more than 2 nails on each hand but less than 5 nails of each hand) nails to each hand. <BR/>During an interview on 2/10/23 at 10:28 a.m., CNA G said residents were to have their nails cleaned and trimmed on shower days by CNAs. CNA G said resident nails were to be cleaned and trimmed as needed in between shower days. CNA G said it was important to ensure nail care was done to avoid infection and unintentional injury (scratches and skin tears).<BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she regularly worked the hall that Resident #5 resided on. CNA E said CNAs and nurses were responsible to ensure residents nails were cleaned and trimmed. CNA E said nurses performed nail care for diabetic residents and CNAs performed nail care for non-diabetic residents. CNA E said there was no set schedule for CNAs to perform nail care and indicated she performed nail care when she saw it needed to be done. CNA E said she did not recall performing nail care for Resident #5 but indicated she would have cleaned and trimmed his nails if she noticed they were long and dirty. CNA E said it was important to ensure nail care was completed to maintain resident hygiene. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected CNAs to ensure nail care was completed for non-diabetic residents as it was needed. The DON said she expected nurses to perform nail care for diabetic residents as it was needed. The DON said it was important to ensure nail care was done to prevent unintentional injuries (such as scratches) and prevent infections. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected staff to ensure resident's nails were cleaned and trimmed. <BR/>Record review of the facility policy and procedure titled Bathing revised on 02/12/20 reflected, .Tasks commonly completed during the bathing process .Report abnormal findings to the nurse in charge .needs shall be discussed with the resident and responsible party during care plan meetings with the interdisciplinary team in order to identify and implement proper hygiene habits and promote resident rights and dignity The policy and procedure did not specifically address nail care. A policy and procedure for nail care was requested but not received. <BR/>3. During an observation on 2/8/23 at 2:44 p.m. revealed Resident #5 could be heard across the hall yelling Somebody come help me. <BR/>During an observation on 2/8/23 at 2:47 p.m. revealed Resident #2 pushed his call light in order to obtain assistance to get up.<BR/>During a continuous observation on 2/8/23 from 2:47 p.m. to 3:15 p.m. revealed Resident #5's call light dome remained lit up and the call light alarm was audible until 3:12 p.m. Resident #5 continued to yell intermittently for help from 2:47 p.m. to 3:15 p.m. Resident #2's call light dome remained lit up and the call light alarm was audible until 3:15 p.m. Resident #5's room was directly adjacent to Resident #2's room. <BR/>During an observation on 2/8/23 at 2:51 p.m., revealed Receptionist I walked by both Resident #2 and Resident #5's rooms as Resident #5 yelled out. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:52 p.m. revealed LVN J walked by both Resident #2 and Resident #5's rooms pushing a treatment cart. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:55 p.m. revealed Admissions Director K walked by both Resident #2 and Resident #5's rooms as Resident #5 yelled out Help. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:57 p.m. revealed an unidentified staff member in a khaki-colored polo pushed a red hand truck/ appliance dolly (tool to move heavy items) by both Resident #2 and Resident #5's rooms. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:58 p.m. revealed Housekeeper L stood in the hallway, 2 rooms down from Resident #2 and Resident #5's rooms. Housekeeper L stood in front of his housekeeping cart with his back toward the surveyor. His head was bent down as if he were looking at something in front of him. <BR/>During an observation on 2/8/23 at 3:02 p.m. revealed CNA H walked by both Resident #2 and Resident #5's rooms. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 3:12 p.m. revealed Maintenance Personnel M answered Resident # 5's call light. <BR/>During an observation on 2/8/23 at 3:15 p.m. revealed CNA H answered Resident #2's call light.<BR/>During an interview on 2/8/23 at 3:16 p.m., maintenance personnel M said answering call lights was everyone's (all staff's) responsibility. Maintenance Personnel M said he may not be able to get/do exactly what the resident requested/needed. Maintenance Personnel M said he could ensure there was not an emergency and notify the nurse of the resident request/need. Maintenance Personnel M said Resident #5 said he just wanted to go home. <BR/>During an interview on 2/8/23 at 3:17 p.m., CNA H said anyone could answer a call light. CNA H said even if the staff were not clinical, they can and should respond to a call light. CNA H said non-clinical staff should check on call lights because there could be an emergency, or the resident might have a simple request. CNA H said she did not immediately check on the call lights because she had just came onto her shift. CNA H said she should have checked on the call lights the first time she went by and notified the residents she would be right back. CNA H said Resident #2 needed help to get up. <BR/>During an interview on 2/8/23 at 3:18 p.m., Housekeeper L said he had worked at the facility since November 2022. Housekeeper L said he noticed the call lights going off but had not been given any instructions regarding call lights. Housekeeper L said he was not sure if he was supposed to answer call lights. <BR/>During an interview on 2/8/23 at 3:29 p.m., Admissions Director K said she had worked at the facility for approximately 3 years. Admissions Director K said any staff could check on a call light, but some residents call out or yell out like every 10 minutes. Admissions Director K said even for the residents that frequently call out she would still check on them. Admissions Director K said she was not sure if Resident #2 and Resident #5 were residents that called out frequently. Admissions Director K said staff had to respond to call lights because the resident might actually need help. Admissions Director K said she did see Resident #2 and Resident #5's call lights when she walked by. Admissions Director K said she did hear Resident #5 yell as she walked by his room. When asked why she did not respond to the call lights or Resident #5's yell for help Admissions Director K said I want to say in my heart of hearts it's because I didn't think they needed Admissions Director K stopped mid-sentence and then said but I can't say that. Admissions Director K then said there was no excuse for not having stopped and checked on Resident #2 and Resident #5's call lights. <BR/>During an interview on 2/8/23 at 3:35 p.m., LVN J said she did not remember walking by Resident #2 and Resident #5's rooms with her cart. LVN J said she certainly would have stopped and checked on the call lights had she noticed they were going off. LVN J said we (all staff) were responsible for answering call lights. <BR/>During an interview on 2/9/23 at 10:19 a.m., Receptionist I said she use to be a CNA and had worked at the facility for 2 &frac12; years. Receptionist I said all staff members were responsible for answering call lights. Receptionist I said it was important to respond to call lights because it could be an emergency. Receptionist I said if the request were something simple, non-clinical staff can assist them or notify the nurse. Receptionist I said she did not remember walking past Resident #2 and Resident #5's call lights yesterday (2/8/23). Receptionist I said she did not remember Resident #5 yelling out for help. Receptionist I said she would have answered the call lights had she noticed them going off. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said all staff clinical or not, were responsible for responding to resident call lights. The DON indicated it was unacceptable that call lights remained unanswered for over 20 minutes while multiple staff members walked by. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected all staff to respond to resident call lights in order to ensure resident needs were met. <BR/>Record review of the facility policy and procedure titled, Call Lights-Answering, revised on 02/12/20 reflected, Standard of Practice: The staff will provide an environment that helps meet the resident's needs by answering call lights appropriately. Procedures: (1) Respond to patients/resident's call lights and emergency lights in a timely manner . (5) If unable to complete the request, do not turn off the call light; the call light will remain on until the service is completed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 3 of 22 residents (Resident #6, Resident #7 and Resident #4) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #6 and Resident #7's oxygen tubing and humidifier bottles were dated per the facility's policy.<BR/>The facility failed to change Resident #6's oxygen tubing and humidifier bottle every Wednesday per the physician's orders. <BR/>The facility failed to change Resident #6 and Resident #7's nebulizer mask and tubing per the facility's policy.<BR/>The facility failed to ensure Resident #6 and Resident #7's nebulizer, mask and tubing were dated per the facility's policy.<BR/>The facility did not ensure Resident #4's suction canister was emptied when it was &frac34; full.<BR/>The facility failed to ensure Resident #4's suction device, tubing, and suction canister were not dated.<BR/>These failures could place residents at risk for of respiratory infections.<BR/>Findings included:<BR/>1.Record review of Resident #6's face sheet dated 2/8/23 revealed Resident #6 was an [AGE] year-old female, and was admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease- constriction of the airways and difficulty breathing), atrial fibrillation (irregular and often rapid heart rate that causes poor blood flow), orthostatic hypotension (type of low blood pressure that occurs when standing up from sitting of lying down), and pain. <BR/>Record review of Resident #6's quarterly MDS dated [DATE] revealed Resident #6 had a BIMS of 12, which indicated she was cognitively intact. Resident #6 required limited to extensive assistance of 1 person for most ADL's. Resident #6 required oxygen therapy.<BR/>Record review of the Resident #6's order summary report dated 2/08/23 revealed an order for oxygen at 2 LPM by a nasal cannula; albuterol sulfate 0.63 mg (milligrams) in 3 mL (milliliters) of solution for nebulization inhalation every four hours as needed for shortness of breath; and ipratropium 0.5 mg with 3 mg in 3 mL of solution for nebulization inhalation every six hours. Resident #6's orders revealed an order for oxygen canister/tubing change every Wednesday evening and date humidifier water and oxygen tubing weekly on Wednesday.<BR/>Record review of Resident #6's eTAR dated 2/08/23 revealed the oxygen/tubing change every Wednesday evening and change & date humidifier water and oxygen tubing weekly on Wednesday was not documented as completed on Wednesday 2/01/23. There was not a task on the eTAR related to changing Resident #6's nebulizer tubing or nebulizer mask.<BR/>Record review of Resident #6's nurses' notes with date range of 10/08/22-2/08/23 revealed there was no documentation the nurses changed Resident #6's oxygen tubing on 2/01/23 or her nebulizer tubing, or nebulizer mask every 48 hours per the facility's policy.<BR/>During an observation and interview on 2/08/23 at 2:00 PM with Resident #6 revealed she had a nebulizer machine (changes liquid medication to a mist) with nebulizer tubing and a mask attached and the tubing nor the mask were dated. The nebulizer with tubing and mask was stored in a bag that reflected the bag was issued 6/22/22. The resident said she received breathing treatments with the nebulizer machine and mask every six hours. Resident #6 was wearing her oxygen at the time of the observation. The oxygen tubing nor the humidifier bottle were dated. Resident #6 said when she left the room in her wheelchair, she had oxygen bottles and she stored her oxygen tubing and cannula in the bag hanging on the oxygen concentrator at her bedside. The bag did not have a date. Resident #6 said she thought the nurses changed her oxygen tubing and nebulizer mask and tubing every month. She did not know when her oxygen tubing and nebulizer mask and tubing were changed last.<BR/>2. Record review of Resident #7's face sheet dated 2/8/23 revealed Resident #7 was a [AGE] year-old female, and was admitted to the facility on [DATE] with diagnoses of heart failure, atrial fibrillation, cerebral atherosclerosis (arteries in the brain become hard, thick, and narrow due to the buildup of plaque or fatty deposits inside the artery walls, which decreases the blow to areas of the brain), kidney failure (kidneys lose the ability to remove waste and balance fluids in the body), spondylosis (age-related wear and tear of the spinal disks), and pain. <BR/>Record review of Resident #7's annual MDS dated [DATE] revealed Resident #7 had a BIMS of 9, which indicated she was moderately cognitively impaired. Resident #7 required supervision to limited assistance of 1 person for most ADL's. Resident #7 required oxygen therapy.<BR/>Record review of Resident #7's order summary report dated 2/08/23 revealed an order for oxygen at 2 LPM by a nasal cannula and ipratropium 0.5 mg with 3 mg in 3 mL of solution for nebulization inhalation three times daily. Resident #7's orders revealed an order to change and date the nebulizer mask/mouthpiece & tubing weekly on Wednesday's night shift. There was not an order related to changing the oxygen tubing.<BR/>Record review of Resident #7's eTAR dated 2/08/23 revealed the change of the nebulizer mask/mouthpiece, & tubing was not documented as completed on Wednesday 2/01/23.<BR/>During an observation and interview on 2/08/23 at 11:49 AM, revealed Resident #7 had oxygen tubing with a nasal cannula attached to a humidifier bottle and they were not dated. The nasal cannula was stored in a bag hanging on the oxygen concentrator and the bag reflected it was issued 6/22/22. Resident #7 said she used her oxygen at night and sometimes during the day when she was short of breath. Resident #7's nebulizer and mask were in a bag, but they were not dated. Resident #7 said she could not remember when her oxygen tubing or nebulizer tubing and mask had last been changed. <BR/>During an interview on 2/08/23 at 3:55 PM with the DON, she said it was a constant struggle trying to get the night shift to do what they were supposed to do. She said she had gone down and visited with Resident #6 and Resident #7 after she knew the surveyor had visited with them and she saw for herself that the oxygen tubing/humidifier bottles and nebulizer/mask were not dated. She said if the tubing/humidifier bottles and nebulizer/masks were not dated, along with no documentation of when they were changed, then they would not be able to determine how long the resident had had the equipment and it could lead to the residents developing respiratory infections. The DON said she was ultimately responsible to ensure the night shift was changing and dating the respiratory equipment per the physician's orders and the facility's policies.<BR/>During an interview on 2/08/23 at 4:13 PM with RN A, she said the night shift nurses were responsible for changing the oxygen tubing and nebulizers/masks on Wednesday nights. She said the oxygen tubing and nebulizer masks should be dated when changed and documented in the resident's chart. She said if the oxygen tubing and nebulizers/masks were not changed regularly they would become nasty and dirty and could cause the resident to develop a respiratory infection. She said she did not specifically check the respiratory equipment (oxygen tubing, nebulizer tubing & masks/mouthpieces) for dates, because night shift was responsible for changing and dating the equipment. She said she would change any respiratory equipment herself and date the equipment if she noticed anything did not look sanitary. <BR/>During an interview on 2/08/23 at 4:25 PM with the Administrator, who was also one of the Infection Preventionists, revealed she expected the oxygen tubing/humidifier bottles and nebulizer/masks to be labeled/dated and it should be documented in the eTAR per the physician's orders. She said she the oxygen tubing/humidifier bottles and nebulizer/masks should be changed per the facility's policies.<BR/>3. Record review of Resident #4's consolidated physician orders dated 2/10/23 indicated he was [AGE] years old and readmitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), colostomy (surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) status, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) status, dysphagia (difficulty swallowing), and shortness of breath. <BR/>Record review of Resident #4's MDS dated [DATE], indicated Resident #4 sometimes made himself understood and usually understood others. The MDS indicated Resident #4 had short-term and long-term memory problems. The MDS indicated Resident #4 had moderately impaired cognitive decision-making skills. The MDS indicated Resident had no behavior of rejecting care. <BR/>Record review of Resident #4's care plan revised on 1/20/23 indicated Resident #4 had increased secretions and an increased risk of aspiration. The care plan interventions included assess for the presence of dyspnea (difficult or labored breathing) and suction as needed. <BR/>During an observation on 2/8/23 at 11:00 a.m. revealed Resident #4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an observation on 2/8/23 at 1:00 p.m. revealed Resident # 4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an observation on 2/8/23 at 3:00 p.m. revealed Resident #4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an interview on 2/9/23 at 9:30 a.m., LVN B said she took care of Resident #4 regularly on the 6:00 a.m. to 6:00 p.m. shift. LVN B said she changed the suction canister and tubing yesterday (2/8/23) evening at approximately 5:00 p.m. when Resident #4's family member pointed out the suction canister was full. LVN B said she had not noticed that the canister was full yesterday during the morning or afternoon. LVN B said it was ultimately the nurse's responsibility but would expect CNAs to notify her if they (CNAs) noted the canister was full. LVN B said the canister and tubing should be dated and initialed. LVN B said the suction canister and tubing should be changed at least every week and as needed. LVN B clarified if the suction device was dropped on the floor the tubing and suction device would be changed. LVN B further clarified if the suction canister was &frac12; way full the canister should be changed. LVN B said the suction equipment will not suction properly if the canister is full. LVN B said she did not suction Resident #4 yesterday prior to 5:00 p.m. LVN B said if he (Resident #4) had needed to be suctioned, and the canister was full, she would have had to retrieve a suction canister before he could have been suctioned. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said suction tubing and suction canisters should be dated to ensure they (suction tubing and suction canisters) are changed weekly. RN C said suction canisters should be emptied before they are full because when full they will not work properly. RN C said a full suction canister could delay a resident receiving suction for a minute or two while staff retrieved another canister. <BR/>During an interview on 2/9/23 at 11:45 a.m., CNA D said she took care of Resident #4 regularly on the day shift. CNA D said nurses handled anything related to suction equipment. CNA D said she did not report the canister was full to the nurse on 2/8/23 because she did not notice it was full. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected staff to ensure suction equipment was dated and suction canisters were changed when the canister was &frac34; full. The DON said she expected nurses to check the level of the canister at least once a shift and when they were in the room providing other care tasks to ensure the canister would be ready for use if suction was needed with no delay in care. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected nurses to follow policy and procedure regarding suction equipment. <BR/>Record review of the facility policy and procedure titled, Respiratory Equipment Change Schedule, reviewed by facility administration on 01/12/22 reflected, Standard of Practice: The community will provide a schedule for changing disposable equipment at regular intervals as determined by manufacturer recommendations and local community standards. Procedures: . provide a schedule for changing disposable equipment at regular intervals as determined by manufacturer recommendations and local community standards . aerosol tubing and aerosol nebulizer to be changed every forty-eight hours . small volume medication nebulizers, place in clean paper bag, labeled with resident's name and leave a resident's bedside . (8) Suction Canister: .(b) Change or empty canister or collection when &frac34; full. (9) Suction tubing .(b) Change or empty canister or collection when &frac34; full .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the residents and/or representatives had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for three (Resident #19, #47, #74) of five residents reviewed for care planning. <BR/>The facility failed to ensure the IDT, Resident #19, Resident #47 and Resident #74, and the POA/RP of Resident #19, Resident #47, and Resident #74 were involved in the review of the comprehensive assessment and were able to discuss their individualized care needs for services to include their need for medical and nursing care, medications, therapy, psychological and dietary needs. <BR/>The failure could affect residents by placing them at risk for not receiving adequate or individualized care. <BR/>Findings included:<BR/>1. <BR/>Record review of Resident 29's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), glaucoma (a group of eye conditions that damage the optic nerve, the health of which is vital for good vision), and hypertension (blood pressure that is higher than normal).<BR/>Record review of Resident #19's quarterly MDS, dated [DATE], reflected she had a BIMS score of 11, which indicated a minimal impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. <BR/>Review of Resident #19's face sheet reflected she had a resident representative who was also listed as her primary contact.<BR/>An interview with Resident #19 on 09/13/2022 at 11:15 am revealed she had not been to her own care plan meeting in six months or greater. Resident #19 stated it was important to her to be a part of her plan of care and she did not want strangers to decide her care. Resident #19 stated that she used to get a letter from the social worker that said when the care plan meetings would be held but she had not gotten one in more than 6 months.<BR/>An interview with Resident #19's primary contact on 09/13/2022 at 12:50 PM revealed she had not known of a care plan meeting but once this year.<BR/>2. <BR/>Record review of Resident 47's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: cerebral infarction ((also known as a stroke) refers to damage to tissues in the brain due to a loss of oxygen to the area), diabetes mellitus (is an impairment in the way the body regulates and uses sugar (glucose) as a fuel), and hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone).<BR/>Record review of Resident # 47's quarterly MDS, dated [DATE], reflected he had a BIMS score of 12, which indicated a minimal impaired cognitive status. His functional status reflected he required extensive assistance with bed mobility, toilet use and personal hygiene. He required set up only for eating.<BR/>Record review of last recorded care plan meeting was dated 11/27/2021. The care plan meeting was recorded as a discharge care plan meeting with the goal of returning home with home health services. The attendees were recorded as the resident representative and the social worker.<BR/>An interview with Resident #47 on 09/12/2022 at 2:12 pm revealed Resident #47 had not had a care plan meeting in over a year. Resident #47 stated he had a family member that would attend if they were invited. Resident #47 wanted to have a care plan meeting to discuss his need for therapy services related to his loss of ROM to his right side. Resident #47 stated he had mentioned his need for therapy to the CNA's and nurses that came to care for him but no one from therapy came to check on him.<BR/>3. <BR/>Record review of Resident 74's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: fracture of left femur (a break in the thighbone), seizures (a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements, or feelings, and in levels of consciousness), Chronic Obstructive Pulmonary Disease (a group of diseases that cause airflow blockage and breathing-related problems).<BR/>Record review of Resident # 74's admission MDS, dated [DATE], reflected she had a BIMS score of 14,which indicated no impaired cognitive status. Her functional status reflected she required limited assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. <BR/>Review of Resident #74's face sheet reflected she had a resident representative who was also listed as her primary contact.<BR/>An interview with Resident #74 on 09/13/2022 at 11:30 am revealed she had not been to her own care plan meeting. Resident #74 stated it was important to her to be a part of her plan of care and she had a lot of questions and things she wished to discuss with the directors of different departments. <BR/>An interview with Resident #74's primary contact on 09/13/2022 at 12:45 PM revealed she had not been informed of a care plan meeting being held for Resident #47.<BR/>Record review of Resident #74's EHR revealed no care plan letter invitations. <BR/>An interview with the SW on 09/14/2022 at 4:15pm revealed she was the one in charge of coordinating the care plan meetings. She stated care plan meetings for skilled resident's occurred on Tuesday and non-skilled residents occurred on Thursday each week. The SW stated she sent out a care plan letter to inform the primary contacts of the care plan meetings and gave a copy to the residents to invite them. Then she scanned the letter into the EHR. The SW stated that she recorded each meeting in the care plan section of the EHR. The SW stated that each care plan meeting the SW, dietary manager, activities, rehab coordinator, resident and resident representative were invited. The SW stated the care plan meetings were held quarterly and as needed. The SW did not know specifically why Resident #19, Resident #47 and Resident #74 did not have recorded care plan meetings. The SW stated not having a care plan meeting with the family and resident present could make the resident feel like they are not part of important decisions about their care and life.<BR/>An interview with the DON on 09/14/2022 at 3:30 pm revealed the care plan meetings were important to be held quarterly and as needed so they family and resident could be a part of their plan of care. The DON stated it was the MDS nurse that gave the schedule of who was due for a care plan meeting and the SW was to schedule and hold the care plan meetings. The DON stated she was unaware that this was not happening quarterly and as needed. The DON stated it was the responsibility of the Social Worker and MDS nurse to ensure the care plan meetings were happening and everyone attended.<BR/>An interview with the Administrator on 09/15/2022 at 3:30 pm revealed the care plan meetings were to be attended by all members of the IDT team and were to be done quarterly and as needed. The Administrator stated the SW was responsible for coordinating the care plan meetings and it had not been brought to her attention that care plan meetings were being missed. The Administrator stated it was important for the residents and family to have a say it the resident's care. The Administrator stated if the residents and family did not get as say in the care of the resident, they could feel their autonomy was not being honored.<BR/>Review of an undated policy titled Care Planning/Interdisciplinary Team on 09/15/2022 at 4:15 pm revealed, The care planning team shall be composed of but not necessarily limited to the following personnel: a. RN assessment coordinator, b. Director of nursing, c. Medical director, d. attending physician, e. Therapist, f. Activity director, g. Social service director, h. Dietician/food service manager, i. Pharmacist, j. other individuals as the resident's need dictates and meet quarterly.the secretary to the team shall be responsible for notifying team members when a meeting is scheduled, providing reports, ect., to be reviewed, and maintaining written reports of all meetings.

**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 11 of 22 residents (Residents #19, #60, #33, #61, #93, #97, #54, #8, #70, #23, and #76) reviewed for reasonable accommodations.<BR/>-The facility failed to ensure Residents #19, #60, #33, #61, #93, #97, #70, and #54 call lights were accessible. <BR/>-The facility failed to replace Resident #93's toilet with a taller, more accessible toilet.<BR/>- The facility failed to respond to Resident #8, Resident #70, Resident #23, and Resident #76 in a timely manner.<BR/>This failure could place residents at risk of injuries, health complications and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of Resident 19's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), glaucoma (a group of eye conditions that damage the optic nerve, the health of which is vital for good vision), and hypertension (blood pressure that is higher than normal).<BR/>Record review of Resident #19's quarterly MDS, dated [DATE], reflected she had a BIMS score of 11, which indicated a minimal impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. <BR/>Record review of Resident #19's care plan dated 06/24/2022 titled self-care deficit revealed Resident #19 required extensive assistance with bed mobility, transfer, ambulation, and toileting. <BR/>During an observation on 09/12/2022 at 10:02 am Resident #19 was looking for her call light and could not find her call light. The call light was noted to be on the floor underneath the bed.<BR/>During an observation and interview on 09/13/2022 at 11:18am Resident #19 was looking for her call light and could not find her call light. The call light was on the floor bedside the bed. Resident #19 was unable to reach the call light. Resident #19 stated she had no way of getting help if she could not use her call light. She stated her call light was not within reach at least once daily. She stated no one can hear you if you scream and she was not able to get out of bed to look for the call light on her own.<BR/>2. Record review of Resident 60's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: dementia (A group of thinking and social symptoms that interferes with daily functioning.), anemia (a condition in which the number of red blood cells is below normal), and major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).<BR/>Record review of Resident # 60's MDS, dated [DATE], reflected he had a BIMS score of 05, which indicated moderately impaired cognitive status. His functional status reflected he required extensive assistance with bed mobility, toilet use and personal hygiene. She required supervision only for eating. <BR/>Record review of Resident #60's care plan dated 07/06/2022, reflected Resident #60 required extensive assistance with bed mobility, transfer, toileting, and personal hygiene. The fall care plan dated 07/06/2022 reflected Resident #60 was a fall risk with multiple falls and call light was to be in reach at all times.<BR/>During an observation and interview on 09/12/2022 at 9:45 am, Resident #60 was lying in bed and stated he could not find his call light. The call light for Resident #60 was noted on the floor beside the bed. Resident #60 stated he had fallen the previous night because he was unable to reach his call light and get help out of the bed.<BR/>During an observation and interview on 09/13/2022 at 4:40 pm, Resident #60 was sitting up on the side of his bed attempting to get out of bed. Resident #60 stated he had to get to the organ to play music. Resident #60's call light was on the floor behind the headboard.<BR/>3. Record review of the face sheet dated 9/14/2022 indicated Resident #33 was [AGE] years old and was admitted on [DATE] with diagnoses including liver cell carcinoma (liver cancer), stroke, and heart disease. <BR/>Record review of a care plan dated 9/3/2022 indicated Resident #33 had a history of anxiety and was prescribed an anti-anxiety medication. Resident #33 had impaired physical mobility and required assistance with self-care. <BR/>Record review of the MDS dated [DATE] indicated Resident #33 was understood and usually understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 8 which indicated Resident #33 was moderately cognitively impaired. Resident #31 required extensive to total assistance from staff with ADLs. <BR/>During an observation on 9/12/2022 at 11:00 a.m., revealed Resident #33 in her bed. The cord to her call light was draped over the rail and the call light was near the floor. The call light was out of reach of the resident. <BR/>During an observation on 09/14/22 at 8:32 a.m., revealed Resident #33 was in her bed. Her call light was on the floor on the right side of bed, out of reach of the resident.<BR/>4. Record review of a face sheet dated 9/14/2022 revealed Resident #61 was [AGE] years old and was initially admitted on [DATE] with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone, or posture), paranoid schizophrenia (a mental disorder characterized by continuous or relapsing episode of psychosis), and moderate intellectual disabilities. <BR/>Record review of a care plan dated 7/19/2022 indicated Resident #61 had a history of cerebral palsy and required extensive assistance with bed mobility and transfers. The care plan indicated Resident #61 was immobile.<BR/>Record review of the most recent MDS dated [DATE] indicated Resident #61 was sometimes understood and sometimes understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) of 8. This score indicated moderate cognitive impairment for Resident #61. The MDS also indicated Resident #61 required limited to extensive assistance from staff for ADLs. <BR/>During an observation on 9/12/22 at 10:21 a.m., Resident #61 was in bed and her call light was on the floor on the right side of her bed and was under a trash can. The call light was out of reach of Resident #61.<BR/>During an observation on 9/12/22 at 12:08 p.m., Resident #61 was in bed and her call light was on the floor on the right side of her bed and was under a trash can. The call light was out of reach of Resident #61.<BR/>During an observation on 9/12/22 at 2:38 p.m., incontinent care was provided for Resident #61. Resident #61's call light was on floor on the right side of her bed and was under the trash can at bedside. The call light was out of Resident #61's reach. <BR/>During an observation on 9/13/22 at 8:55 a.m., Resident #61 was asleep in bed. The resident's call light was on the floor on the right side of her bed and was under the trash can. <BR/>During an interview on 9/15/22 at 10:10 a.m., LVN E said she did see call lights off to the side and out of reach of residents. She said the morning of 9/15/2022, Resident #61's call light was on her bedside table. She said it would probably be better with a clip on the cord. She said if a resident cannot reach their call light, they would not be able to call for help .<BR/>5. Record review of a face sheet dated 9/14/2022 indicated Resident #93 was [AGE] years old and was initially admitted on [DATE] with diagnoses of presence of right artificial shoulder joint, diabetes, and abnormality gait and mobility. <BR/>Record review of consolidated physician orders dated 9/14/2022 for Resident #93 indicated an order dated 8/22/2022 for a sling ever am shift, monitor sling to right arm QD (every day). <BR/>Record review of a care plan with dated 6/16/2022 indicated Resident #93 had decrease ROM (range of motion) to right shoulder, right elbow, and right wrist. <BR/>Record review of the MDS dated [DATE] indicated Resident #93 was understood and understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 13 indicating Resident #93 was cognitively intact. The MDS indicated Resident #93 required supervision only during toilet use. The MDS indicated Resident #93 had mood disorders of anxiety and depression. <BR/>During an observation and interview on 9/12/2022 at 3:17 p.m., Resident #93 said his toilet is too low and he has trouble getting off the toilet and back into his wheelchair. The resident had amputations to both lower extremities. There was a motorized wheelchair at bedside. The resident said he can transfer himself. The bathroom was observed. The toilet did appear low and other than a bar on the far wall there was not adaptive equipment. <BR/>During an interview on 9/14/2022 at 11:01 a.m., Resident #93 said he had resided in his current room since February 2022. He said he had complained to Maintenance Supervisor several times about his toilet being too low. He said he remembers reporting this to the Maintenance Supervisor in February 2022. He said at one point they did bring him an over the commode seat, but it did not help him. He said he complained to the administrator at least twice. He said on 9/13/2022 the administrator told him that she thought the toilet had already been replaced. He said since February he has had trouble getting on and off the toilet from his electric wheelchair. He said it had been worse the last 3 weeks because his right arm had been in a sling.<BR/>During an observation and interview on 9/14/2022 at 11:22 a.m., Maintenance Supervisor said the procedure for maintenance issues was for staff to fill out a work order and place it in his box. He said Resident #93 had complained to him weeks ago about his toilet being too low for him. He said he could not remember exactly how long it had been. He said the issue was never reported to him in writing and he said he had carried him a taller over the commode toilet seat, but he could not use it because it kept moving on him. He said there was a delay in getting the toilet replaced because the taller toilet was on backorder. He said he had a new toilet in the back of his truck. He said he went to a hardware store on 9/13/2022 and bought a new taller toilet. The Maintenance Supervision measured the lower toilet in Resident #93 bathroom. The toilet measured 15 inches from the floor to the toilet seat. The Maintenance Supervisor measured Resident #93's electric wheelchair. The wheelchair measured 25 inches from the floor to the top of seat. <BR/>During an interview on 09/14/2022 at 3:23 p.m., CNA C said it had been at least 6 months since she had provided care to Resident #93. She said at that time he reported to her that his toilet was too low. She said he had told her he might need help because it was too low. She said she reported the issue to the nurses and to the Maintenance Supervisor at that time.<BR/>6. Record review of a face sheet dated 9/14/2022 revealed Resident #97 was [AGE] years old and was initially admitted on [DATE] with diagnoses including urinary tract infection, pressure ulcer, and chronic pain syndrome. <BR/>Record review of a care plan dated 9/12/2022 indicated Resident #97 had impaired physical mobility and required assistance from staff. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #97 was usually understood and understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) of 9 which indicated Resident #97 was moderately cognitively impaired. The MDS indicated Resident #97 required extensive assistance with ADLs.<BR/>During an interview on 9/14/2022 at 11:45 a.m., Resident #97 said her mattress was changed on 9/13/2022. While her mattress was being changed, her call light was draped over the end table beside her bed. She said afterwards she was uncomfortable in the bed but could not use the call light to call for help. She said she had to yell out for help until someone came to her room to help her reposition in the bed. <BR/>During an interview on 9/14/2022 at 3:34 p.m., CNA D said every shift she comes in for her shift, call lights are in the floor and out of reach of resident. She said call lights should be in reach of each resident. <BR/>7. Record review of the face sheet dated 09/14/22 revealed Resident #54 was [AGE] years old, female, and admitted on [DATE] with diagnosis including cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and heart failure (heart doesn't pump enough blood for your body's needs). <BR/>Record review of the MDS dated [DATE] revealed Resident #54 was usually understood and usually understood others. The MDS revealed Resident #54 had clear speech and impaired vision with corrective lenses. The MDS revealed Resident #54 had a BIMS of 08 which indicated mild cognitive impairment and required total dependence for all ADLs except eating. <BR/>Record review of the care plan dated 08/17/22 revealed Resident #54 was a fall risk related to history of heart failure and peripheral vascular disease and high fall risk as evidence by right and left lower extremity weakness and cognitive status: mildly/moderately impaired. Interventions include keep call light and most frequently used personal items within reach. <BR/>During an interview and observation on 09/12/22 at 2:59 p.m., Resident #54 was lying in bed visibly upset and crying. She said she had been needing help, but no one came. She said it happens all the time. She said she could not find her call light. The call light was at the head of the bed out of reach.<BR/>8.Record review of the face sheet dated 09/14/22 revealed Resident # 8 was [AGE] years old, female and admitted on [DATE] with diagnosis including cerebral ischemia (acute brain injury that results from impaired blood flow to the brain), unsteadiness on feet, abnormal posture, lack of coordination, muscle weakness, and muscle wasting and atrophy(shortening). <BR/>Record review of the MDS dated [DATE] revealed Resident #8 was understood and usually understood others. The MDS revealed Resident #8 had clear speech and highly impaired vision with corrective lenses. The MDS revealed Resident #8 had a BIMS score of 12 which indicated mild cognitive impairment and required limited assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing.<BR/>Record review of the care plan dated 05/26/22 revealed Resident #8 was a fall risk related to history of stroke, heart failure, hypertension, and high fall risk assessment as evidence by joint mobility interferes with balance, generalized weakness, and extensive assist for transfer. Interventions included assist resident with ADLs as needed and keep call light and most frequently used items within reach. <BR/>During an observation on 09/12/22 at 9:42 a.m., Resident #8 was hollering out and mumbling to herself. Resident #8 was standing up in front of her recliner with her brief off. Resident #8 told a CNA, I tried to wait for help, but no one came.<BR/>During an interview on 09/12/22 at 10:47 a.m., Resident #8 said staff take a long time to answer the call and did not think she needed assistance with being changed. She said sometimes she must take matters in her own hands and change herself, like this morning. <BR/>During an observation on 09/13/22 at 11:40 a.m., Resident #8 call light was going off. CNA V answered the call light at 12:14 p.m. Resident #8 told CNA V she needed to be changed.<BR/>9. Record review of the face sheet dated 09/14/22 revealed Resident #70 was [AGE] years old female and admitted on [DATE] with diagnoses including acquired absence of right leg above the knee, age related debility (physical weakness), and cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). <BR/>Record review of the MDS dated [DATE] revealed Resident #70 was understood and understood others. The MDS revealed Resident had clear speech and adequate vision with corrective lenses. The MDS revealed Resident #70 had a BIMS of 14 which indicated intact cognition and required extensive assistance for toilet use and total dependence for transfers, dressing, personal hygiene, and bathing. <BR/>Record review of the care plan dated 08/04/22 revealed Resident #70 was a fall risk related to high fall risk assessment as evidence by amputation, joint mobility interferes with balance, and cognitive status. Interventions included keep call light and most frequently used personal items within reach. <BR/>During an interview on 09/12/22 at 3:27 p.m., Resident #70 said there was a delay in the call light response time, from 30 to 45 minutes. <BR/>During an interview on 09/13/22 at 9:25 a.m., Resident #70 said she could not find her call light in the middle of the morning. She said she needed to call the nurse for some pain medication because she was in pain. Resident #70 said when she could not find her call light in the middle of the morning, it was attached to her body pillow that fell on the floor. She said someone came in and picked up the pillow but not her call light.<BR/>During an interview and observation on 09/13/22 at 4:24 p.m., Resident #70's call light was on the floor, and she said she needed to be changed. <BR/>10. Record review of the face sheet dated 09/15/22 revealed Resident # 23 was [AGE] years old, male, and admitted on [DATE] with diagnosis including transient ischemic attack (is a stroke that lasts only a few minutes) and cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). <BR/>Record review of the MDS dated [DATE] revealed Resident #23 was understood and understood others. The MDS revealed Resident #23 had a BIMS score of 12 which indicated mild cognitive impairment and required limited assistance with transfers and dressing but extensive assistance with toilet use and bathing. <BR/>Record review of the care plan dated 06/29/22 revealed Resident #23 was a fall risk related to fall evidence by generalized weakness and cognitive status: mildly/moderately impaired. Interventions included keep call light and most frequently used personal items within reach. <BR/>During an interview on 09/12/22 at 11:38 a.m., Resident #23 said staff did not answer the call light timely. He said sometimes it takes them 1-2 hours for staff to answer the light. He said it happened on all the shifts.<BR/>11. Record review of the face sheet dated 09/14/22 revealed Resident #76 was [AGE] years old, male, and admitted on [DATE] with diagnoses including cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), heart failure (heart doesn't pump enough blood for your body's needs), and obesity. <BR/>Record review of the MDS dated [DATE] revealed Resident #76 was understood and understood others. The MDS revealed Resident #76 had clear speech, moderate difficulty hearing, and impaired vision with corrective lenses. The MDS revealed Resident #76 had a BIMS score of 09 which indicated mild cognitive impairment and required extensive assistance for bed mobility, dressing, personal hygiene and total dependence for transfers, toilet use and bathing. <BR/>Record review of the care plan dated 05/04/22 had fall risk related to fall, history of heart failure, and high fall risk assessment as evidence by generalized weakness and cognitive status. Interventions included keep call light and most frequently used personal items within reach.<BR/>During an interview on 09/12/22 at 11:24 a.m., Resident #76 said the CNAs take forever to answer the call light.<BR/>During an interview on 09/14/22 at 1:27 p.m., CNA V said she had worked at the facility 2 years ago and returned 2 days ago. She said call lights should be answered within 2 minutes. She said 2 CNAs are normally on the halls. She said no residents had complained to her about call light response time. She said the day Resident #8's call light was unanswered for an extended period was because she and the other CNA were off the floor. She said they both were in the dining room helping with lunch. She said both CNAs are not both supposed to leave the floor and she did not inform the ADON. She said call lights being within reach and answered timely prevented falls and accidents for continent residents. She said resident probably felt frustrated when the call lights were not answered or could not find it to get help. <BR/>During an interview on 09/14/22 at 2:52 p.m., LVN W said she had previously worked at the facility 5 years ago and returned last week. She said call lights should be answered asap because you do not know if the issues were minor or major. She said any staff member can answer call lights and ensure they are within reach. She said call lights are mostly answered timely. She said properly placed call light and timely response could prevent falls and the resident could be calling about chest pain, shortness of breath, or incontinent care. <BR/>During an interview on 09/14/22 at 3:25 p.m., CNA X said she was the CNA coordinator but had been working the floor. She said call lights should be answered asap and the facility trained CNAs to follow the same guidelines. She said call lights should be hooked out something within reach and eyesight. She said she had not heard any residents complain but she did not work the 100-hall often. She said proper placed call light and timely response could prevent falls and residents could be calling for help because they were having a stroke or heart attacked. She said call lights not being answered timely and within reach could make the resident feel neglected. She said it was the CNAs responsibility for timely call lights response and placing them within reach. <BR/>During an interview on 09/15/22 at 11:07 a.m., CNA Y said she had worked at the facility since August 2019. She said she worked 2pm-10pm shift and worked the 100-hall frequently. She said call lights should be answered within 2-3 minutes and attached to the bed remote control or bed sheets. She said call lights were important because it was the resident's line of communication and could prevent falls. She said it was the CNAs responsibility for timely call lights response and placing them within reach.<BR/>During an interview on 9/14/22 at 4:59 p.m., the DON said she expected the nurses and CNAs to put the call lights within reach of the residents even if they could not use it. The DON said call lights being in reach was important for the resident to be able to have access to call out for assistance and comforting in knowing the call light was there to call out for help. The DON said not having call lights in reach could result in a fall and a need unnoticed until a routine check. She said it was her responsibility to ensure all direct care staff placed the call lights within reach of each resident. The DON said daily routine rounds were made by the ADON to ensure call lights were in reach. The DON said it was her understanding that rounds were made, and call lights were in reach. <BR/>A policy dated 02/12/2022 titled Call Light Answering revealed: Standards of Practice: The staff will provide an environment that helps meet the residents needs by answering call lights appropriately. Respond to patients/resident's call lights and emergency lights in a timely manner .when leaving room, be sure the call light is placed within the resident's reach.

Based on interview, and record review, the facility failed to promptly resolve grievances and failed to demonstrate their response and rationale for the response, for 7 of 7 residents in a group meeting (Anonymous Resident (AR) 1 Anonymous Resident (AR) 7) reviewed for grievances. <BR/>The facility failed to ensure AR1-AR7's grievances of staff not filling out meal ticket prior to meals and not answering call lights timely were promptly resolved as evidenced by not following up to ensure the issue was resolved.<BR/>This deficient practice could place the residents at risk for decreased quality of life and feelings of neglect.<BR/>Findings included: <BR/>Record review of the Resident Council Minutes dated 1/31/22 revealed all department heads requested to be present for meeting .dietary concern .condiments tray .environmental services .missing clothing and socks .2/7/22 .resident council response sheet completed by dietary manager .staff provide tray condiments per resident diet order .however due to residents taking them back to their room supply is limited .packets of salt and pepper are being substituted .resident council response sheet completed by environmental director .clothing out in laundry .will be returned .labeling machine has been purchased . <BR/>Record review of the Resident Council Minutes dated 2/28/22 revealed .old business reviewed .resident voiced concern of tv's not working .administration: direct tv was scheduled and reset service .it is currently working .nursing: meals tickets are not being filled out .staff have been in-serviced and it is better .please discuss to ensure compliance is present .<BR/>Record review of the Resident Council Minutes dated 3/28/22 revealed .old business .meal tickets are ongoing concern . No attached resident council response sheet to demonstrate response. <BR/>Record review of the Resident Council Minutes dated 5/31/22 revealed .old business .resident stated that response to call light continue to improve . No attached resident council response sheet to explain what was implemented to address this concern. <BR/>Record review of the Resident Council Minutes dated 6/27/22 revealed .old business .concern resolved .some residents voiced concern of their meal tickets not being filled out by CNAs . Blank resident council response sheet attached to minutes. No response to explain what and how the concern was resolved. <BR/>Record review of the Resident Council Minutes dated 7/25/22 revealed .old business .ongoing concern related to meal ticket are not always filled out prior to meal service . Blank resident council response sheet attached to minutes. No response to explain what and how the concern was resolved.<BR/>Record review of the Resident Council Minutes dated 8/29/22 revealed .old business .filling out meal menu continue to be a concern . Blank resident council response sheet attached to minutes. No response to explain what and how the concern was resolved.<BR/>During a confidential resident group meeting on 09/13/22 at 10:05 a.m., AR1-AR7 were in attendance and wished to remain anonymous. All residents in the confidential meeting said they attended regularly. All residents in the confidential meeting said CNAs not filling out or filling out the meal ticket incorrectly had been an ongoing issue. All residents in the confidential meeting said CNAs take a long time to answer the call light or will come and turn the light off without addressing their needs. AR1 said she/he had waited to be placed on commode forever and had been left on it for over 30 minutes. AR 2 said she/he several times had to go out in the hall and find a CNA to help her roommate. All residents said no staff departments had attended the meetings to address the issues and provided resolutions. The residents said the former President of Resident Council would take the concerns to the Administrator after the meetings, and sometimes he would come back with information, but nothing had changed. AR3 said the facility not fixing issues was one of the reasons the former President left. <BR/>During an interview on 09/14/22 at 9:15 a.m., the dietary manager said there was 103 residents so she could not make rounds and speak to all about their concerns. She said she learned about food complaints while visiting resident and from resident council. She the biggest problem is the meal tickets are not being filled out with the resident's choices. She said she had attended one resident council meeting and individual addressed those issues. <BR/>During an interview on 09/14/22 at 1:27 p.m., CNA V said she had worked at the facility 2 years ago and returned 2 days ago. She said call lights should be answered within 2 minutes. She said 2 CNAs are normally on the halls. She said no residents had complained to her about call light response time. She said call lights being within reach and answered timely prevented falls and accidents for continent residents. She said resident probably felt frustrated when the call lights were not answered or could not find it to get help. She said she knew she was responsible for get the resident's meal tickets and filling them to the resident preference. She said most of the time she was able to do it. She said she heard residents complain about not getting want they wanted. She said the residents get upset and asked for an alternative meal. She said this probably made the resident's feel frustrated. <BR/>During an interview on 09/14/22 at 2:52 p.m., LVN W said she had previously worked at the facility 5 years ago and returned last week. She said call lights should be answered asap because you do not know if the issues were minor or major. She said any staff member can answer call lights and ensure they are within reach. She said call lights are mostly answered timely. She said proper placed call light and timely response could prevent falls and the resident could be calling about chest pain, shortness of breath, or incontinent care. <BR/>During an interview on 09/14/22 at 3:25 p.m., CNA X said she was the CNA coordinator but had been working the floor. She said call lights should be answered asap and the facility trained CNAs to follow the same guidelines. She said call lights should be hooked out something within reach and eyesight. She said she had not heard any residents complain but she did not work the 100-hall often. She said proper placed call light and timely response could prevent falls and residents could be calling for help because they were having a stroke or heart attacked. She said call lights not being answered timely and within reach could make the resident feel neglected. She said it was the CNAs responsibility for timely call lights response and placing them within reach. CNA X said the Dietary Manager put the meal tickets at the nursing station and the aide for each hall is responsible for pick them up. She said they must be turned in by a certain time and placed in box by the kitchen. She said she did not know if all the CNAs knew it was their responsibility or if they completed the tickets. She said she had heard residents complain about not getting want they wanted. She said it was important get their meal preference because they live here, and it probably made them frustrated. <BR/>During an interview on 09/14/2022 at 4:15pm the DON stated it was the responsibility of the CNAs to go to each resident that was able to communicate the types of food they wanted for each meal and collect that information for the kitchen. The tray cards were given to the CNA's the day prior to the meal and were to be returned to the kitchen by 10 am the morning of the meals. The DON stated she was aware this was not always done because staffing had been an issue and the facility was trying to keep the residents taken care of and things like meal tickets have been put on the back burner. The DON said not getting the desired food choices could lead to residents not eating and weight loss.<BR/>During an interview on 09/15/22 at 2:52 p.m., the activity director said she did assist the resident in recording their minutes. She said group concerns was documented on the minutes and grievance form for individual concerns needed to be addressed. She said after each resident council meetings she took the complaints to departments it addressed and any grievance to the social worker for her to file. She said the call light and meal ticket issues was a nursing department issues and would have been given to the DON. She said after that, she did not have any more involvement. <BR/>During an interview on 09/15/22 at 3:01 p.m., the social worker said she worked for the facility for 10 years left and has been back for 2 years. She said she was not technically the grievance official; the Administrator was. She said as the social worker, she attends the meeting before it starts and goes over 2 resident rights a month. She said she submitted the grievance in the system and the Administrator kept up with the logs. She said if a grievance comes up in the resident council meeting, the activity lets me know, and I submit it. She said if it a group council concern, the activity director goes straight to the Administrator. The social worker said AR1 had filed a grievance about an issue and the Administrator addressed it, but she could not find any documentations. <BR/>During an interview on 09/15/22 at 3:12 p.m., the Administrator said the president of resident council lead the meetings. She said the president presents the concerns to her and she tries to get a response back within 24 hours. She said the concerns were presented in the morning meetings and a resolution proposed. She said the president was told the resolution and he notified the council members. She said the resolution should be posted on the resident council meeting minutes. She said if it was a department issue, then the department head should fill out a form to address the issue and it should be attached to the minutes. She said regarding the meal ticket issues, before the former president left 3 weeks ago, he was informed the facility hired 2 hospitality aides to fill out meal tickets and ask for meal preferences. She said she knew he told some people about the resolutions but probably not everyone. She said she did not know why resolutions were not on meetings minutes or grievance from the meeting, not in the grievance binder. She said it was important for the resident council members to have their concerns and grievance promptly addressed so they knew the facility took them seriously and was heard in their home. <BR/>During an interview on 09/15/22 at 5:27 p.m., the DON said the activity director brought her nursing related issues such as call lights response time and meal tickets. She said the activity director writes down the resolution and informs the resident council president or members at the next meeting. She said administrator staff attended meetings. She said it could frustrate the council group if they felt their concerns were not being addressed or taken seriously.<BR/>Record review of the grievance book from 01/2022-09/2022 did not reveal any complaints related to resident council concerns of delayed call light response time and meal tickets. <BR/>Record review of a facility grievance policy dated 01/12/20 revealed .the facility will ensure prompt resolution to all grievance .keeping resident .informed throughout investigation and resolution process .the facility grievance process will be overseen by a designated Grievance who will be responsible for receiving and tracking grievance through their conclusion .communicate with resident throughout process to resolution and coordinate with other staff .systematic mechanism for receiving and promptly acting upon issues .monitoring and trending grievances and complaints .all grievance identified during the resident council meeting will be submitted to administrator and/or designee for investigation and resolution .reporting of resolution outcome will be given to the resident council per protocol .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure that 2 residents (Resident #312 and Resident #101) had grievances promptly resolved of 22 residents reviewed for grievances. <BR/>The facility failed to implement a systematic procedure to ensure Resident #312 and Resident #101's grievances of staff members being rough and rude were promptly resolved after they both reported their grievances to their therapist.<BR/>This deficient practice could place the residents at risk for decreased quality of life and abuse.<BR/>Findings included:<BR/>1.Record review of the face sheet dated 9/15/22 revealed Resident #312 was a [AGE] year-old, female, and admitted on [DATE] with diagnoses including back pain with recent back surgery, high blood pressure, and heart disease.<BR/>Record review of the admission MDS dated [DATE] revealed Resident #312's MDS had not been completed.<BR/>Record review of the Resident #312's Care Plan dated 9/15/22 revealed resident had impaired physical mobility with intervention to provide appropriate level of assistance to promote safety of resident.<BR/>During an interview with Resident #312 on 9/12/22 at 11:35 AM, revealed she felt a CNA was rough and rude with her when the CNA was helping her turn off her back onto her side and the CNA put her hand on her back incision. She said it had only been four days since her surgery when the CNA put her hand on her incision when turning her onto her side and it hurt her. She said she hollered out in pain and the CNA rudely told her that she was just trying to get her to help herself. She said she did not know the CNA's name, but she had an eyebrow ring (later identified as CNA Q). She said she had reported the incident to the nurse and to the therapists while doing physical therapy. She said the therapists reported the incident to someone in Administration, but she had not heard back from anyone. She said she had not had that CNA since last 9/09/22. Resident #312 appeared to be cognitively intact.<BR/>2.Record review of the face sheet dated 9/15/22 revealed Resident #101 was a [AGE] year-old, female, and admitted on [DATE] with diagnoses including left femur (upper leg) fracture, urinary tract infection, diabetes (disease of too much sugar in the blood), and history of falls.<BR/>Record review of the admission MDS dated [DATE] revealed Resident #101 had a BIMS of 13, which indicated she was cognitively intact. <BR/>During an observation and interview with Resident #101 on 9/12/22 at 11:29 AM, revealed there were some staff with bad attitudes. She said the day shift staff were excellent, but there was a CNA with an eyebrow piecing (later identified as CNA Q) that was just plain rude and always complained. She said CNA Q was rough when she would yank her adult diaper from under her. She said she had a broken hip, and it would hurt her when the diaper was yanked from under her and demonstrated to surveyor. She said she had reported the rough and rudeness to the therapist while they were having therapy one day a couple weeks ago. She said there were several other residents in the group therapy session that also said the CNA was rough and rude. She said the therapist reported it to their boss, but she had not heard anything back about it. She said with therapy she was able to perform her own care now and did not call for assistance from the CNAs unless absolutely necessary.<BR/>During a group interview with PT (physical therapist) M, OTA (occupational therapy assistant) N, PTA (physical therapy assistant) O, and OTA P on 9/14/22 at 3:35 PM revealed they had received multiple complaints from multiple residents related to CNAs being rough and rude during a therapy session with multiple residents in the room. They said Resident #312 had told them of an incident that had occurred when a CNA with an eyebrow ring (identified as CNA Q) turned her and put her hand in the resident's back incision and hurt her, then was rude to the resident. They said Resident #101 also said CNA Q was rough and rude with her when she removed her adult diapers. They said then multiple other residents that were no longer at the facility, then commented that CNA Q and another CNA, CNA R, were rough and rude with them also. They said they reported the incident and the other residents' comments to the Director of Therapy. They said the Director of Therapy would relay information to the department heads in their morning meetings. They said the DON was aware.<BR/>During an interview with the Director of Therapy on 9/14/22 at 3:56 PM revealed she had received the verbal complaints from her staff related to CNA Q and CNA R being rough and rude to residents and she had reported it verbally to the DON approximately two weeks ago . She said when she receives complaints, she would report it to the nurse on the floor or the ADON, if available. She said she would also report it in the morning meetings to the department heads. She said the Social Worker or the Administrator would complete the grievance forms and follow up on the complaint/grievance. <BR/>During an interview with DON on 9/14/22 at 4:29 PM revealed she had not received a report from the Director of Therapy related to rough or rude staff approximately two weeks ago. She said she had been out sick two weeks ago with Covid and then was off work for vacation. She said she had received a report from a nurse on a different CNA and that CNA was terminated. She said if she had received the report from the Director of Therapy, she would have already done an investigation of the CNAs and implemented inventions to correct the issues. She said she was going to have the Social Worker do a safe survey with all the residents on the 600 hall and follow up with Resident #312 and Resident #101 to start the investigation.<BR/>During an interview with Resident #312 and roommate, Resident #101, on 9/15/22 at 10:08 AM revealed the social worker had come to visit them on the evening of 9/14/22 and took their statements related to the CNAs being rough and rude . <BR/>During an interview with the ADON J on 9/15/22 at 10:44 AM revealed she had worked for the facility for about nine months and as the ADON for about two months. She said she had to work on the floor frequently and was not able to keep up with her ADON duties. She said she had received reports of a CNA being rough and rude a while back, but that CNA was terminated. She said she had not received any incidents involving Resident #312 or Resident #101 concerning rough or rude staff from the Director of Therapy. She said residents could feel neglected if their concerns/grievances were not reported and responded to timely.<BR/>During an interview with the DON on 9/15/22 at 11:32 AM, revealed they did the safe surveys and talked to Resident #312 and Resident #101. She said they did not receive any complaints of abuse, but they did receive several issues about customer service. She said she had talked to the two and they did not remember anything other than being nothing but kind to residents. She said she was going to start by assigning CNA Q and CNA R computer trainings related to customer service and turning techniques. She said they would also do one-on-one trainings with the Social Worker on different care scenarios and how to respond. She said she would continue to evaluate the two CNAs and determine if other actions needed to be taken. She said usually complaints are given to herself or the Administrator CNAs and they start the grievance form in the software and then they get the Social Worker and any department heads needed involved. She said she had asked the Director of Therapy about not reporting the incident to her and the Director of Therapy said the surveyor made her nervous and she just said she reported to her, but she actually could not remember who she reported to . She said if residents do not have their complaints/grievances resolved it could lead to the resident being unhappy at the facility.<BR/>During an interview with the Social Worker on 9/15/22 at 2:34 PM revealed she would fill out the grievance form in the software if she received a complaint/grievance. She said she would let the Administrator know of the complaint/grievance so she could determine if there was any abuse that would need to be reported. She said if there was no abuse, then the Administrator would let her know what department head needed to address the complaint/grievance. She said once the appropriate department addresses/resolves the complaint/grievance, the Administrator will close out the complaint and notify the complainant of the resolution. She said she had received complaints in the past related to staff being rough and rude and had reported it to the Administrator, but it was not related to CNA Q or CNA R. She said she would do one-on-one trainings with staff when needed to try to salvage staff with re-education trainings as part of their corrective interventions . She said she had not received grievances involving Resident #312 or Resident #101 related to rude or rough staff.<BR/>During an interview with the Administrator on 9/15/22 at 3:12 PM revealed anyone could take a complaint/grievance from a resident and then it should be reported to the Social Worker or the Administrator to be entered into the online grievance form. Then the grievance would be given to the appropriate department head to resolve the grievance and then she would follow up with the complainant to let them know of the resolution. She said their facility was proactive and did safe surveys weekly and the department heads did visits with residents at least a couple times a week to help address any issues before they become issues. She agreed that there was a break in communication in the reporting of the rough and rude CNAs from the Director of Therapy. She said if the grievances had been reported appropriately by the Director of Therapy, then they would have investigated the allegations immediately. She said residents could feel unhappy and/or unsafe if their grievances were not resolved promptly.<BR/>Record review of the facility's Grievance policy dated 9/22/17 and revised 1/12/20 revealed .resident has the right to voice grievances to the facility or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal . with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and or other residents, and other concerns regarding their facility stay . the facility will ensure prompt resolution to all grievances . the facility will provide a mechanism for filing a grievance . provide a planned, systematic mechanism for receiving and promptly acting upon issues expressed by residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good grooming and personal hygiene for a resident who is unable to carry out activities of daily living were provided for 2 of 4 residents reviewed for activities daily living (Resident #2 and Resident #5)<BR/>The facility did not clean or trim the nails of Resident #2 and Resident #5. <BR/>The facility failed to promptly respond to Resident #2 and Resident #5's call lights who were ADL dependent.<BR/>These failures could place dependent residents at risk of poor hygiene, infections, injuries and unmet needs. <BR/>Findings included: <BR/>Record review of Resident #2 's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including respiratory failure, colon cancer, diabetes, and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred). <BR/>Record review of Resident #2's MDS dated [DATE] indicated Resident #2 made himself understood and usually understood others. The MDS indicated Resident #2 had moderately impaired cognitive function (BIMS of 10). The MDS indicated he had no behavior of rejecting care. The MDS indicated he required limited assistance with locomotion in his wheelchair, supervision only with toilet use and eating. The MDS indicated he required extensive assistance with dressing, personal hygiene and bathing. The MDS indicated bed mobility had only occurred once or twice during the 7 days look back period. The MDS indicated transfers and walking had not occurred during the 7 days look back period. <BR/>Record review of Resident #2's care plan dated 12/7/22 indicated his ADL dependency was not specifically addressed. <BR/>During an observation on 2/8/23 at 11:15 a.m. revealed Resident #2 laid in his bed. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/>During an interview and observation on 2/8/23 at 2:44 p.m. revealed Resident #2 sat in his bed. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/> Resident #2 said he had been at the facility approximately 2 months. He said no one had offered to trim and clean his nails since he had been at the facility.<BR/>During an observation and interview on 2/9/23 at 9:05 a.m. revealed Resident #2 sat in his wheelchair. His nails were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under several of the nails. CNA F was making his bed. CNA F said nail care was usually done on shower days by the CNAs. CNA F indicated she had just administered a shower to Resident #2. CNA F said nurses trimmed the nails of diabetic residents. <BR/>During an observation on 2/9/23 at 11:17 a.m. revealed Resident #2 was in therapy sitting in his wheelchair. CNA F stood at his side viewing his nails. The nails to both his hands were long (approximately 1 centimeter past the end of his fingers). There was a dark brown substance under all of his nails.<BR/>During an interview on 2/9/23 at 11:18 a.m., CNA F said she did not know if Resident #2 was a diabetic. CNA F said she cleaned Resident #2's nails in the shower by washing over the top of his hands but indicated she did not clean under his nails. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said she worked the hall on which Resident #2 resided on 2/8/23. RN C said there was no set schedule for diabetic nail care and nurses just performed the care as it needed to be done. RN C said no CNAs had reported to her that any diabetic resident needed nail care yesterday (2/8/23). RN C said Resident #2's nails were very thick and would have to be soaked before they could be cut. RN C said that might be why the nail care had not been performed. RN C said it was important to ensure nail care was completed to prevent infection. <BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she regularly worked the hall that Resident #2 resided on. CNA E said CNAs and nurses were responsible to ensure residents nails were cleaned and trimmed. CNA E said nurses performed nail care for diabetic residents. CNA E said there was no set schedule for CNAs to perform nail care and indicated she performed nail care when she saw it needed to be done. CNA E said if she saw nail care was needed for a diabetic resident, she would notify the nurse. CNA E said she could not remember if she notified RN C that nail care was needed for Resident #2. CNA E said it was important to ensure nail care was completed to maintain resident hygiene.<BR/>2. Record review of Resident #5's consolidated physician orders dated 2/10/23 indicated he was [AGE] years old admitted to facility on 1/16/23 with diagnoses including atherosclerotic heart disease (heart disease caused by the buildup of fats, cholesterol and other substances in and on the artery walls), and rheumatoid arthritis (chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility) and dementia. <BR/>Record review of Resident #5's MDS dated [DATE] indicated Resident #5 usually understood and usually made himself understood. The MDS indicated he had moderately impaired cognitive function (BIMS of 9). The MDS indicated he had no behavior of rejecting care. The MDs indicated transfers had only occurred once or twice during the 7 days look back period. The MDS indicated locomotion in his wheelchair had not occurred during the 7 days look back period. The MDS indicated he required limited assistance with walking in his room and eating. The MDS indicated he required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and bathing. <BR/>Record review of Resident #5's care plan revised on 2/1/23 indicated his ADL dependency was not specifically addressed.<BR/>During an observation and interview on 2/8/23 at 3:45 p.m. revealed Resident #5 laid in his bed. His nails were long (approximately 1/2 centimeter past the end of his fingers). There was a dark brown substance under several (more than 2 nails on each hand but less than 5 nails of each hand) nails to each hand. Resident #5 said he wanted his nails to be cleaned and trimmed. Resident #5 said he did not know when his nails were last cleaned and trimmed. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said she worked the hall on which Resident #5 resided on 2/8/23. RN C said CNAs were responsible to perform nail care for non-diabetic residents. RN C said there was no set schedule for CNAs to perform nail care and indicated CNAs were to perform the nail care as needed. RN C said it was important to ensure nail care was completed to prevent infection.<BR/>During an observation on 2/10/23 at 9:32 a.m. revealed Resident #5 laid in his bed. His nails were long (approximately 1/2 centimeter past the end of his fingers). There was a dark brown substance under several (more than 2 nails on each hand but less than 5 nails of each hand) nails to each hand. <BR/>During an interview on 2/10/23 at 10:28 a.m., CNA G said residents were to have their nails cleaned and trimmed on shower days by CNAs. CNA G said resident nails were to be cleaned and trimmed as needed in between shower days. CNA G said it was important to ensure nail care was done to avoid infection and unintentional injury (scratches and skin tears).<BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she regularly worked the hall that Resident #5 resided on. CNA E said CNAs and nurses were responsible to ensure residents nails were cleaned and trimmed. CNA E said nurses performed nail care for diabetic residents and CNAs performed nail care for non-diabetic residents. CNA E said there was no set schedule for CNAs to perform nail care and indicated she performed nail care when she saw it needed to be done. CNA E said she did not recall performing nail care for Resident #5 but indicated she would have cleaned and trimmed his nails if she noticed they were long and dirty. CNA E said it was important to ensure nail care was completed to maintain resident hygiene. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected CNAs to ensure nail care was completed for non-diabetic residents as it was needed. The DON said she expected nurses to perform nail care for diabetic residents as it was needed. The DON said it was important to ensure nail care was done to prevent unintentional injuries (such as scratches) and prevent infections. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected staff to ensure resident's nails were cleaned and trimmed. <BR/>Record review of the facility policy and procedure titled Bathing revised on 02/12/20 reflected, .Tasks commonly completed during the bathing process .Report abnormal findings to the nurse in charge .needs shall be discussed with the resident and responsible party during care plan meetings with the interdisciplinary team in order to identify and implement proper hygiene habits and promote resident rights and dignity The policy and procedure did not specifically address nail care. A policy and procedure for nail care was requested but not received. <BR/>3. During an observation on 2/8/23 at 2:44 p.m. revealed Resident #5 could be heard across the hall yelling Somebody come help me. <BR/>During an observation on 2/8/23 at 2:47 p.m. revealed Resident #2 pushed his call light in order to obtain assistance to get up.<BR/>During a continuous observation on 2/8/23 from 2:47 p.m. to 3:15 p.m. revealed Resident #5's call light dome remained lit up and the call light alarm was audible until 3:12 p.m. Resident #5 continued to yell intermittently for help from 2:47 p.m. to 3:15 p.m. Resident #2's call light dome remained lit up and the call light alarm was audible until 3:15 p.m. Resident #5's room was directly adjacent to Resident #2's room. <BR/>During an observation on 2/8/23 at 2:51 p.m., revealed Receptionist I walked by both Resident #2 and Resident #5's rooms as Resident #5 yelled out. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:52 p.m. revealed LVN J walked by both Resident #2 and Resident #5's rooms pushing a treatment cart. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:55 p.m. revealed Admissions Director K walked by both Resident #2 and Resident #5's rooms as Resident #5 yelled out Help. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:57 p.m. revealed an unidentified staff member in a khaki-colored polo pushed a red hand truck/ appliance dolly (tool to move heavy items) by both Resident #2 and Resident #5's rooms. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 2:58 p.m. revealed Housekeeper L stood in the hallway, 2 rooms down from Resident #2 and Resident #5's rooms. Housekeeper L stood in front of his housekeeping cart with his back toward the surveyor. His head was bent down as if he were looking at something in front of him. <BR/>During an observation on 2/8/23 at 3:02 p.m. revealed CNA H walked by both Resident #2 and Resident #5's rooms. The call light domes for both Resident #2 and Resident #5's rooms were visibly lit up and the call light alarms were audible.<BR/>During an observation on 2/8/23 at 3:12 p.m. revealed Maintenance Personnel M answered Resident # 5's call light. <BR/>During an observation on 2/8/23 at 3:15 p.m. revealed CNA H answered Resident #2's call light.<BR/>During an interview on 2/8/23 at 3:16 p.m., maintenance personnel M said answering call lights was everyone's (all staff's) responsibility. Maintenance Personnel M said he may not be able to get/do exactly what the resident requested/needed. Maintenance Personnel M said he could ensure there was not an emergency and notify the nurse of the resident request/need. Maintenance Personnel M said Resident #5 said he just wanted to go home. <BR/>During an interview on 2/8/23 at 3:17 p.m., CNA H said anyone could answer a call light. CNA H said even if the staff were not clinical, they can and should respond to a call light. CNA H said non-clinical staff should check on call lights because there could be an emergency, or the resident might have a simple request. CNA H said she did not immediately check on the call lights because she had just came onto her shift. CNA H said she should have checked on the call lights the first time she went by and notified the residents she would be right back. CNA H said Resident #2 needed help to get up. <BR/>During an interview on 2/8/23 at 3:18 p.m., Housekeeper L said he had worked at the facility since November 2022. Housekeeper L said he noticed the call lights going off but had not been given any instructions regarding call lights. Housekeeper L said he was not sure if he was supposed to answer call lights. <BR/>During an interview on 2/8/23 at 3:29 p.m., Admissions Director K said she had worked at the facility for approximately 3 years. Admissions Director K said any staff could check on a call light, but some residents call out or yell out like every 10 minutes. Admissions Director K said even for the residents that frequently call out she would still check on them. Admissions Director K said she was not sure if Resident #2 and Resident #5 were residents that called out frequently. Admissions Director K said staff had to respond to call lights because the resident might actually need help. Admissions Director K said she did see Resident #2 and Resident #5's call lights when she walked by. Admissions Director K said she did hear Resident #5 yell as she walked by his room. When asked why she did not respond to the call lights or Resident #5's yell for help Admissions Director K said I want to say in my heart of hearts it's because I didn't think they needed Admissions Director K stopped mid-sentence and then said but I can't say that. Admissions Director K then said there was no excuse for not having stopped and checked on Resident #2 and Resident #5's call lights. <BR/>During an interview on 2/8/23 at 3:35 p.m., LVN J said she did not remember walking by Resident #2 and Resident #5's rooms with her cart. LVN J said she certainly would have stopped and checked on the call lights had she noticed they were going off. LVN J said we (all staff) were responsible for answering call lights. <BR/>During an interview on 2/9/23 at 10:19 a.m., Receptionist I said she use to be a CNA and had worked at the facility for 2 &frac12; years. Receptionist I said all staff members were responsible for answering call lights. Receptionist I said it was important to respond to call lights because it could be an emergency. Receptionist I said if the request were something simple, non-clinical staff can assist them or notify the nurse. Receptionist I said she did not remember walking past Resident #2 and Resident #5's call lights yesterday (2/8/23). Receptionist I said she did not remember Resident #5 yelling out for help. Receptionist I said she would have answered the call lights had she noticed them going off. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said all staff clinical or not, were responsible for responding to resident call lights. The DON indicated it was unacceptable that call lights remained unanswered for over 20 minutes while multiple staff members walked by. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected all staff to respond to resident call lights in order to ensure resident needs were met. <BR/>Record review of the facility policy and procedure titled, Call Lights-Answering, revised on 02/12/20 reflected, Standard of Practice: The staff will provide an environment that helps meet the resident's needs by answering call lights appropriately. Procedures: (1) Respond to patients/resident's call lights and emergency lights in a timely manner . (5) If unable to complete the request, do not turn off the call light; the call light will remain on until the service is completed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 3 of 22 residents (Resident #6, Resident #7 and Resident #4) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #6 and Resident #7's oxygen tubing and humidifier bottles were dated per the facility's policy.<BR/>The facility failed to change Resident #6's oxygen tubing and humidifier bottle every Wednesday per the physician's orders. <BR/>The facility failed to change Resident #6 and Resident #7's nebulizer mask and tubing per the facility's policy.<BR/>The facility failed to ensure Resident #6 and Resident #7's nebulizer, mask and tubing were dated per the facility's policy.<BR/>The facility did not ensure Resident #4's suction canister was emptied when it was &frac34; full.<BR/>The facility failed to ensure Resident #4's suction device, tubing, and suction canister were not dated.<BR/>These failures could place residents at risk for of respiratory infections.<BR/>Findings included:<BR/>1.Record review of Resident #6's face sheet dated 2/8/23 revealed Resident #6 was an [AGE] year-old female, and was admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease- constriction of the airways and difficulty breathing), atrial fibrillation (irregular and often rapid heart rate that causes poor blood flow), orthostatic hypotension (type of low blood pressure that occurs when standing up from sitting of lying down), and pain. <BR/>Record review of Resident #6's quarterly MDS dated [DATE] revealed Resident #6 had a BIMS of 12, which indicated she was cognitively intact. Resident #6 required limited to extensive assistance of 1 person for most ADL's. Resident #6 required oxygen therapy.<BR/>Record review of the Resident #6's order summary report dated 2/08/23 revealed an order for oxygen at 2 LPM by a nasal cannula; albuterol sulfate 0.63 mg (milligrams) in 3 mL (milliliters) of solution for nebulization inhalation every four hours as needed for shortness of breath; and ipratropium 0.5 mg with 3 mg in 3 mL of solution for nebulization inhalation every six hours. Resident #6's orders revealed an order for oxygen canister/tubing change every Wednesday evening and date humidifier water and oxygen tubing weekly on Wednesday.<BR/>Record review of Resident #6's eTAR dated 2/08/23 revealed the oxygen/tubing change every Wednesday evening and change & date humidifier water and oxygen tubing weekly on Wednesday was not documented as completed on Wednesday 2/01/23. There was not a task on the eTAR related to changing Resident #6's nebulizer tubing or nebulizer mask.<BR/>Record review of Resident #6's nurses' notes with date range of 10/08/22-2/08/23 revealed there was no documentation the nurses changed Resident #6's oxygen tubing on 2/01/23 or her nebulizer tubing, or nebulizer mask every 48 hours per the facility's policy.<BR/>During an observation and interview on 2/08/23 at 2:00 PM with Resident #6 revealed she had a nebulizer machine (changes liquid medication to a mist) with nebulizer tubing and a mask attached and the tubing nor the mask were dated. The nebulizer with tubing and mask was stored in a bag that reflected the bag was issued 6/22/22. The resident said she received breathing treatments with the nebulizer machine and mask every six hours. Resident #6 was wearing her oxygen at the time of the observation. The oxygen tubing nor the humidifier bottle were dated. Resident #6 said when she left the room in her wheelchair, she had oxygen bottles and she stored her oxygen tubing and cannula in the bag hanging on the oxygen concentrator at her bedside. The bag did not have a date. Resident #6 said she thought the nurses changed her oxygen tubing and nebulizer mask and tubing every month. She did not know when her oxygen tubing and nebulizer mask and tubing were changed last.<BR/>2. Record review of Resident #7's face sheet dated 2/8/23 revealed Resident #7 was a [AGE] year-old female, and was admitted to the facility on [DATE] with diagnoses of heart failure, atrial fibrillation, cerebral atherosclerosis (arteries in the brain become hard, thick, and narrow due to the buildup of plaque or fatty deposits inside the artery walls, which decreases the blow to areas of the brain), kidney failure (kidneys lose the ability to remove waste and balance fluids in the body), spondylosis (age-related wear and tear of the spinal disks), and pain. <BR/>Record review of Resident #7's annual MDS dated [DATE] revealed Resident #7 had a BIMS of 9, which indicated she was moderately cognitively impaired. Resident #7 required supervision to limited assistance of 1 person for most ADL's. Resident #7 required oxygen therapy.<BR/>Record review of Resident #7's order summary report dated 2/08/23 revealed an order for oxygen at 2 LPM by a nasal cannula and ipratropium 0.5 mg with 3 mg in 3 mL of solution for nebulization inhalation three times daily. Resident #7's orders revealed an order to change and date the nebulizer mask/mouthpiece & tubing weekly on Wednesday's night shift. There was not an order related to changing the oxygen tubing.<BR/>Record review of Resident #7's eTAR dated 2/08/23 revealed the change of the nebulizer mask/mouthpiece, & tubing was not documented as completed on Wednesday 2/01/23.<BR/>During an observation and interview on 2/08/23 at 11:49 AM, revealed Resident #7 had oxygen tubing with a nasal cannula attached to a humidifier bottle and they were not dated. The nasal cannula was stored in a bag hanging on the oxygen concentrator and the bag reflected it was issued 6/22/22. Resident #7 said she used her oxygen at night and sometimes during the day when she was short of breath. Resident #7's nebulizer and mask were in a bag, but they were not dated. Resident #7 said she could not remember when her oxygen tubing or nebulizer tubing and mask had last been changed. <BR/>During an interview on 2/08/23 at 3:55 PM with the DON, she said it was a constant struggle trying to get the night shift to do what they were supposed to do. She said she had gone down and visited with Resident #6 and Resident #7 after she knew the surveyor had visited with them and she saw for herself that the oxygen tubing/humidifier bottles and nebulizer/mask were not dated. She said if the tubing/humidifier bottles and nebulizer/masks were not dated, along with no documentation of when they were changed, then they would not be able to determine how long the resident had had the equipment and it could lead to the residents developing respiratory infections. The DON said she was ultimately responsible to ensure the night shift was changing and dating the respiratory equipment per the physician's orders and the facility's policies.<BR/>During an interview on 2/08/23 at 4:13 PM with RN A, she said the night shift nurses were responsible for changing the oxygen tubing and nebulizers/masks on Wednesday nights. She said the oxygen tubing and nebulizer masks should be dated when changed and documented in the resident's chart. She said if the oxygen tubing and nebulizers/masks were not changed regularly they would become nasty and dirty and could cause the resident to develop a respiratory infection. She said she did not specifically check the respiratory equipment (oxygen tubing, nebulizer tubing & masks/mouthpieces) for dates, because night shift was responsible for changing and dating the equipment. She said she would change any respiratory equipment herself and date the equipment if she noticed anything did not look sanitary. <BR/>During an interview on 2/08/23 at 4:25 PM with the Administrator, who was also one of the Infection Preventionists, revealed she expected the oxygen tubing/humidifier bottles and nebulizer/masks to be labeled/dated and it should be documented in the eTAR per the physician's orders. She said she the oxygen tubing/humidifier bottles and nebulizer/masks should be changed per the facility's policies.<BR/>3. Record review of Resident #4's consolidated physician orders dated 2/10/23 indicated he was [AGE] years old and readmitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), colostomy (surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) status, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) status, dysphagia (difficulty swallowing), and shortness of breath. <BR/>Record review of Resident #4's MDS dated [DATE], indicated Resident #4 sometimes made himself understood and usually understood others. The MDS indicated Resident #4 had short-term and long-term memory problems. The MDS indicated Resident #4 had moderately impaired cognitive decision-making skills. The MDS indicated Resident had no behavior of rejecting care. <BR/>Record review of Resident #4's care plan revised on 1/20/23 indicated Resident #4 had increased secretions and an increased risk of aspiration. The care plan interventions included assess for the presence of dyspnea (difficult or labored breathing) and suction as needed. <BR/>During an observation on 2/8/23 at 11:00 a.m. revealed Resident #4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an observation on 2/8/23 at 1:00 p.m. revealed Resident # 4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an observation on 2/8/23 at 3:00 p.m. revealed Resident #4 laid in his bed. The suction device, tubing, and suction canister were not dated. The suction canister (temporary storage container that's used to collect the infectious medical waste until it is disposed of properly) was filled to the brim with a clear watery substance. Multiple white mucus like segments floated within the watery substance. <BR/>During an interview on 2/9/23 at 9:30 a.m., LVN B said she took care of Resident #4 regularly on the 6:00 a.m. to 6:00 p.m. shift. LVN B said she changed the suction canister and tubing yesterday (2/8/23) evening at approximately 5:00 p.m. when Resident #4's family member pointed out the suction canister was full. LVN B said she had not noticed that the canister was full yesterday during the morning or afternoon. LVN B said it was ultimately the nurse's responsibility but would expect CNAs to notify her if they (CNAs) noted the canister was full. LVN B said the canister and tubing should be dated and initialed. LVN B said the suction canister and tubing should be changed at least every week and as needed. LVN B clarified if the suction device was dropped on the floor the tubing and suction device would be changed. LVN B further clarified if the suction canister was &frac12; way full the canister should be changed. LVN B said the suction equipment will not suction properly if the canister is full. LVN B said she did not suction Resident #4 yesterday prior to 5:00 p.m. LVN B said if he (Resident #4) had needed to be suctioned, and the canister was full, she would have had to retrieve a suction canister before he could have been suctioned. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said suction tubing and suction canisters should be dated to ensure they (suction tubing and suction canisters) are changed weekly. RN C said suction canisters should be emptied before they are full because when full they will not work properly. RN C said a full suction canister could delay a resident receiving suction for a minute or two while staff retrieved another canister. <BR/>During an interview on 2/9/23 at 11:45 a.m., CNA D said she took care of Resident #4 regularly on the day shift. CNA D said nurses handled anything related to suction equipment. CNA D said she did not report the canister was full to the nurse on 2/8/23 because she did not notice it was full. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected staff to ensure suction equipment was dated and suction canisters were changed when the canister was &frac34; full. The DON said she expected nurses to check the level of the canister at least once a shift and when they were in the room providing other care tasks to ensure the canister would be ready for use if suction was needed with no delay in care. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected nurses to follow policy and procedure regarding suction equipment. <BR/>Record review of the facility policy and procedure titled, Respiratory Equipment Change Schedule, reviewed by facility administration on 01/12/22 reflected, Standard of Practice: The community will provide a schedule for changing disposable equipment at regular intervals as determined by manufacturer recommendations and local community standards. Procedures: . provide a schedule for changing disposable equipment at regular intervals as determined by manufacturer recommendations and local community standards . aerosol tubing and aerosol nebulizer to be changed every forty-eight hours . small volume medication nebulizers, place in clean paper bag, labeled with resident's name and leave a resident's bedside . (8) Suction Canister: .(b) Change or empty canister or collection when &frac34; full. (9) Suction tubing .(b) Change or empty canister or collection when &frac34; full .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 7 of 22 residents reviewed for palatable food. (Residents #313, Resident #101, Resident #312, Resident #91, Resident #19, Resident #38 and Resident #44)<BR/>The facility failed to provide palatable food served at an appetizing temperature or taste to Residents #313, Resident #101, Resident #312, Resident #91, Resident #19, Resident #38 and Resident #44 who complained the food was served cold and did not taste good. <BR/>This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. <BR/>Findings included:<BR/>1. Record review of the face sheet dated 9/15/22 revealed Resident #313 was a [AGE] year old, male, and admitted on [DATE] with diagnoses including acute kidney injury (abrupt deterioration in kidney function), acute posthemorrhagic anemia (quickly losing a large volume of circulating red blood cells that carry oxygen), acute cystitis with hematuria (sudden inflammation of the urinary bladder also known as a urinary tract infection, with blood in the urine), diabetes (disease of too much sugar in the blood), congestive heart failure (the heart does not pump blood as well as it should), depression (mood disorder that causes persistent feelings of sadness and loss of interest), and COPD (chronic obstructive pulmonary disease- constriction of the airways and difficulty breathing). <BR/>Record review of the admission MDS dated [DATE] revealed Resident #313 had a BIMS of 6, which indicated he was severely cognitively impaired. He required supervision and set up for eating. He required one to two- person limited to extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, toilet use, bathing, and personal hygiene. <BR/>Record review of the Resident #313s order summary report dated 9/15/22 revealed an order for a regular reduced concentrated sweets diet.<BR/>During an interview on 9/12/22 at 11:14 AM, Resident #313 revealed the food had no seasoning and he did not like it. <BR/>2. Record review of the face sheet dated 9/15/22 revealed Resident #101 was a [AGE] year-old, female, and admitted on [DATE] with diagnoses including left femur (upper leg) fracture, urinary tract infection, diabetes (disease of too much sugar in the blood), and history of falls.<BR/>Record review of the admission MDS dated [DATE] revealed Resident #101 had a BIMS of 13, which indicated she was cognitively intact. She required set up only for eating. <BR/>Record review of the Resident #101s order summary report dated 9/15/22 revealed an order for a regular reduced concentrated sweets diet.<BR/>During an interview on 9/15/22 at 10:18 AM, Resident #101 revealed the food was terrible and had only one good meal since she was admitted to the facility. She said the chicken was tough and dry, meals had no flavor, and her eggs were always cold. She said her family had to bring her food to the facility. <BR/>3. Record review of the face sheet dated 9/15/22 revealed Resident #312 was a [AGE] year-old, female, and admitted on [DATE] with diagnoses including back pain with recent back surgery, high blood pressure, and heart disease.<BR/>Record review of the admission MDS dated [DATE] revealed Resident #312's MDS had not been completed.<BR/>Record review of the baseline care plan dated 9/15/22 revealed Resident #312 was on a regular diet (non-restrictive diet).<BR/>Record review of the Resident #312's order summary report dated 9/15/22 revealed an order for a regular diet.<BR/>During an interview on 9/15/22 at 10:08 AM, Resident #312 revealed the food was cold, had no flavor, and did not taste good. She said she often could not tell what the food was. Resident #312 appeared to be cognitively intact. <BR/>4. Record review of the face sheet dated 9/15/22 revealed Resident #91 was a [AGE] year-old, female, and admitted on [DATE] with diagnoses including right femur (upper leg) fracture, ESRD (end stage renal (kidney) disease), diabetes (disease of too much sugar in the blood), and osteoarthritis (when flexible tissue at the ends of bones wears down).<BR/>Record review of the admission MDS dated [DATE] revealed Resident #91 had a BIMS of 13, which indicated she was cognitively intact. She required set up only for eating. <BR/>Record review of the Resident #91s order summary report dated 9/15/22 revealed an order for a regular renal diet (a diet low in sodium, phosphorous, and protein) <BR/>During an interview on 9/15/22 at 10:33 AM, Resident #91 revealed the food was cold, especially the eggs, most of the meat was so tough she could not chew it, and the food had no seasonings/flavor .<BR/>During an interview on 9/15/22 at 10:44 AM with ADON J, revealed she had received complaints from residents stating the food did not taste good. She said she had reported the food complaints to the Dietary Manager and the Administrator.<BR/>5. Record review of Resident #19's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), glaucoma (a group of eye conditions that damage the optic nerve, the health of which is vital for good vision), and hypertension (blood pressure that is higher than normal).<BR/>Record review of Resident #19's September 2022 physician orders revealed an order dated 07/22/2022 for a regular diet with thin liquids. An order dated 08/01/2022 indicated Resident #19 was to receive 2.0 Calorie Med Pass supplement 120 ml three times daily.<BR/>Record review of Resident #19's quarterly MDS, dated [DATE], reflected she had a BIMS score of 11, which indicated a minimal impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. <BR/>Record review of Resident #19's EHR reflected the following care plan interventions for nutrition on 07/12/2022: <BR/>- Resident #19 would be provided favorite foods and beverages.<BR/>- Resident #19's food preferences would be updated<BR/>During an interview on 09/12/2022 at 9:55 am, Resident #19 stated the food was disgusting and unappetizing. Resident #19 stated, we are just served whatever the kitchen feels like putting on a plate. Resident #19 stated most of the time it is combinations of food that do not go together at all and turns my stomach. Resident #19 stated we have all reported this to the nurses, Director, and Administrator until we are blue in the face.<BR/>During an observation on 09/12/2022 at 12:38pm, Resident #19 was not eating the lunch meal served by the facility. Resident #19 stated she was not eating fish with refried beans. The plate had a square breaded fish patty and a scoop of refried beans on it. The tray card had choices of fish or quesadilla, rice or refried bean, salad, and dessert. Resident #19 ate 25% of her lunch meal eating only 3 bites of the fish patty and eating the banana strawberry dessert.<BR/>6. Record review of Resident 38's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: rheumatoid arthritis (A chronic inflammatory disorder affecting many joints, including those in the hands and feet), dementia (A group of thinking and social symptoms that interferes with daily functioning), and anemia (A condition in which the blood doesn't have enough healthy red blood cells).<BR/>Record review of Resident #38's September 2022 physician orders revealed an order dated 01/27/2021 for a regular mechanical soft diet with thin liquids. <BR/>Record review of Resident #38's annual MDS, dated [DATE], reflected she had a BIMS score of 11, which indicated a minimal impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. <BR/>Record review of Resident #38's EHR reflected the following care plan goal for nutrition on 09/03/2022: <BR/>- Resident #38 would be comfortable with food and fluids provided over the next 90 days<BR/>During an interview on 09/12/2022 at 9:40 am, Resident #38 stated the food served at the facility was cold and tasteless. Resident #38 stated she did not like over 50% of the things served for lunch and supper. Resident #38 stated she felt the facility served a menu that people from the north would enjoy. Resident #38 stated she survived on snacks brought in by her relatives and provided by the facility.<BR/>During an observation on 09/12/2022 at 12:45 pm. Resident #38 had a plate with a square breaded fish patty and a scoop of rice. Resident #38 stated the fish was cold, the rice was hard, and she ate the strawberry and banana dessert and drank her tea. Resident #38 stated she would be ok until they brought snacks around. Resident #38 stated the CNA asked her if she wanted something different but Resident #38 stated she did not know what a quesadilla was, and it did not sound good.<BR/>7. Record review of the face sheet dated 9/14/2022 indicated Resident #44 was [AGE] years old and was admitted on [DATE] with diagnoses including kidney failure, atrial fibrillation (abnormal heart rhythm), and depressive episodes.<BR/>Record review of a care plan last revised on 7/20/2022 indicated Resident #44 had an altered nutritional status. There was an intervention for a diet as ordered by the physician. There was a goal of the resident will be comfortable with food and fluids provided. <BR/>Record review of the MDS dated [DATE] indicated Resident #44 usually understood others and was understood. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 12, indicating Resident #44 was moderately cognitively impaired. <BR/>During an interview on 9/12/2022 10:45 a.m., Resident #44 said the food was not cooked well and was undercooked. She said the food was always cold. She said she had been served rolls that were still doughy inside. She said her family member brings her food because she cannot eat the food. <BR/>During an observation on 9/12/2022 at 12:06 p.m., the food tray cart was delivered to the 400 Hall. There was no aides or nurses present. <BR/>During an observation on 9/12/2022 at 12:19 p.m., the first tray was being passed to residents on the 400 Hall. <BR/>During an observation on 9/12/2022 12:34 p.m., the final tray was served on the 400 Hall. <BR/>During an observation and interview on 9/13/2022 at 12:20 p.m., a tray was sampled by the Dietary Manager and 5 surveyors. The spaghetti with meat sauce was tepid, the peas were undercooked and unseasoned, the toast was tough and there was no butter or garlic seasoning (flavorless), and the brownie was dry. The Dietary Manager said the spaghetti was not hot enough because the bottom plate insulator was not present. She said the brownie was dry. <BR/>During an interview on 9/14/22 at 9:15 a.m., the Dietary Manager said she randomly talks to residents daily about food concerns. She said there were 103 residents, so she did not make rounds and speak to all of them about their concerns. She said she learned of food complaints while visiting with residents and from resident counci l. She said when staff brought her a specific complaint, she visited with the resident to resolve the issue. She said she even went to a resident council meeting to talk to residents. She said if the food was cold it was because the trays were not being passed immediately on the hall.<BR/>During an interview on 9/14/2022 at 3:23 p.m., CNA C said there are days the food trays come and none of her residents will eat the food. She said the main complaint is they do not get the food they ordered. She said she has reported food complaints to kitchen staff. <BR/>During an interview on 9/14/2022 at 3:34 p.m., CNA D had heard complaints of food trays being too cold and not seasoned correctly . She said she did offer substitutes when the resident does not like the food. She said if the food was cold she reheated the food and reported the issue to kitchen staff.<BR/>During an interview on 9/15/2022 at 10:10 a.m., LVN E said she did occasionally hear food complaints. She said most complaints were that they just did not like the food, or the food was cold. She said she reports complaints to the Dietary Manager. <BR/>During an interview on 9/15/2022 at 1:40 p.m., the DON said she heard food complaints every now and then. She said she was usually in the dining room and the complaints she heard was that the resident did not like what they are served. She said there are always substitutes available. <BR/>During an interview on 9/15/2022 at 2:16 p.m., the Administrator said she heard food complaints when residents told her, told the kitchen staff and from resident council. She said Resident #44 had a sensitive palate and her family brought her food. She said they did have a food committee to handle food complaints. She said she felt the food had improved and they no longer needed to have a food committee. She said they were doing food surveys and those have been coming back positive. She said she sampled food trays 3 times a week. She said after the sample tray was tasted by the Dietary Manager and the surveyors she tasted the peas, and they were undercooked.<BR/>Review of a facility Hot and Cold Food Temperatures dated August 1, 2018, indicated, .the temperatures of the food items will be managed to conserve maximum nutritive value and flavor and to be free of harmful organisms and substances .all hot food items must be served to the resident at a palatable temperature .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to accommodate residents' food preferences for 4 of 21 residents (Resident #8, Resident #19, Resident #67, and Resident #70) reviewed for preference.<BR/>The facility failed to ensure Resident #8 received milk with all meals.<BR/>The facility failed to obtain and honor Resident #19, Resident #67's and Resident #70's meal preference.<BR/>These failures could result in a decrease in resident choices, diminished interest in meals, and weight loss. <BR/>Findings included:<BR/>1. Record review of the face sheet dated 09/14/22 revealed Resident # 8 was [AGE] years old, female and admitted on [DATE] with diagnosis including cerebral ischemia (acute brain injury that results from impaired blood flow to the brain), abnormal weight loss, and vitamin deficiency.<BR/>Record review of the consolidated physician orders dated 09/14/22 revealed Resident #8 had liquid consistency nectar/mildly thick diet ordered on 09/05/22. The consolidated physician ordered dated 09/05/22 revealed wavier against medical advice signed by resident/family to receive milk with every meal. <BR/>Record review of the MDS dated [DATE] revealed Resident #8 was understood and usually understood others. The MDS revealed Resident #8 had clear speech and highly impaired vision with corrective lenses. The MDS revealed Resident #8 had a BIMS score of 12 which indicated mild cognitive impairment and required limited assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. And was independent with eating. <BR/>Record review of the care plan dated 07/12/22 revealed Resident #8 had altered nutritional status related to need for assistance/cueing with meals, dysphagia/swallowing difficulty and thickened liquids as evidence by decrease appetite, mechanically altered diet, palliative care form signed, and waiver for AMA signed. Interventions included provide favorite foods and beverages and necessary assistance with food and fluids. <BR/>During an interview on 09/12/22 at 10:27 a.m., Resident #8 said she asked for milk with her meals and seldom got it. She said dietary had come by to find out what she liked to help with her appetite. She said she really liked the milkshakes they brought her, but they did not have it today. <BR/>During an observation on 09/12/22 at 12:17 p.m., Resident #8 had a pureed diet with no milk on her tray.<BR/>During an observation on 09/13/22 at 8:54 a.m., Resident #8 ate a good portion of her meal, but milk was not observed on the tray. <BR/>2. Record review of Resident #19's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), glaucoma (a group of eye conditions that damage the optic nerve, the health of which is vital for good vision), and hypertension (blood pressure that is higher than normal).<BR/>Record review of Resident #19's September 2022 physician orders revealed an order dated 07/22/2022 for a regular diet with thin liquids. An order dated 08/01/2022 indicated Resident #19 was to receive 2.0 Calorie Med Pass supplement 120 ml three times daily.<BR/>Record review of Resident #19's quarterly MDS, dated [DATE], reflected she had a BIMS score of 11, which indicated a minimal impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. <BR/>Record review of Resident #19's EHR reflected the following care plan interventions for nutrition on 07/12/2022: <BR/>- <BR/>Resident #19 would be provided favorite foods and beverages.<BR/>- <BR/>Resident #19's food preferences would be updated<BR/>During an interview on 09/12/2022 at 9:55 am, Resident #19 stated the food was disgusting and unappetizing. She stated she was supposed to get a choice for lunch and dinner and the CNA's were supposed to come around and circle the resident's choice on the menu. Resident #19 stated she could not remember the last time the CNA's came around and asked the residents what they wanted for each meal. Resident #19 stated, we are just served whatever the kitchen feels like putting on a plate. Resident #19 stated most of the time it is combinations of food that do not go together at all and turns my stomach. Resident #19 stated we have all reported this to the Nurses, Director, and Administrator until we are blue in the face.<BR/>During an observation on 09/12/2022 at 12:38pm, Resident #19 was not eating the lunch meal served by the facility. Resident #19 stated she was not eating fish with refried beans. The plate had a square breaded fish patty and a scoop of refried beans on it. The tray card had choices of fish or quesadilla, rice or refried bean, salad, and dessert. There were no choices circled on the tray card.<BR/>During an interview on 09/12/2022 at 1:15pm, CNA J stated it was the responsibility of the CNA's to ask the residents that could answer what choices they would like to make for lunch and supper. CNA J stated the kitchen gave the CNA's the tray cards either the day before or that morning and wanted them filled out and turned back in right after breakfast. CNA J stated they work short a lot of the time and do not have chance to get them done every day, but they try to do it when they can. CNA J stated her priority when she comes to work each day was to keep her residents clean and dry the best she can. CNA J stated she would like to be able to do it all, but it is not always possible.<BR/>3. Record review of the face sheet dated 09/15/22 revealed Resident #67 was [AGE] years old male and admitted on [DATE] with diagnoses including cerebral infarction (stroke), vitamin deficiency, and type 2 diabetes. <BR/>Record review of the consolidated physician orders dated 09/15/22 revealed on 02/10/22 Resident #67 had a reduced concentrated sweets diet.<BR/>Record review of the MDS dated [DATE] revealed Resident #67 was understood and usually understood others. The MDS revealed Resident #67 had a BIMS score of 09 which indicated mild cognitive impairment. The MDS revealed Resident #67 required limited assistance for transfers and dressing, extensive for toilet use, personal hygiene, and bathing. And independent for eating.<BR/>Record review of the care plan dated 03/30/22 revealed Resident #67 had altered nutritional status as evidence by diet, med pass supplement, increased nutrient needs, and medical diagnosis. Intervention included implement med pass, monitor oral intake of food and fluid, and provide prescribed diet. The care plan dated 03/30/22 revealed Resident preference with a goal of person-centered care plan developed and implemented to meet goals and address the resident's medical, physical, mental and psychosocial needs. <BR/>Record review of a blank meal ticket and note dated 08/30/22 revealed a written note by Resident #67 given to the dietary manager. The note stated, .did not order anything on list ur trying to force me to eat stuff I did not order. Stop it! I resent it! I did not order anything on plate .let me order and I'll eat but I ain't eating what other people order .this suck forcing other people's food on others .did not get any [NAME] .<BR/>During an interview on 09/12/22 at 11:38 a.m., Resident #67 was asleep with his breakfast tray on the bedside table. After interviewing Resident #54, his roommate, Resident #67 woke up and said he did not want his breakfast because it was probably not what he ordered and went back to sleep. <BR/>4. Record review of the face sheet dated 09/14/22 revealed Resident #70 was [AGE] years old female and admitted on [DATE] with diagnoses including acquired absence of right leg above the knee, cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and vitamin deficiency. <BR/>Record review of the consolidated physician orders dated 09/14/22 revealed Resident #70 had regular; no added salt diet ordered on 08/05/22.<BR/>Record review of the MDS dated [DATE] revealed Resident #70 was understood and understood others. The MDS revealed Resident #70 had a BIMS of 14 which indicated intact cognition and required extensive assistance for toilet use and total dependence for transfers, dressing, personal hygiene, and bathing. And independent for eating.<BR/>Record review of the care plan dated 08/05/22 revealed Resident #70 had altered nutritional status related to increased needs for wound care and missing teeth as evidence by regular, NAS diet. Interventions included provide diet as prescribed and provide snacks. The care plan dated 08/04/22 revealed Resident preference related to resident wants to be involved in care decisions. Goal of resident's wishes be respected, and autonomy will be maintained.<BR/>During an interview on 09/12/22 at 3:27 p.m., Resident #70 said she orders fried eggs for breakfast and gets them sometimes. She said she orders cranberry juice and gets apple juice instead which she hates. <BR/>During an interview on 09/14/22 at 9:15 a.m., the Dietary Manager said there was 103 residents so she could not make rounds and speak to all about their concerns. She said she learned about food complaints while visiting resident and received Resident #67 note. She said the biggest problem is the meal tickets are not being filled out with the resident's choices. <BR/>During an interview on 09/14/22 at 1:27 p.m., CNA V said most of the time she was able to do fill out meal tickets. She said she heard residents complain about not getting want they wanted. She said the residents get upset and asked for an alternative meal. She said this probably made the resident's feel frustrated not getting what they wanted.<BR/>During an interview on 09/14/22 at 2:52 p.m., LVN W said she had previously worked at the facility 5 years ago and returned last week. LVN W said certain residents did complain about not getting what they ordered. She said it probably made them upset because they do not have a lot of things in their control. <BR/>During an interview on 09/14/22 at 3:25 p.m., CNA X said she was the CNA coordinator but had been working the floor. CNA X said the dietary manager put the meal tickets at the nursing station and the aide for each hall was responsible for picking them up. She said they must be turned in by a certain time and placed in the box by the kitchen. She said she did not know if all the CNAs knew it was their responsibility or if they completed the tickets. She said she had heard residents complain about not getting want they wanted. She said it was important get their meal preference because they live here, and it probably made them frustrated.<BR/>During an interview on 09/14/2022 at 4:15pm the DON stated it was the responsibility of the CNAs to go to each resident that was able to communicate the types of food they wanted for each meal and collect that information for the kitchen. The tray cards were given to the CNA's the day prior to the meal and were to be returned to the kitchen by 10 am the morning of the meals. The DON stated she was aware this was not always done because staffing had been an issue and the facility was trying to keep the residents taken care of and things like meal tickets have been put on the back burner. The DON said not getting the desired food choices could lead to residents not eating and weight loss.<BR/>During an interview on 09/14/22 at 4:24 p.m., Resident #70 said she got upset when she did not get what she ordered. She said about 4 times a week she received what she ordered on her meal ticket. She said the dietary manager had not come to ask her about food preference nor did the facility ask during her admission.<BR/>During an interview on 09/15/2022 at 3:30 PM the Administrator stated that it was the duty of the CNA to give each resident their tray ticket and assist and allow them to choose their meals each day. The Administrator stated about 20% of the resident independently filled out the meal ticket. The Administrator stated the facility offered the main menu with 2 options, alternative choices, or write down food items. The Administrator stated the process did not always happen but if the resident did not like the meal served the facility would happily make them what they wanted to eat. The facility had an always available menu for the residents to choose from if they did not like any of the chooses for a particular meal. The Administrator stated for physician order food items should be listed on the dietary card. She stated Resident #8 not receiving her milk at every meal was a dietary and aide issue. The Administrator stated all staff should make sure what is list on dietary card, the residents received. The Administrator said she did not know about Resident #67's note to dietary and the dietary manager should had brought it to her to file a grievance. The Administrator stated she expected the staff to allow the residents to choose their meals because resident preferences and choices were important to the resident's autonomy. The Administrator stated giving the resident what they ordered was important but more importantly encouraged consumption of meals and adequate nutrition. <BR/>Record review of the Resident Council Minutes dated 3/28/22 revealed .old business .meal tickets are ongoing concern . <BR/>Record review of the Resident Council Minutes dated 6/27/22 revealed .some residents voiced concern of their meal tickets not being filled out by CNAs .<BR/>Record review of the Resident Council Minutes dated 7/25/22 revealed .old business .ongoing concern related to meal ticket are not always filled out prior to meal service . <BR/>Record review of the Resident Council Minutes dated 8/29/22 revealed .old business .filling out meal menu continue to be a concern . <BR/>Record review of the grievance book from 01/2022-09/2022 did not reveal any complaints related meal tickets.<BR/>Record review of a undated facility food likes and dislikes policy revealed .the dietary manager will interview the resident to determine the resident's food likes and dislikes .a written record shall be maintained .resident shall be visited periodically to determine if any changes .the dietary manage shall investigate complaints to determine if substitutions can be made .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 7 of 22 residents (Resident #19, #77, #60, #30, #36, #87, #61) reviewed for hydration. <BR/>The facility failed to ensure Resident #19, #77, #60, #30, #36, #87, and #61 were provided access to ice and water throughout the day.<BR/>This failure could place residents at risk for dehydration. <BR/>Findings include:<BR/>1.Record review of Resident #19's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), glaucoma (a group of eye conditions that damage the optic nerve, the health of which is vital for good vision), and hypertension (blood pressure that is higher than normal).<BR/>Record review of Resident #19's September 2022 physician orders revealed an order dated 07/22/2022 for a regular diet with thin liquids. An order dated 08/01/2022 indicated Resident #19 was to receive 2.0 Calorie Med Pass supplement 120 ml three times daily.<BR/>Record review of Resident #19's quarterly MDS, dated [DATE], reflected she had a BIMS score of 11, which indicated a minimal impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. <BR/>Record review of Resident #19's EHR reflected the following care plans dated 08/19/2022<BR/>- <BR/>Resident #19 had a history or urinary tract infections<BR/>- <BR/>Resident #19's had a problem with constipation and fluids should be encouraged.<BR/>During an observation on 09/12/2022 at 09:55 am, Resident #19's water pitcher was noted to be on the bedside table at the foot of her bed. Resident #19's water pitcher was empty and out of reach.<BR/>During an interview on 09/12/2022 at 9:55 am, Resident #19 stated it does not matter that she cannot reach her water pitcher because it is empty. The water girl came last night before supper, and we have not had any since then. Resident #19 stated they only passed ice and water once a day in the evening and she is often out of water for over half of the day. Resident #19 stated she asked several times for fresh ice and water. Resident #19 stated she had reported not getting fresh water to the nurses, director, and administrator.<BR/>During an observation on 09/12/2022 at 12:38pm, Resident #19's water pitcher remained at the foot of her bed on her overbed table, and it was empty.<BR/>2. Record review of Resident 77's face sheet reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and dementia (A group of thinking and social symptoms that interferes with daily functioning).<BR/>Record review of Resident #77's September 2022 physician orders revealed an order dated 08/24/2014 for a regular diet large portion, mechanical soft meat with thin liquids. An order dated 09/20/2020 indicated facility was to encourage fluids every shift.<BR/>Record review of Resident #77's quarterly MDS, dated [DATE], reflected he had a BIMS score of 09, which indicated a moderate impaired cognitive status. His functional status reflected she required limited assistance with bed mobility, toilet use and personal hygiene. He required set up only for eating. <BR/>Record review of Resident #77's EHR reflected the following care plans dated 05/18/2022<BR/>- <BR/>Resident #77 had a history or urinary tract infections, and fluids should be encouraged.<BR/>During an observation on 09/12/2022 at 10:00 am, Resident #77's had no water pitcher.<BR/>During an interview on 09/12/2022 at 10:05 am, Resident #77 stated he had not had a water pitcher in a long time. Resident #77 stated he just drank what the nurse gave him with is pills and what came on his lunch tray. Resident #77 stated he would like to have fresh water everyday but was told by the CNAs they were out of water pitchers.<BR/>During an observation on 09/13/2022 at 12:38pm, Resident #77 had not water pitcher in his room.<BR/>During an observation on 09/14/2022 at 10:00 am, Resident #77 had not water pitcher in his room. Resident #77had no cup of water at his bed side.<BR/>3. Record review of Resident #30's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: hypertension ( blood pressure that is higher than normal), Diabetes mellitus type 2 (an impairment in the way the body regulates and uses sugar (glucose) as a fuel), and cerebral infarction ( is the pathologic process that results in an area of necrotic tissue in the brain (cerebral infarct).<BR/>Record review of Resident #30's September 2022 physician orders revealed an order dated 07/02/2020 for a regular diet large portion, reduced concentrated sweet with thin liquids. <BR/>Record review of Resident #30's quarterly MDS, dated [DATE], reflected he had a BIMS score of 08, which indicated a moderate impaired cognitive status. His functional status reflected he required extensive assistance with bed mobility, toilet use and personal hygiene. He required set up only for eating. <BR/>Record review of Resident #30's EHR reflected the following care plans dated 07/02/2020<BR/>- <BR/>Resident #77 had altered nutrition and fluids should be encouraged.<BR/>During an observation on 09/13/2022 at 10:15 am, Resident #30 had no water pitcher.<BR/>During an interview on 09/13/2022 at 10:25 am, Resident #30 stated he had not had a water pitcher in several weeks. Resident #30 stated he just drank what came on his tray. Resident #30 stated he would like to have fresh water every day because he stays thirsty all the time.<BR/>During an observation on 09/13/2022 at 12:38pm, Resident #30 had no water pitcher in his room.<BR/>During an observation on 09/13/2022 at 3:45pm, Hospitality Aide Z passed ice on the 200 hall. <BR/>During an observation on 09/13/2022 at 3:50pm, Resident #30 had no water pitcher at his bedside. Resident #30's roommate had fresh ice and water.<BR/>4. Record review of Resident #36's face sheet reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: dementia (A group of thinking and social symptoms that interferes with daily functioning), hyperlipidemia (A condition in which there are high levels of fat particles (lipids) in the blood), and Vitamin B12 anemia (A decrease in red blood cells when the body can't absorb enough vitamin B-12).<BR/>Record review of Resident #36's September 2022 physician orders revealed an order dated 07/02/2020 for a regular diet with thin liquids. <BR/>Record review of Resident #36's quarterly MDS, dated [DATE], reflected he had a BIMS score of 04, which indicated a severely impaired cognitive status. His functional status reflected he required extensive assistance with bed mobility, toilet use, and eating/dinking. <BR/>Record review of Resident #36's EHR reflected the following care plans dated 03/26/2022<BR/>- <BR/>Resident #36 had altered nutrition and fluids should be encouraged.<BR/>During an observation on 09/13/2022 at 10:17 am, Resident #36's had no water pitcher.<BR/>During an observation on 09/13/2022 at 12:40pm, Resident #36 had no water pitcher in his room.<BR/>During an observation on 09/13/2022 at 3:45pm, Hospitality Aide Z passed ice on the 200 hall. <BR/>During an observation on 09/13/2022 at 3:55pm, Resident #36 had no water pitcher at his bedside. Resident #36's roommate had fresh ice and water.<BR/>During an interview on 09/13/2022 at 4:00pm, Hospitality Aide Z stated she was only to pass ice and answer the call lights. She was not allowed to do any patient care. Hospitably Aide Z stated she did not have access to the charting system for the CNAs because she was not allowed to chart. Hospitality Aide Z stated she did not give Resident #36, #77, and #30 any ice and water because they did not have a water pitcher and she was not sure if they were on a thickened liquid diet. Hospitality Aide Z stated there were several residents on the 200 hall with no water pitchers and she was unsure why they did not have pitchers and had not asked the nurse.<BR/>5. Record review of Resident #87s face sheet reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: hypertension (blood pressure that is higher than normal), COPD (a group of diseases that cause airflow blockage and breathing-related problems) and A fib (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart).<BR/>Record review of Resident #87's September 2022 physician orders revealed an order dated 03/01/2022: regular diet with thin liquids.<BR/>Record review of Resident #87's MDS 08/12/2022, reflected she had a BIMS of 09, which indicated a moderate impaired cognitive status. Her functional status reflected she required limited assistance with bed mobility, toilet use and personal hygiene and supervision for eating. <BR/>Record review of Resident #87's EHR reflected the following care plan goal for nutrition dated 04/13/2021:<BR/>- <BR/>Resident #87 had altered nutrition and fluids should be encouraged.<BR/>During an observation 09/12/2022 at 9:45 am, Resident #87's water pitcher was on the dresser by the foot of her bed. Resident #87's water pitcher was empty.<BR/>During an observation on 09/13/2022 at 10:12am, Resident #87's water pitcher continued to be on the dresser at the foot of her bed and was empty.<BR/>During an interview on 09/13/2022 at 10:12 am, Resident #87 stated she was tired of not having cold water available. Resident #87 stated she asked the nurses and CNA that day to get her ice and no one had brought it to her. Resident #87 stated they get water once per day if they are lucky.<BR/>6. Record review of a face sheet dated 9/14/2022 revealed Resident #61 was [AGE] years old and was initially admitted on [DATE] with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone, or posture), paranoid schizophrenia (a mental disorder characterized by continuous or relapsing episode of psychosis), and moderate intellectual disabilities. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #61 was sometimes understood and sometimes understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) of 8. This score indicated moderate cognitive impairment for Resident #61. The MDS also indicated Resident #61 required limited to extensive assistance from staff for ADLs. <BR/>Record review of a care plan dated 7/19/2022 indicated Resident #61 had a history of cerebral palsy and required extensive assistance with bed mobility and transfers. The care plan indicated Resident #61 was immobile. <BR/>During an observation on 9/12/22 at 10:21 a.m., Resident #61 was in bed. Her lips were dry and cracked. Her mouth appeared dry. Her water cup was sitting on her bedside table. The table was touching her roommate's bed. The water cup was empty. The table and the cup were out of reach of the resident. <BR/>During an observation on 9/12/22 12:08 p.m., Resident #61 water cup was sitting on her bedside table. The table was touching her roommate's bed. The water cup was empty. The table and the cup were out of reach of the resident.<BR/>During an observation and interview on 9/13/22 at 3:17 p.m., Resident #61 was in her bed. Resident #61's water cup was at the foot of the bed on her bedside table. The cup was out of reach of resident. Resident #61 said she can only reach her water if it was beside her bed. She said if it was at the foot of the bed, she would have to call for help. She said at times her water cup is empty.<BR/>Record review of grievances for the past 6 months April 2022 to September 2022, revealed a grievance was made concerning having no available hydration with a resolution for the ADON to re-educate staff on the importance of hydration with having ice water available at bedside at all times.<BR/>During an interview with the DON on 09/14/2022 at 3:45pm, the DON revealed the facility had just implemented a hydration program a few weeks prior. The DON stated it was her job to monitor the hydration program by doing periodic rounds to ensure residents had water. The hydration program consisted of hiring hospitality aides to ensure that ice and water were passed routinely. The DON stated she was unsure why there was not fresh water and ice passed throughout the day. The DON stated the facility had been out of water pitchers and they just came in on the truck that day and they would be passed out immediately. She stated the facility was using cups from the kitchen to offer water to the residents. The DON stated they had been out of water pitchers for a week or two. The DON stated it was the job of the CNAs and hospitality aides to pass ice at least once per shift. It was the job of the nurses to ensure it was getting done and if they had an issue getting it done, they were to report to the DON or Administrator. The DON stated she was aware there was a problem with the residents getting ice and water each shift and that was why the facility hired the extra hospitality aides to assist with hydration. The DON stated hydration was important to prevent dehydration, urinary tract infections and kidney damage.<BR/>During an interview with the Administrator on 09/15/2022 at 3:00 pm, the Administrator stated the hydration program had been going on for several months. The facility recently hired more hospitality aides to assist the CNAs and ensure the ice and water were being passed in a timely manner. The Administrator stated ice should be passed once a shift and as needed by the CNA or hospitality aide. She stated it was the responsibility of the nurses on the floor to ensure the residents stayed hydrated. The Administrator stated she had not been informed the residents were not getting ice and water passed each shift. The Administrator stated not having hydration could lead to dehydration and urinary tract infections that could be detrimental to the elderly. The Administrator stated it was the job of the DON to monitor for hydration and the facility had been without enough water pitchers for less than a week and were using kitchen glasses to provide hydration until the new pitchers arrived.<BR/>Hydration policy requested from DON on 09/15/2022 at 3:30pm. Hydration policy not provided prior to exit.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety.<BR/>The facility failed to ensure that all staff members wore hairnets appropriately.<BR/>The facility failed to ensure that all kitchen staff members wore N95 mask appropriately while on outbreak status. <BR/>These failures could place residents at risk of foodborne illness and food contamination.<BR/>Findings include: <BR/>During an observation on 9/12/2022 at 9:00 a.m., the Dietary Manager was in the kitchen. Her hair net did not cover all of her hair. There was exposed hair across her forehead and unrestrained hair all of the way around the hairnet. <BR/>During an observation on 9/12/2022 at 9:03 a.m., the plastic container for the sugar was open to air. <BR/>During an observation on 9/12/2022 at 9:10 a.m., Dietary Aide F was in the kitchen with a baseball cap on her head. She did not have on a hair net. She had unrestrained hair from around the baseball cap and had hair sticking out of the back of the cap in knotted up ponytail. There were loose hairs touching her shoulders and her back. <BR/>During an observation and interview on 9/12/2022 at 9:12 a.m., there were 3 tubes of expired dishwasher testing strips hanging on the wall opposite of the dishwasher. The tubes had expirations dates of 2-2021, 3-2022, and 8-2022. The Dietary Manager said she did not know the testing strips were expired and the company had just brought her some new ones. <BR/>During an observation on 9/13/22 at 7:56 a.m., Dietary Aide G was preparing breakfast trays with the N95 mask under his chin. His nose and mouth were exposed. <BR/>During an observation on 9/13/22 at 10:01 a.m., Dietary Aide G was at the dishwasher on the clean side (on the side of the dishwasher where the clean dishes are processed and put away) with his N95 mask below his chin and his nose and mouth exposed. Dietary Aide F was standing at the counter while food was being prepared. She had on a baseball cap and no hairnet. There was a ponytail out of the back and loose hairs were touching her back. There were unrestrained hairs sticking out around the baseball cap. <BR/>During an observation on 9/13/2022 at 10:33 a.m., [NAME] H began pureeing foods. At times her mask was down below her nose . <BR/>During an observation on 9/13/2022 at 10:34 a.m., the Dietary Manager was in the kitchen with her hair net only covering the top of her hair. There was exposed loose hair across her forehead and loose hairs all the way around the hairnet. <BR/>During an observation on 9/13/2022 at 10:51 a.m., Dietary Aide F was sweeping the kitchen during lunch preparation. She did not have on a hairnet. She had on a baseball cap with hair sticking out of the back and hair sticking out from under cap. There were 3 pieces of long hair, unattached from her head, stuck to the back of her shirt. <BR/>During an observation on 9/13/2022 at 11:29 a.m., [NAME] H was taking the temperature of the foods on the steam table. Her mask slid down under her nose on multiple occasions. <BR/>During an observation on 9/13/2022 at 11:30 a.m., the Dietary Manager and Dietary Aide F were wrapping silver ware in napkins. Dietary Aide F had on a baseball cap with unrestrained hair sticking out of the baseball cap. The Dietary Manager's hair was not completely covered with her hairnet. She had loose hair touching her shoulder and unrestrained hair across her forehead. <BR/>During an observation on 9/13/2022 at 11:41 a.m., Dietary Aide F was covering prepared plates and placing trays on cart with no hairnet. At times she would lean across incomplete trays during tray preparation. <BR/>During an observation on 9/13/2022 at 11:43 a.m., CNA A was standing in the kitchen sorting dietary tickets with no hairnet on while trays were being prepared. She was standing at a counter next to pre-prepared drinks for the residents. <BR/>During an interview on 9/14/2022 at 9:03 a.m., Dietary Aide F said she had been in-serviced on wearing hair nets in the kitchen. She said she did not wear a hair net because she wore a baseball cap and she thought all of her hair was tucked into her baseball cap. She said no one in the kitchen had told her the hair was not contained under the baseball cap and to wear a hairnet. <BR/>During an interview on 9/14/2022 at 9:05 a.m., Dietary Aide G said he had worked at the facility for a month. He said he had been oriented on COVID-19 and the importance of wearing a mask. He said it gets hot in the kitchen and he pulls his mask down .<BR/>During an interview on 9/14/2022 at 9:13 a.m., [NAME] H said she tried to keep her mask pulled up. She said her mask slid down her face when she was talking. She said she did know about COVID-19 and that she was supposed to be wearing her mask over her nose.<BR/>During an interview on 9/14/2022 at 9:15 a.m., the Dietary Manager said she thought wearing a baseball cap was ok. She said she thought all of her hair was contained in her hairnet. She said she in-services her staff monthly. She said residents could be negatively affected by hair contaminating food and the residents might not want to eat the food. She said due to Covid-19 all staff were supposed to be wearing masks that covered their nose and mouth. <BR/>During an interview on 9/14/2022 01:40 p.m., CNA A said she was unaware she was supposed to wear a hair net in the area she was in inside the kitchen. She said she thought it was only if you went past the preparation table. She said it made sense though since there were prepared drinks on the counter where she was standing.<BR/>During an interview on 9/15/2022 at 1:40 p.m., the DON said the facility had been on outbreak status, but she was not sure the exact date the outbreak started. She said all staff should have been wearing N95 mask appropriately. She said the Administrator wanted all staff to wear N95 mask and staff could not even wear a K-N95. <BR/>During an interview on 9/15/2022 at 2:16 p.m., the Administrator said anyone in the kitchen should be wearing a hair net and the hair net should be covering all their hair. She said wearing a hair net inappropriately could cause hair to get into the food and cause contamination of the food item. She said if there were undated and unlabeled food, then staff would not be aware the food might be out of date. She said all employees should be wearing a N95 mask. She said even in the kitchen staff should be wearing a mask and it should be covering their face. She said staff not wearing a mask appropriately around other staff or residents could lead to continued outbreak of Covid-19. <BR/>Review of a facility Employee Infection Control, Nutrition Services dated May 28, 2020 indicated, .anyone who enters the kitchen will have all hair restrained using bouffant caps, mesh or net, beard guard and clothing which covers body hair .<BR/>Review of a facility Competencies for Nutrition Services Employees checklist dated 7/2020 indicated, .Consistently uses hair restraints (and beard guards) properly .when indicated in the event of a respiratory or viral outbreak, wears a mask and other PPE as directed. SEE DIAGRAM pg. 6 .How to Wear a Medical Mask Safely .Do's .cover your mouth, nose, and chin .Don'ts .Do not wear mask only over mouth or nose .do not remove the mask to talk to someone .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 7 residents reviewed for pharmacy services. (Resident #1)<BR/>The facility failed administer all scheduled medications to Resident #1. <BR/>This failure could place residents at risk for inaccurate drug administration and side effects from missed doses of medication. <BR/>Findings included:<BR/>Record review of a face sheet dated 10/03/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), muscle spasms, and recurrent depressive disorders. <BR/>Record review of physician's orders dated 10/04/23 indicated an order for Amlodipine (blood pressure medication) 5 milligram tablet, 1 tablet 1 time per day with a start date on 06/27/21. There was an order for Claritin (medication for allergy symptoms) 10 milligram tablet, 1 tablet 1 time per day with a start date of 05/08/23. There was an order Clonidine HCL (blood pressure medication) 0.1 milligram tablet, 1 time per day with a start date of 06/27/21. There was an order for Citalopram (used for depression) 10 milligram tablet, 1 time per day with a start date of 06/27/21. There was an order for Colace (stool softener) 100 milligram tablet 2 times per day with a start date of 11/01/22. There was an order for Cyclobenzaprine (treats pain and muscle stiffness) 5 milligram tablet every 8 hours with a start date of 11/01/22. There was an order for a multi vitamin, 1 tablet 1 time per day with a start date of 11/01/22. There was an order for Esomeprazole Magnesium (used to treat stomach and esophagus problems such as acid reflex, ulcer) 20 milligram, delayed release, 1 time per day with a start date of 06/27/21. There was an order for Fluticasone Propionate 50 micrograms/actuation nasal spray, 1 spray nasally 2 times per day with a start date of 05/08/23. There was an order for Levetiracetam (used to treat seizures) 100 milligrams/milliliters oral solution, 10 milliliters 2 times per day with a start date of 06/27/21. There was an order for Robitussin Cough-Chest Congestion DM 5 milligram/50 milligrams/5 milliliters every 6 hours with a start date of 11/01/22. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #1 was rarely to never understood. The MDS indicated a BIMS was not conducted due to Resident #1 being rarely to never understood. The MDS indicated Resident #1 received an antidepressant. The MDS indicated Resident #1 had an active diagnosis of hypertension (high blood pressure), a seizure disorder or epilepsy, and depression. <BR/>Record review of a care plan last revised on 05/31/23 indicated Resident #1 was prescribed an anti-convulsant - Levetiracetam (used to treat seizures) 100 milligrams/milliliters oral solution, 10 milliliters 2 times per day. There was an intervention to administer the medication as ordered. The care plan indicated the resident was prescribed an anti-depressant, Citalopram (used for depression) 10 milligram tablet, 1 time per day. There was an intervention to administer the medication as ordered. The care plan indicated the resident was prescribed anti-hypertensive medications, Amlodipine (blood pressure medication) 5 milligram tablet, 1 tablet 1 time per day and Clonidine HCL (blood pressure medication) 0.1 milligram tablet, 1 time per day. There was an intervention to administer the medications as ordered. <BR/>Record review of an eMAR (electronic medication administration record) dated 07/01/23 - 07/31/23 indicated on 07/04/23, Amlodipine and Clonidine were not administered as ordered. On 07/05/23, Amlodipine, Citalopram, Claritin, Clonidine, Colace, Cyclobenzaprine, a multi-vitamin, Esomeprazole Magnesium, Fluticasone Propionate, Levetiracetam, and Robitussin Cough-Chest were not administered as ordered. On 07/08/23, 07/10/23, 07/13/23, 07/14/23, 07/18/23, 07/19/23, 07/20/23, 07/23/23, 07/24/23, 07/25/23 Resident #1 did not receive Amlodipine and Clonidine as ordered. On 07/28/23, Resident #1 did not receive Amlodipine and Clonidine as order. The eMAR indicated on 07/29/23, Resident #1 did not receive Clonidine, Colace, Robitussin Cough-Chest Congestion and Levetiracetam were not administered as ordered. <BR/>Record review of an eMAR dated 09/01/23 - 09/30/23 indicated on 9/10/23, Resident #1 did not receive Citalopram as ordered. The eMAR indicated on 09/18/23 and 09/26/23, Resident #1 did not receive Amlodipine and Clonidine as ordered. <BR/>Record Review of Nurse's notes dated 07/01/23 - 09/30/2023 indicated on 07/28/23 a nurse's note read, Medication was administered outside of scheduled parameters, provider informed that resident medication was delayed . The note was signed by the DON. There were no further notes concerning delayed medication or medications that were not administered. <BR/>During an interview on 10/3/23 at 4:20 p.m., a family member of Resident #1 said on 07/28/23 Resident #1 did not receive his medication as prescribed.<BR/>During an interview on 10/03/23 at 5:05 p.m., a family member said Resident #1 had not always received his scheduled medications. The family member said they had found medications at the bedside. <BR/>During an interview on 10/04/23 at 2:48 p.m., the DON said she did not know why Residents #1's medications were not given on time on 7/28/2023. She said she did not know what happened. She said for some reason the medications were delayed and the nurse practitioner was notified.<BR/>During an interview on 10/5/2023 at 9:32 a.m., LVN D said document did indicate Resident #1 did miss several medications in July and September. She said if they were held for any reason there should be a nurse's note. She said the blood pressure medications may have been held due the resident's blood pressure or heart rate. She said, if it's not documented it's not done.<BR/>During an interview on 10/5/23 at 10:33 a.m., the DON said according to the documentation for July and September it did appear Resident #1 did not receive all of his medications. She said that the blood pressure medicines were probably held because his vital signs. She said she would have expected if the medicine was being held because of the vital signs, this should be documented. She said residents' not receiving their medications could cause them to have high or low blood pressure.<BR/>During an interview on 10/05/23 at 11:50 a.m., the Administrator said she would expect Resident #1 to get his scheduled medications as ordered. She said any negative outcome would depend on the medication such affecting blood pressure.<BR/>Review of a Medications - Guidelines on Clinical Practice policy dated January 12, 2020 indicated, .Staff will provide medications in accordance with standard practice guidelines .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 residents reviewed for tube feeding management (Resident #4). <BR/>The facility failed to ensure Resident #4's tube feeding formula was labeled with the time and date it was started.<BR/>This failure could place residents receiving tube feedings at risk of gastrointestinal disturbances (relating to the stomach and the intestines), and bacterial infection. <BR/>Findings included:<BR/>Record review of the Resident #4's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old and readmitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), colostomy (surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) status, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) status, dysphagia (difficulty swallowing), and shortness of breath. <BR/>Record review of Resident #4's MDS dated [DATE], indicated Resident #4 sometimes made himself understood and usually understood others. The MDS indicated Resident #4 had short-term and long-term memory problems. The MDS indicated Resident #4 had moderately impaired cognitive decision-making skills. The MDS indicated Resident #4 had an active diagnosis of non-traumatic spinal cord dysfunction, quadriplegia, and history of CVA, TIA or stroke. The Nutritional approaches section of the MDS did not address Resident #4's feeding tube. <BR/>Record review of Resident #4's care plan revised on 1/20/23 indicated Resident #4 received enteral feedings. The care plan interventions included to monitor the tolerance of tube feedings and provide automatic water flush via the tube feeding pump. <BR/>During an observation on 2/8/23 at 11:00 a.m. revealed Resident # 4 laid in his bed. His tube feeding ran at 60 ml/hr (milliliters per hour). There was no time, date, initials or resident identification information on the formula bag, the formula tubing, the water bag, or the water tubing. Between the formula bag and the water bag hung an empty bag that was dated 2/6/23. There was a dry, crusting light brown substance at the bottom of the empty bag. <BR/>During an observation on 2/8/23 at 1:00 p.m. revealed Resident # 4 laid in his bed. His tube feeding ran at 60 ml/hr (milliliters per hour). There was no time, date, initials or resident identification information on the formula bag, the formula tubing, the water bag, or the water tubing. Between the formula bag and the water bag hung an empty bag that was dated 2/6/23. There was a dry, crusting light brown substance at the bottom of the empty bag. <BR/>During an observation on 2/8/23 at 3:00 p.m. revealed Resident # 4 laid in his bed. His tube feeding ran at 60 ml/hr (milliliters per hour). There was no time, date, initials or resident identification information on the formula bag, the formula tubing, the water bag, or the water tubing. Between the formula bag and the water bag hung an empty bag that was dated 2/6/23. There was a dry, crusting light brown substance at the bottom of the empty bag. <BR/>During an interview on 2/9/23 at 9:30 a.m., LVN B said she took care of Resident #4 yesterday but had not hung his tube feeding. She said the tube feeding should have been dated, initialed and timed. LVN B said the tube feeding could only hang for 24 hours. She said if it was not dated and timed it was hard to say how long the tube feeding had hung. LVN B said usually Resident #4's tube feeding ran continuously except for a 2 hour down time. LVN B said usually the tube feeding was changed on the night shift but indicated there had been times she had to change it on her shift (6:00 a.m. -6:00 p.m.). LVN B said the reason the change ended up on her shift at times could be because the down time went longer than 2 hours or the feeding had to be held due to a large residual volume (gastric residual volume refers to the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding. Nurses withdraw this fluid via the feeding tube by pulling back on the plunger of a large [usually 60 mL] syringe at intervals typically ranging from four to eight hours). LVN B said again, that was why it was important to date and time the tube feeding when it was hung to ensure it did not hang greater than 24 hours. LVN B said if the tube feeding hung longer than 24 hours the formula could spoil and could cause Resident #4 to get sick. LVN B said the tubing was not usually labeled because it came as a set with the tube feeding and water flush. <BR/>During an interview on 2/9/23 at 9:50 a.m., RN C said nurses should time, date and initial any medications administered to a resident. RN C said that included tube feedings and water flushes. RN C said Resident #4's tube feeding should have been properly labeled to ensure the tube feeding did not hang longer than 24 hours. LVN B said if the tube feeding hung longer than 24 hours the formula could sour and could cause GI. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected nurses to time, date and initial any medications administered to a resident that cannot be completely administered by the nurse while in the room (such as IV medications/fluids and tube feedings). The DON said one reason it was important for said Resident #4's tube feeding to have been properly labeled was to ensure the tube feeding did not hang longer than 24 hours. The DON said if the tube feeding hung longer than 24 hours the formula could go bad, and Resident #4 could get sick. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected nurses to follow policy and procedure regarding the administration of tube feedings. <BR/>The facility policy and procedure titled Enteral Nutrition For Closed System Nasogastric, Nasointestinal, Gastric and Jejunal Feeding Tubes, revised on 01/12/20 reflected, Standard of Practice: Enteral Nutrition therapy will be performed in a safe manner by a qualified license nurses according to standard practice guidelines .Procedure: .(11) Label formula container with the resident's name, room, date, starting time, rate (ml/hr) and your initials

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 2 residents reviewed for care plans. (Resident# 29)<BR/>The facility failed to implement the care plan intervention to report to Resident #29's provider, of his blood glucose levels (is a test that mainly screens for diabetes by measuring the level of glucose (sugar) in your blood) that were less than 100 per the physician orders.<BR/>This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services.<BR/>Findings included:<BR/>Record review of Resident #29's face sheet dated 10/30/23 indicated Resident #29 was 91-years-old male and admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)). <BR/>Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated Resident #29 was usually understood and usually understood others. The MDS indicated Resident #29's BIMS score was 10 which indicated moderate cognitive impairment and required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and bathing. <BR/>Record review of Resident #29's care plan dated 11/11/22 indicated Resident #29 received an antidiabetic (are medicines developed to stabilize and control blood glucose levels amongst people with diabetes). Interventions included observe for signs of hypoglycemia (low blood sugar, the body's main energy source) and treat per hypoglycemic protocol and report pertinent lab results to physician. <BR/>Record review of Resident #29's Physician Summary Report dated 10/01/23-10/31/23 Novolin 70/30 (is used for the treatment of diabetes only) Unit-100 Insulin (helps your body turn food into energy and controls your blood sugar levels) 100 unit/ml subcutaneous (a short needle is used to inject a drug into the tissue layer between the skin and the muscle) suspension 35 units/units subcutaneous 1 time per day, Notify MD/NP for FSBS (blood glucose monitoring) less than 60 or greater than 350. Hold if blood sugar is less than 100 and contact MD. *MD call. Dx: diabetes mellitus (a group of diseases that result in too much sugar in the blood (high blood glucose)), Started on 09/14/23. Discontinued by LVN Q on 10/05/23.<BR/>Record review of Resident #29's Physician Summary Report dated 10/01/23-10/31/23 Humulin 70/30 Unit-100 Insulin 100 unit/ml subcutaneous 20 Units/units subcutaneous daily at bedtime, Blood Glucose Check Site Location, hold if Blood sugar is less than 100 and contact MD. MD call. Dx: Type 2 diabetes mellitus, Started on 09/14/23. Discontinued by LVN Q on 10/05/23.<BR/>Record review of Resident #29's Consolidated Physician Order dated 10/05/23 reflected Novolin 70/30 Unit-100 Insulin 100 unit/ml subcutaneous suspension 30 units/units subcutaneous 1 time per day, Notify MD/NP for FSBS less than 60 or greater than 350. Hold if blood sugar is less than 100 and contact MD. MD call. <BR/>Record review of Resident #29's Consolidated Physician Order dated 10/05/23 reflected Humulin 70/30 Unit-100 Insulin 100 unit/ml subcutaneous 15 Units/units subcutaneous daily at bedtime, Blood Glucose Check Site Location, hold if Blood sugar is less than 100 and contact MD. MD call.<BR/>Record review of Resident #29's MAR dated 10/01/23-10/31/23 indicated Novolin 70/30 Unit-100 Insulin 100 unit/ml subcutaneous suspension 35 units/units subcutaneous 1 time per day, Notify MD/NP for FSBS less than 60 or greater than 350. Hold if blood sugar is less than 100 and contact MD. MD call. Dx: diabetes mellitus. Start date: 09/14/23. End date: 10/05/23. Blood glucose results indicated:<BR/>*10/02/23 BSG 63 (LVN T)<BR/>*10/03/23 BSG 81 (LVN T)<BR/>*10/04/23 BSG 90 (LVN Q)<BR/>*10/05/23 BSG 58 (LVN Q)<BR/>Record review of Resident #29's MAR dated 10/01/23-10/31/23 indicated Novolin 70/30 Unit-100 Insulin 100 unit/ml subcutaneous suspension 30 units/units subcutaneous 1 time per day, Notify MD/NP for FSBS less than 60 or greater than 350. Hold if blood sugar is less than 100 and contact MD. MD call. Dx: diabetes mellitus. Start date: 10/05/23. Blood glucose results indicated:<BR/>*10/06/23 BSG 69 (LVN T)<BR/>*10/08/23 BSG 60 (LVN T)<BR/>*10/11/23 BSG 64 (LVN T)<BR/>*10/13/23 BSG 85 (LVN Q)<BR/>*10/18/23 BSG 85 (LVN Q)<BR/>*10/22/23 BSG 61 (LVN T)<BR/>*10/29/23 BSG 87 (Agency LVN)<BR/>Record review of Resident #29's nurses note dated 01/30/23-10/30/23 indicated on 10/05/23 by LVN Q . [Resident #29] BS at 0630 a.m. was 58 . [Resident #29] was a little sweaty but other signs or symptoms of hypoglycemia .APRN QQ was notified orders given to give 2 glasses of juice and recheck after breakfast .recheck was done [Resident #29] BS 98 . No other entries noted regarding BS less than 100 or notification of the MD/NP. <BR/>During an interview on 11/01/23 at 9:30 a.m., APRN QQ said Resident #29 recently joined his services. He said the facility had notified him about Resident #29's BSGs being less than 100 about 3 times. He said he had not been notified of Resident #29's BSG being less than 100, a total of 10 times noted on the MAR. He said the facility may had called Resident #29's hospice company about the BSG results. He said he recalled once modifying Resident #29's insulin orders due to a low BSG result. He said he gave verbal orders and wrote some on his rounding paperwork. He said reporting Resident #29's BSG results were important to monitor recurring trends of hypoglycemia. He said it was also important to avoid sympathetic hypoglycemia (the nutritionally deprived brain also stimulates the sympathetic nervous system, leading to neurogenic symptoms such as sweating, palpitations, tremulousness, anxiety, and hunger). He said it important to be notified to decrease the dosage of Resident #29's insulin to reduce the risk of hypoglycemia. <BR/>On 11/02/23 at 1:20 p.m., attempted to contact LVN T by phone. A voice message was left but no to return call prior or after exit. <BR/>During an interview on 11/02/23 at 2:06 p.m., LVN N said when a MD/NP was notified regarding lab results such as low BSGs, the nurse should document in a progress note. She said it was important to follow the Resident #29's care plan interventions. She said most care plan interventions correlated with physician's orders. She said if the MD/NP made changes it could be documented in a nurses note and 24-hour report. She said it was important to notify the MD/NP in case they needed to be sent to the hospital or receive intravascular fluid. She said untreated hypoglycemia could result in a coma and death. <BR/>During an interview on 11/02/23 at 3:04 p.m., the DON said nursing administration tried to go over too high and low BSG in morning meetings. She said they mostly went over high BSG because the computer system flagged high BSG. She said she did not recall being notified or reviewing Resident #29's BSG results less than 100. She said she did recall APRN QQ gave an order to give Resident #29 some juice to address a BSG result less than 100. She said low BSG could indicate infection. She said if a resident was sympathetic, gel should be given, and provider contacted. She said notifying a MD/NP for BSG less than 100 was not a standard order, it normally was less than 60. She said nurses should document notification of the physician and new orders if received in a nurses note or on the MAR. She said a resident being hypoglycemia was not good. She said Resident #29 could go into a diabetic coma or DKA (diabetic ketoacidosis is a serious complication of diabetes that can be life-threatening). She said she tried to monitor all resident BSG results every morning, but it was easier to monitor the high results because they sent an alert. She said she also reviewed and monitored the 24-hour report of pertinent lab results. She said some days it did not happened due to other duties. She said care plans are used by nurses to outline a plan of care for a resident. She said when care plan interventions were not followed, needs could not be addressed. <BR/>During an interview on 11/02/23 at 4:07 p.m., the ADM said care plan are used to determine individualized care needs of the resident and intervention put in place to address those needs. She said if the intervention was not followed the resident's needs could not be addressed or met by the staff. <BR/>Record review of a facility's Comprehensive Care Plans policy reviewed 04/17/23 indicated .the services that are to be furnished to attain or maintain the resident's highest practicable physical .qualified staff responsible for carrying out interventions specified in the care plan will be notified of their role and responsibilities for carrying out the interventions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care and provide the resident and their representative with a summary of the baseline care plan that included goals of the resident, summary of medications and dietary instructions, and services and treatments within 48 hours of admission for 4 of 10 residents reviewed for baseline care plans. (Resident #94, Resident #352, Resident #358, and Resident #361)<BR/>1.The facility failed to develop a baseline care plan with initial goals and the minimum healthcare information necessary to provide person-centered care within 48 hours of admission for Resident #94, Resident #352, Resident #358, and Resident #361.<BR/>These failures could place residents at risk of not receiving care and services to meet their needs. <BR/>Findings included:<BR/>1. Record review of Resident #94's face sheet dated 10/31/23 indicated Resident #94 was admitted to the facility on [DATE] with diagnoses including sepsis (serious condition resulting from harmful bacteria in the blood) due to MRSA (methicillin resistant staphylococcus aureus-bacteria), ESBL (extended spectrum beta lactamase resistance), weakness, abnormality of gait and mobility, lack of coordination, cognitive communication deficit, history of cerebral infarction (disruption of blood flow to the brain, also called a stroke), and traumatic subdural hemorrhage (bleeding in the skull caused by a traumatic head injury).<BR/>Record review of Resident #94's admission MDS assessment revealed it had not been completed.<BR/>Record review of Resident #94's undated care plan revealed there were no interventions related to PICC line care, dialysis three days a week for end stage renal disease, or therapy services. <BR/>Record review of Resident #94's Consolidated Orders dated 10/31/23 revealed she was receiving daptomycin 500 mg IV every other day for MRSA and had PICC line dressing changes as needed. Resident #94 had orders for dialysis on Monday, Wednesday, and Fridays at 4:00 PM and she had orders for physical, occupational, and speech therapy.<BR/>2. Record review of Resident #352's face sheet dated 10/31/23 indicated Resident #352 was admitted to the facility initially on 10/17/23 and readmitted on [DATE] (resident went to emergency room on [DATE] and returned same day) with diagnoses including surgery for an abdominal aortic aneurysm (enlargement of the main blood vessel that delivers blood to the body at the level of the abdomen, could be life-threatening if it bursts), severe protein-calorie malnutrition (lack of proper nutritional intake of protein and calories), weakness, abnormalities of gait and mobility, lack of coordination, history of respiratory failure, and elevated white blood cell count (could mean a bacterial or viral infection).<BR/>Record review of Resident #352's admission MDS assessment dated [DATE] indicated Resident #352 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated Resident #352 had no cognitive impairment. The MDS indicated Resident #352 was receiving IV feedings. The MDS indicated Resident #352 had a PICC line for IV access on admission. The MDS showed triggered care areas of ADL functional/rehabilitation potential, dehydration/fluid maintenance and nutritional status with TPN (total parenteral nutrition-nutrition given through an IV into the blood).<BR/>Record review of Resident #352's care plan dated 10/31/23 revealed was no interventions related to changing the PICC line care, therapy, severe protein-calorie malnutrition, and abdominal aortic aneurysm.<BR/>Record review of Resident #352's Consolidated orders dated 10/31/23 revealed she had orders for PICC line dressing changes; she was receiving physical and occupational therapy for functional deficits with self-care and mobility; and she had wound care to her abdomen with a diagnosis of an abdominal aortic aneurysm. <BR/>3. Record review of Resident #358's face sheet dated 11/01/23 indicated Resident #358 admitted to the facility on [DATE] with diagnoses including a fracture to her right lower leg, osteomyelitis to right foot & ankle, weakness, hypertension, abnormality of gait and mobility, lack of coordination, atrial fibrillation (irregular, often rapid, heart rate that commonly causes poor blood flow), and heart disease.<BR/>Record review of Resident #358's admission MDS dated [DATE] indicated Resident #358 was understood and understood others. The MDS indicated a BIMS score of 12 which indicated Resident #358 had moderate cognitive impairment. The MDS showed triggered care areas of ADL functional/rehabilitation potential, dehydration/fluid maintenance with IV antibiotics, and pain.<BR/>Record review of Resident #358's undated care plan did not include interventions for PICC line care, external fixator to right lower leg, or ADL care needs.<BR/>Record review of Resident #358's Consolidated orders dated 10/31/23 revealed orders for PICC line dressing changes weekly and as needed if it becomes damp, loose, soiled, sign or symptoms of infection and she had wound care orders for pin care to the external fixator, wound care to a wound to her ankle.<BR/>Record review of Resident #358's nurse's notes dated 10/10/23 revealed she had an external fixator to her right ankle.<BR/>4. Record review of Resident #361's face sheet dated 10/30/23 revealed Resident #361 was admitted to the facility on [DATE] with diagnoses including lymphedema (swelling in an arm or leg caused by a blockage in the lymphatic system, part of the immune and circulatory systems), pneumonia (infection in lungs), weakness, abnormalities of gait and mobility, heart failure, and diabetes (high sugar levels in blood).<BR/>Record review of Resident #361's admission MDS dated [DATE] indicated Resident #361 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated Resident #361 was cognitively intact. Resident #361 required extensive assistance of 2 persons for most ADLs. Resident #361 was always incontinent of urine and frequently incontinent of bowel. The MDS said Resident #361 did not have pressure ulcers. The MDS showed triggered care areas of ADL functional/rehabilitation potential and at risk for pressure ulcers.<BR/>Record review of Resident #361's undated care plan revealed it did include the care areas of pressure ulcer, surgical wound, below knee amputation, therapy, diabetes, heart failure, and diet were not initiated within 48 hours of admission.<BR/>Record review of Resident #361's Consolidated orders dated 10/31/23 revealed orders for occupational and physical therapy, wound care to a left below the knee amputation incision, wound care to his coccyx, insulin for his diabetes, he was receiving furosemide for edema and amiodarone for heart failure, and he had regular no added salt and reduced concentrated sweets diet.<BR/>During an interview on 11/01/23 at 11:18 AM, LVN KK said he had worked at the facility for 6 months. LVN KK said the base line care plan should be initiated on admission and then an RN had to complete it. LVN KK said the purpose of baseline care plan was so residents received the appropriate care they needed. LVN KK said the resident would be at risk of not having their needs met if the base line care plan was not completed timely and did not include the care areas needed to provide care to the resident.<BR/>During an interview on 11/01/23 at 6:02 PM, LVN O said she had worked at the facility for five years. LVN O said she did not know exactly who was responsible for the base line care plan, but it was part of the admission process. LVN O said the baseline care plan will not let her complete it and she can only save it and then it asks for a RN signature at the end. LVN O said the purpose of the base line care plan was to have all the information to care for the resident to guide the resident's care. LVN O said the resident would be at risk of not having their needs met if the base line care plan was not completed timely and included all the pertinent care areas to care for the resident.<BR/>During an interview on 11/02/23 at 8:36 AM, ADON P said she had worked at the facility since July of 2023. ADON P said the base line care plan was initiated by the admitting nurse during the admission assessment. ADON P said their admission assessment had the base line care plan built into it. ADON P said the purpose of the baseline care plan was to make sure all the resident's needs were being met and initiated within 24 hours. ADON P said the base line care plan was a guideline for the care of the resident. ADON P said the base line care plan becomes the comprehensive care plan. ADON P said she used an admission audit form to check off that all areas of the admission assessment were completed, which included the admitting nurse initiating the baseline care plan. She said she had to work the floor regularly and had gotten behind on completing the admission audits. ADON P said if the base line care plan did not include all needed care areas to care for the resident and was not initiated within 24 hours, the resident could not have their needs met.<BR/>During an interview on 11/02/23 at 10:05 AM, the DON said she had worked at the facility for six years. The DON said the admitting nurse was supposed to complete the admission assessment upon admission and their software had the base line care plan built into part of the admission assessment. The DON said the base line care plan should be completed within 24-48 hours and include interventions and goals to guide the resident's care until the comprehensive care plan was completed. The DON said she was ultimately responsible for ensuring the base line care plans were completed. The DON said the resident would be at risk of not having their needs met if the base line care plan did not include interventions and goals to care for the resident within 24-48 hours. <BR/>During an interview on 11/02/23 at 10:52 AM, the ADM said she would expect the base line care plan to be completed within 48 hours of the resident's admission to establish the basic needs of the resident with interventions and goals put in place to meet the needs of the resident until the comprehensive care plan could be completed. The ADM said the receiving nurse would be responsible for completing the base line care plan during admission. The ADM said the resident was at risk for not having their needs met if the baseline care plan was not completed within 48 hours and did not have inventions and goals to meet the resident's needs.<BR/>Review of the facility's policy titled Care Plans-Process with a revised date of February 2020 indicated . initiate a baseline care plan and complete within 48 hours of admission based on the physician's orders and nursing evaluation . the base line care plan facilitates care until the comprehensive care plan is developed within the first 14 days .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Residents #1) reviewed for resident rights.<BR/>CNA E did not sit as she assisted Resident #1 with dining. <BR/>CNA E did not refrain from talking on her cell phone while she assisted Resident #1 with dining. <BR/>The facility did not ensure Resident #1 was clothed in his personal clothing. <BR/>These failures could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth.<BR/>Findings included:<BR/>Record review of Resident #1's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including Hemiplegia or hemiparesis (hemiplegia refers to a severe or complete loss of strength, whereas hemiparesis refers to a relatively mild loss of strength) following cerebral infarction (stroke) affecting the left non-dominant side, type II diabetes, shortness of breath, nausea/ vomiting, and depression. <BR/>Record review of Resident #1's MDS dated [DATE] indicated Resident #1 was usually understood and usually understood others. The MDS indicated Resident #1 had severe cognitive impairment (BIMS of 5). The MDS indicated he had no behavior of rejecting care during the 7 days look back period. The MDS indicated he required extensive assistance with bed mobility, transfers, locomotion in his wheelchair, dressings, eating, toilet use, and personal hygiene. The MDS indicated Resident #1 was completely dependent on staff for bathing. The MDS indicated Resident #1 was always incontinent of bowel and bladder. <BR/>Record review of Resident #1's care plan revised on 11/15/22 indicated Resident #1 had a self-care deficit. The care plan interventions included to give the resident as many choices as possible about care and provide assistance with self-care as needed. <BR/>During an observation on 2/8/23 at 11:10 a.m. revealed Resident #1 laid in his bed wearing a hospital gown. <BR/>During an observation on 2/8/23 at 12:45 p.m. revealed the door to Resident # 1's door was open. CNA E stood at Resident #1's bedside. CNA E said loudly Well what are you going to then?. A few moments later CNA E again said, Well what are you going to then? and then said I gotta go. The surveyor entered the room. CNA E continued to stand at Resident #1's bedside and fed him several bites from his food tray. <BR/>During an observation and interview on 2/8/23 at 2:50 p.m. revealed Resident #1 laid in his bed wearing a hospital gown. Resident #1 said he did not want to wear a hospital gown. Resident #1 said his family member had brought him some clothes and pointed at the armoire. There were multiple personal clothing items hanging in the armoire. Resident #1 said he guessed he had to wear the gown because that was what they (facility staff) put on him. Resident #1 could not say how long he had been wearing the hospital gown or who had placed the hospital gown on him. Resident #1 said CNA E talked on the phone while she fed him today (2/8/23) and felt it was rude. <BR/>During an interview on 2/10/23 at 10:28 a.m., CNA G said there was no reason for a resident to have been in a hospital gown. CNA G said the facility had clothes that were donated for resident use if a resident did not have any personal clothes available. CNA G said if a resident did not want to wear a hospital gown and was placed in hospital gown, it could take away the resident's dignity. CNA G said CNAs should not stand while feeding a resident because it could cause the resident to feel intimidated. CNA G said another reason CNAs should not stand while feeding a resident was to ensure the resident did not have any signs of aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). CNA G said under no circumstance should a CNA take a personal phone call while he/she administered resident care. CNA G said to take a personal call during the administration of patient care was not only disrespectful but would also divert attention away from the resident. <BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she should not have stood while feeding Resident #1. CNA E said she should have sat at Resident #1's bedside while she assisted him with eating because it was more respectful than standing. CNA E said she stood while she fed Resident #1 because she was in a hurry. CNA E said she did not notice Resident #1 was wearing a hospital gown and indicated he should have been wearing his personal clothes. CNA E said she should not have taken the personal call while she assisted Resident #1 but did so because she had a family situation. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected staff to sit while they assisted residents with eating in order to promote respect and safety. The DON said it was not acceptable for a resident to be in a hospital gown and to do so (place a resident in a hospital gown) could affect the resident's dignity. The DON said it was not acceptable for staff to have taken a phone call while assisting a resident. The DON said she expected staff to go to the break room or their car if they had to take a phone call. The DON said a staff member taking a phone call in front of a resident was a dignity issue and could also confuse the resident. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected staff to ensure residents were clothed in their personal clothing if it was the resident's preference. The Administrator said she expected staff to ensure respect and dignity were provided to residents. The Administrator indicated taking personal phone calls during resident care activities and standing while feeding a resident did not promote respect and dignity.<BR/>Record review of the undated facility policy and procedure titled, Exercise of Rights reflected, Policy Statement- Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to our facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Residents #1) reviewed for resident rights.<BR/>CNA E did not sit as she assisted Resident #1 with dining. <BR/>CNA E did not refrain from talking on her cell phone while she assisted Resident #1 with dining. <BR/>The facility did not ensure Resident #1 was clothed in his personal clothing. <BR/>These failures could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth.<BR/>Findings included:<BR/>Record review of Resident #1's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including Hemiplegia or hemiparesis (hemiplegia refers to a severe or complete loss of strength, whereas hemiparesis refers to a relatively mild loss of strength) following cerebral infarction (stroke) affecting the left non-dominant side, type II diabetes, shortness of breath, nausea/ vomiting, and depression. <BR/>Record review of Resident #1's MDS dated [DATE] indicated Resident #1 was usually understood and usually understood others. The MDS indicated Resident #1 had severe cognitive impairment (BIMS of 5). The MDS indicated he had no behavior of rejecting care during the 7 days look back period. The MDS indicated he required extensive assistance with bed mobility, transfers, locomotion in his wheelchair, dressings, eating, toilet use, and personal hygiene. The MDS indicated Resident #1 was completely dependent on staff for bathing. The MDS indicated Resident #1 was always incontinent of bowel and bladder. <BR/>Record review of Resident #1's care plan revised on 11/15/22 indicated Resident #1 had a self-care deficit. The care plan interventions included to give the resident as many choices as possible about care and provide assistance with self-care as needed. <BR/>During an observation on 2/8/23 at 11:10 a.m. revealed Resident #1 laid in his bed wearing a hospital gown. <BR/>During an observation on 2/8/23 at 12:45 p.m. revealed the door to Resident # 1's door was open. CNA E stood at Resident #1's bedside. CNA E said loudly Well what are you going to then?. A few moments later CNA E again said, Well what are you going to then? and then said I gotta go. The surveyor entered the room. CNA E continued to stand at Resident #1's bedside and fed him several bites from his food tray. <BR/>During an observation and interview on 2/8/23 at 2:50 p.m. revealed Resident #1 laid in his bed wearing a hospital gown. Resident #1 said he did not want to wear a hospital gown. Resident #1 said his family member had brought him some clothes and pointed at the armoire. There were multiple personal clothing items hanging in the armoire. Resident #1 said he guessed he had to wear the gown because that was what they (facility staff) put on him. Resident #1 could not say how long he had been wearing the hospital gown or who had placed the hospital gown on him. Resident #1 said CNA E talked on the phone while she fed him today (2/8/23) and felt it was rude. <BR/>During an interview on 2/10/23 at 10:28 a.m., CNA G said there was no reason for a resident to have been in a hospital gown. CNA G said the facility had clothes that were donated for resident use if a resident did not have any personal clothes available. CNA G said if a resident did not want to wear a hospital gown and was placed in hospital gown, it could take away the resident's dignity. CNA G said CNAs should not stand while feeding a resident because it could cause the resident to feel intimidated. CNA G said another reason CNAs should not stand while feeding a resident was to ensure the resident did not have any signs of aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). CNA G said under no circumstance should a CNA take a personal phone call while he/she administered resident care. CNA G said to take a personal call during the administration of patient care was not only disrespectful but would also divert attention away from the resident. <BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she should not have stood while feeding Resident #1. CNA E said she should have sat at Resident #1's bedside while she assisted him with eating because it was more respectful than standing. CNA E said she stood while she fed Resident #1 because she was in a hurry. CNA E said she did not notice Resident #1 was wearing a hospital gown and indicated he should have been wearing his personal clothes. CNA E said she should not have taken the personal call while she assisted Resident #1 but did so because she had a family situation. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected staff to sit while they assisted residents with eating in order to promote respect and safety. The DON said it was not acceptable for a resident to be in a hospital gown and to do so (place a resident in a hospital gown) could affect the resident's dignity. The DON said it was not acceptable for staff to have taken a phone call while assisting a resident. The DON said she expected staff to go to the break room or their car if they had to take a phone call. The DON said a staff member taking a phone call in front of a resident was a dignity issue and could also confuse the resident. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected staff to ensure residents were clothed in their personal clothing if it was the resident's preference. The Administrator said she expected staff to ensure respect and dignity were provided to residents. The Administrator indicated taking personal phone calls during resident care activities and standing while feeding a resident did not promote respect and dignity.<BR/>Record review of the undated facility policy and procedure titled, Exercise of Rights reflected, Policy Statement- Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to our facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 o1 dining room and 6 of 22 residents reviewed for environment. (Resident #13, Resident #28, Resident #33, Resident #61, Resident #84, and Resident #97)<BR/>The facility failed to remove 4 used beds from the dining room.<BR/>The facility did not ensure clean carpets in the rooms of Resident #13, Resident #28, Resident #33, Resident #61, Resident #84 and Resident #97.<BR/>These failures placed residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth.<BR/>Findings included:<BR/>1. Record review of the face sheet 9/14/2022 indicated Resident #13 was [AGE] years old and was admitted on [DATE] with diagnoses including anxiety disorder, other recurrent depressive disorders, and moderate intellectual disabilities. <BR/>Record review of a care plan revised on 7/29/2022 indicated Resident #13 had a history of anxiety and was prescribed an antidepressant. <BR/>Record review of the MDS dated [DATE] indicated Resident #13 was understood and understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) of 13 indicating Resident #13 was cognitively intact. The MDS indicated Resident #13 required limited to extensive assistance from staff for all activities of daily living. <BR/>2. Record review of the face sheet 9/14/2022 indicated Resident #28 was [AGE] years old and was admitted on [DATE] with diagnoses including diabetes, generalized muscle weakness, and essential hypertension (high blood pressure).<BR/>Record review of a care plan dated 6/4/2022 indicated Resident #28 had impaired physical mobility related to generalized weakness. <BR/>Record review of the MDS dated [DATE] indicated Resident #28 usually understood and usually understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 12 which indicated Resident #28 was cognitively intact. Resident #28 required extensive assistance from staff for all ADLs. <BR/>3. Record review of the face sheet dated 9/14/2022 indicated Resident #33 was [AGE] years old and was admitted on [DATE] with diagnoses including liver cell carcinoma (liver cancer), stroke, and heart disease. <BR/>Record review of a care plan dated 9/3/2022 indicated Resident #33 had a history of anxiety and was prescribed an anti-anxiety medication. Resident #33 had impaired physical mobility and required assistance with self-care. <BR/>Record review of the MDS dated [DATE] indicated Resident #33 was understood and usually understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 8 which indicated Resident #33 was moderately cognitively impaired. Resident #31 required extensive to total assistance from staff with ADLs. <BR/>4. Record review of a face sheet dated 9/14/2022 revealed Resident #61 was [AGE] years old and was initially admitted on [DATE] with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone, or posture), paranoid schizophrenia (a mental disorder characterized by continuous or relapsing episode of psychosis), and moderate intellectual disabilities. <BR/>Record review of a care plan dated 7/19/2022 indicated Resident #61 had a history of cerebral palsy and required extensive assistance with bed mobility and transfers. The care plan indicated Resident #61 was immobile.<BR/>Record review of the most recent MDS dated [DATE] indicated Resident #61 was sometimes understood and sometimes understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) of 8. This score indicated moderate cognitive impairment for Resident #61. The MDS also indicated Resident #61 required limited to extensive assistance from staff for ADLs.<BR/>5. Record review of a face sheet dated 9/14/2022 revealed Resident #84 was [AGE] years old and was admitted on [DATE] with diagnoses including stroke, diabetes, and essential hypertension (high blood pressure). <BR/>Record review of a care plan dated 8/18/2022 indicated Resident #84 was prescribed an anti-anxiety and antidepressant medication. The care plan indicated Resident #84 had a speech deficit as evidenced by unclear speech. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #84 was usually understood and usually understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) of 6 indicating severe cognitive impairment. The MDS indicated Resident #84 extensive to total assistance from staff for all ADLs.<BR/>6. Record review of a face sheet dated 9/14/2022 revealed Resident #97 was [AGE] years old and was initially admitted on [DATE] with diagnoses including urinary tract infection, pressure ulcer, and chronic pain syndrome. <BR/>Record review of a care plan dated 9/12/2022 indicated Resident #97 had impaired physical mobility and required assistance from staff. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #97 was usually understood and understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) of 9 which indicated Resident #97 was moderately cognitively impaired. The MDS indicated Resident #97 required extensive assistance with ADLs.<BR/>An observation on 9/12/2022 at 10:10 a.m., revealed there was a strong foul odor of urine in the 400 Hall. The odor was present on both ends of the hall and was strongest in the middle of the hall near between rooms [ROOM NUMBERS].<BR/>An observation on 9/12/2022 at 10:12 a.m., revealed multiple white stains of various sizes on the carpet in the room of Resident #97. There were many small white stains scattered on the carpet in front of the dresser. <BR/>An observation on 9/12/2022 at 10:21 a.m., revealed multiple stains on the carpet throughout the room of Resident 13 and Resident 61. Near the bed of Resident 13 were several stains that appeared to be food stains and there were food crumbs. <BR/>An observation on 9/12/2022 at 10:41 a.m., revealed there were multiple stains throughout the room. In front of the chest of drawers nearest the door was a dried, pink stain on the carpet. Near the bed of Resident #84 were many stains that appeared to be food stains. There were more than 10 light brown stains of an unknown substance stuck to the carpet. The carpet in general had a dirty appearance. There were two large white stained areas on the carpet near the door.<BR/>An observation on 9/12/2022 at 11:00 a.m., revealed multiple large white stains on the carpet near the entrance of Resident #28 and Resident #33's room. <BR/>An observation on 9/12/2022 at 12:02 p.m., revealed there were 4 used beds noted in the dining room. One of the beds with a large circular dark stain on the center of the mattress. There were 4 headboards noted along the opposite wall. There were residents present in the dining room eating lunch. There was one table within 5 feet of the beds with a male resident eating lunch. <BR/>An observation on 9/12/2022 02:48 p.m. revealed there were no changes to the carpet in the room of Resident #84. <BR/>An observation on 9/13/22 at 7:56 a.m., revealed there were residents present in the dining room eating breakfast. There were 2 beds in dining room along the wall each with 2 mattresses stacked on top of each other. There were headboards propped against the opposite wall. <BR/>An observation on 9/13/2022 at 8:04 a.m., there was a strong foul odor of urine in the 400 Hall. The odor was present on both ends of the hall and was strongest in the middle of the hall near between rooms [ROOM NUMBERS]. <BR/>An observation on 9/13/22 at 8:05 a.m., revealed multiple white stains of various sizes on the carpet in the room of Resident #97 . There were many small white stains scattered on the carpet in front of the dresser. The resident was in her bed. <BR/>An observation on 9/13/22 8:45 a.m., revealed 8 large white stains noted in the carpet near the door of the room of Resident #28 and Resident #33. The carpet was worn, and the trash can of Resident #28 was turned over . Each Resident was in their bed. <BR/>An observation on 9/13/22 8:51 a.m., revealed there were multiple stains throughout the room. In front of the chest of drawers nearest the door was a dried, pink stain on the carpet. Near the bed of Resident #84 were many stains that appeared to be food stains. There were more than 10 light brown stains of an unknown substance stuck to the carpet. The carpet in general had a dirty appearance. There were two large white stained areas on the carpet near the door. <BR/>During an interview on 9/14/2022 9:15 a.m., the Dietary Manager said the beds in the dining room were because the facility was getting new beds and the old ones were being stored in the dining room until they were loaded on a truck. She said the beds had all been swapped out the previous week and she thought those were left because there was no room on the truck. She said she was unaware one of the beds had a large brown stain in the center of the mattress . She said she would not want to eat a meal next to a stained bed.<BR/>An observation on 9/14/2022 at 11:44 a.m., revealed there was a strong foul odor of urine in the 400 Hall. The odor was present on both ends of the hall and was strongest in the middle of the hall near between rooms [ROOM NUMBERS].<BR/>During an observation and interview on 9/14/2022 at 11:45 a.m., revealed multiple white stains of various sizes on the carpet in the room of Resident #97. There were many small white stains scattered in from of the dresser. Resident #97 said the stains on the floor bothered her because she did not know what they were. <BR/>During an observation and interview on 9/14/2022 at 11:52 a.m., Resident #13 said she had resided in her room a good while. She said the carpet had been stained and dirty since moving into the room. She said she did not know what the stains were. She said they could be splashed milk. The was a small brown smear noted near the chair she was sitting in. Resident #13 said she would like the carpet to be kept clean. She said her mama taught her to be clean. She said if her carpet at home had looked like the carpet in her room, she would have it cleaned. She said the housekeepers do vacuum and sweep but they do not shampoo the stains out of the carpet. <BR/>During an interview on 9/14/2022 at 1:51 p.m., the Floor Technician B revealed he cleans the carpets on the hall. He said he did weekly rounds and cleans each carpet in the resident rooms once a week. He said Resident #84 drops food on the floor, and he cleaned Resident #84's carpet prior to the beginning of the survey on the morning of 9/12/2022. He said when he made rounds he checked for stains and cleans them when he cleans the carpets .<BR/>During an observation and interview on 9/14/2022 at 3:34 p.m., CNA D said carpets in a lot of the resident's room were nasty and did not appear to have been cleaned. She said she had seen carpets being cleaned in the front of the facility. She said she had never witnessed carpets being shampooed in any residents' rooms.<BR/>During an interview on 9/15/2022 at 9:10 a.m., the Housekeeping Supervisor said that there were not any carpets in resident's rooms cleaned on Monday, 9/12/2022. He said there are 8 rooms with carpet on the 400 Hall. He said Floor Technician was supposed to clean the carpets in the residents' rooms every two weeks and as needed. He said himself and Floor Technician B made rounds on 9/14/2022. He said there was not a specific day the carpets were cleaned in the residents' rooms, just every two weeks. He said there is no specific day the carpets are cleaned in the residents' room, just every two weeks. He said the cleanings are not documented anywhere. He said the carpets are old. He said they try to clean the halls on Thursdays or Fridays. Observed the carpets in the rooms of Resident #97, Resident #13, Resident #61, Resident #33, Resident 28, and Resident #84 with the supervisor. He said agreed the carpets were dirty and stained. He said some of the white stains were bleach stains but not all of them were. <BR/>During an interview on 9/15/2022 at 1:40 p.m., the DON said they just had 90 beds delivered and were trying to get the used ones left in the dining room moved out of the facility. She said it was not ok that residents had to eat next to a stained bed . She said the carpets in residents' room should be kept clean and shampooed. She said she was unsure how often the carpets in the residents' rooms were shampooed. She said an unclean environment could make a resident uncomfortable. <BR/>During an interview on 9/15/2022 at 2:16 p.m., the Administrator the facility had received 90 new beds at one time. She said the old beds in the dining room were waiting to be loaded onto a truck to be removed. She said she would not want to eat near an old, stained bed. She said she would expect floors to be kept clean and the carpets should have been seen during daily rounds and should have been cleaned. When shown a picture of the floor of Resident 84's room, she agreed the floor was dirty, stained and needed to be cleaned . She said there were daily Ambassador rounds made to check the resident's rooms. <BR/>Review of an undated Homelike Environment facility policy indicated, .It is the policy of the facility to ensure that the environment provided by the facility is safe, sanitary, functional, and comfortable .institutional odors will be addressed and eliminated .

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Residents #1) reviewed for resident rights.<BR/>CNA E did not sit as she assisted Resident #1 with dining. <BR/>CNA E did not refrain from talking on her cell phone while she assisted Resident #1 with dining. <BR/>The facility did not ensure Resident #1 was clothed in his personal clothing. <BR/>These failures could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth.<BR/>Findings included:<BR/>Record review of Resident #1's consolidated physician's orders dated 2/10/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including Hemiplegia or hemiparesis (hemiplegia refers to a severe or complete loss of strength, whereas hemiparesis refers to a relatively mild loss of strength) following cerebral infarction (stroke) affecting the left non-dominant side, type II diabetes, shortness of breath, nausea/ vomiting, and depression. <BR/>Record review of Resident #1's MDS dated [DATE] indicated Resident #1 was usually understood and usually understood others. The MDS indicated Resident #1 had severe cognitive impairment (BIMS of 5). The MDS indicated he had no behavior of rejecting care during the 7 days look back period. The MDS indicated he required extensive assistance with bed mobility, transfers, locomotion in his wheelchair, dressings, eating, toilet use, and personal hygiene. The MDS indicated Resident #1 was completely dependent on staff for bathing. The MDS indicated Resident #1 was always incontinent of bowel and bladder. <BR/>Record review of Resident #1's care plan revised on 11/15/22 indicated Resident #1 had a self-care deficit. The care plan interventions included to give the resident as many choices as possible about care and provide assistance with self-care as needed. <BR/>During an observation on 2/8/23 at 11:10 a.m. revealed Resident #1 laid in his bed wearing a hospital gown. <BR/>During an observation on 2/8/23 at 12:45 p.m. revealed the door to Resident # 1's door was open. CNA E stood at Resident #1's bedside. CNA E said loudly Well what are you going to then?. A few moments later CNA E again said, Well what are you going to then? and then said I gotta go. The surveyor entered the room. CNA E continued to stand at Resident #1's bedside and fed him several bites from his food tray. <BR/>During an observation and interview on 2/8/23 at 2:50 p.m. revealed Resident #1 laid in his bed wearing a hospital gown. Resident #1 said he did not want to wear a hospital gown. Resident #1 said his family member had brought him some clothes and pointed at the armoire. There were multiple personal clothing items hanging in the armoire. Resident #1 said he guessed he had to wear the gown because that was what they (facility staff) put on him. Resident #1 could not say how long he had been wearing the hospital gown or who had placed the hospital gown on him. Resident #1 said CNA E talked on the phone while she fed him today (2/8/23) and felt it was rude. <BR/>During an interview on 2/10/23 at 10:28 a.m., CNA G said there was no reason for a resident to have been in a hospital gown. CNA G said the facility had clothes that were donated for resident use if a resident did not have any personal clothes available. CNA G said if a resident did not want to wear a hospital gown and was placed in hospital gown, it could take away the resident's dignity. CNA G said CNAs should not stand while feeding a resident because it could cause the resident to feel intimidated. CNA G said another reason CNAs should not stand while feeding a resident was to ensure the resident did not have any signs of aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). CNA G said under no circumstance should a CNA take a personal phone call while he/she administered resident care. CNA G said to take a personal call during the administration of patient care was not only disrespectful but would also divert attention away from the resident. <BR/>During an interview on 2/10/23 at 10:46 a.m., CNA E said she should not have stood while feeding Resident #1. CNA E said she should have sat at Resident #1's bedside while she assisted him with eating because it was more respectful than standing. CNA E said she stood while she fed Resident #1 because she was in a hurry. CNA E said she did not notice Resident #1 was wearing a hospital gown and indicated he should have been wearing his personal clothes. CNA E said she should not have taken the personal call while she assisted Resident #1 but did so because she had a family situation. <BR/>During an interview on 2/10/23 at 12:00 p.m., the DON said she expected staff to sit while they assisted residents with eating in order to promote respect and safety. The DON said it was not acceptable for a resident to be in a hospital gown and to do so (place a resident in a hospital gown) could affect the resident's dignity. The DON said it was not acceptable for staff to have taken a phone call while assisting a resident. The DON said she expected staff to go to the break room or their car if they had to take a phone call. The DON said a staff member taking a phone call in front of a resident was a dignity issue and could also confuse the resident. <BR/>During an interview on 2/10/23 at 2:30 p.m., the Administrator said she expected staff to ensure residents were clothed in their personal clothing if it was the resident's preference. The Administrator said she expected staff to ensure respect and dignity were provided to residents. The Administrator indicated taking personal phone calls during resident care activities and standing while feeding a resident did not promote respect and dignity.<BR/>Record review of the undated facility policy and procedure titled, Exercise of Rights reflected, Policy Statement- Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to our facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #14) of 6 residents reviewed for quality of care. <BR/>The facility failed to ensure Resident #14 had supervision that prevented him from going outside and falling causing a hematoma and abrasion to his head.<BR/>This failure could result in residents experiencing accident, injuries, and diminished quality of life. <BR/>Findings included:<BR/>1. Record review of an undated face sheet reflected Resident #14 was a [AGE] year-old male that admitted to the facility on [DATE] with the diagnosis of dementia, atrial fibrillation (irregular heartbeat), and diabetes mellitus type II and discharged [DATE].<BR/>Record review of Resident #14's admission MDS dated [DATE] reflected he had a BIMS of 01 which indicated severe cognitive impairment. The MDS also indicated Resident #14 had some physically aggressive behavior and he required partial to moderate assistance with ADLs.<BR/>Record review of Resident #14's care plan dated 05/07/2024 reflected a care plan titled Behavioral Changes with the problem of high elopement risk. The goal was to keep the resident safe within the facility. <BR/>Record review of admission assessment dated [DATE] indicated Resident #14 was a high elopement risk scoring a 22 out of 25 points scored for elopement.<BR/>Record review of an incident report dated 06/22/2024 revealed Resident #14 exited the front of the building and fell from his wheelchair onto the ground outside the front entrance of the building. Resident #14 sustained an abrasion to his forehead and a hematoma.<BR/>During an interview on 08/14/2024 at 10:02 a.m., RN P stated Resident #14 attempted to find an exit all day every day since the day he was admitted . She stated he was hard to redirect about 50% of the time. She stated she learned to redirect him with food and sitting in the dining room and that worked most of the time. She stated he would push right past you if you were standing in the way of him and where he was attempting to go. She stated she had not felt he was being mean, she stated he just had not registered that someone was in front of him.<BR/>During an interview on 08/14/2024 at 2:20 p.m., LVN Q stated on 06/22/2024 at lunch time Resident #14 went outside the front door of the facility and fell from his wheelchair onto his right side striking his head on the ground causing a hematoma and abrasion to his right forehead. She stated she was alerted by a family member of his presence outside because the staff was busy serving lunch, and no one saw him go outside. She stated she was aware he was an elopement risk, and they were doing frequent checks on him every 15-20 minutes and keeping him in eyesight if he were out of this room. LVN Q stated all the staff pitched in and tried to keep an eye on Resident #14, but it was not always possible to watch him. She stated he just slipped out because all hands are on deck when it was meal service time. She stated he was exit seeking every day because of his dementia. She stated he had gotten outside once before but the staff saw him before the door even closed behind him and redirected him back into the facility. LVN Q stated she had not believed he would have fallen that time if he had not been outside because it appeared to her the wheel on his wheelchair went off the sidewalk and dumped him out onto the ground. She stated the next day he discharged to a secured unit on 06/23/2024.<BR/>During an interview on 08/15/2024 at 2:00 p.m., the DON stated she was aware Resident #14 was an elopement risk and she understood there were other facilities that could take better care of his needs, but his family insisted he stay at the facility. She stated the family was devastated when we informed them that he could no longer stay at our facility, and we needed to find him a safe place to live immediately. The DON stated Resident #14 had 4-5 falls while he was here from the wandering up and down the hall all day and night. She stated the fall he had on 06/22/2024 could have been prevented had Resident #14 not been exit seeking and found his way outside, where the sidewalk caused him to be dumped from his wheelchair.<BR/>During an interview on 08/15/2024 at 3:15 p.m., the ADM stated she was aware Resident #14 was an elopement risk and the facility was trying different things to see if an adjustment period might calm that behavior down. She stated unfortunately it was not a successful match for him to remain in the facility because all the resident's must be safe that stay at the facility.<BR/>Review of facility's fall prevention policy titled Fall Evaluation and Prevention, dated revised August 2020, reflected The facility will evaluate residents for their fall risk and develop interventions for prevention . Upon Admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls.

Based on interview, and record review the facility failed to post in a place readily accessible to residents, and family members and legal representative of residents, the results of the most recent survey including any plans of correction without identifying information about complainants or residents for 2 of 2 survey results binders reviewed. <BR/>The facility failed to ensure the most recent abbreviated standard survey results, exit date 08/15/24, was posted in the survey results book. <BR/>This failure could place residents at risk of not being aware of past and current violation findings from state surveys and investigations conducted in the facility. <BR/>Findings included:<BR/>During a record review on 12/03/24 at 11:23 AM, this surveyor reviewed the survey/inspection results book in the lobby of the facility. The most recent state visit result in both binders was dated 12/01/23. <BR/>During a record review on 12/04/24 at 08:28 AM, this surveyor reviewed the survey/inspection results book in the lobby of the facility. The most recent state visit result in both binders was dated 12/01/23.<BR/>During an interview on 12/04/24 at 04:25 PM, RNC R said they do not have a policy related to the survey results book being updated. She said the book should have the inspection and survey results including those that have citations.<BR/>During an interview on 12/05/24 at 01:29 PM, RNC R said the Administrator was responsible for updating the survey results book. She said she was unsure how many visits were missed but the books were updated after this surveyor's last interview.<BR/>During a record review on 12/05/24 at 01:32 PM, this surveyor reviewed the survey/inspection results books. They were updated and included the previously missing 8/15/24 visit.<BR/>During an interview on 12/05/24 at 2:10PM, the Administrator said he was responsible for ensuring the survey results books were up to date in the lobby. He said there was not a risk to the resident because of the books not being completely up to date.

Based on observation, interview and record review, the facility failed to ensure the DON served as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents for 10 shifts in the last 90 days. The census was 96.<BR/>The DON worked as a charge nurse or CNA 3 times in August 2023<BR/>The DON worked as a charge nurse or CNA 3 times in September 2023.<BR/>The DON worked as a charge nurse or CNA 4 times in October 2023.<BR/>This failure could place residents at risk by leaving nursing staff without supervisory coverage and leaving essential DON functions undone. <BR/>Findings included:<BR/>During observation and interview on 10/30/2023 at 10:00 a.m., the DON was changing linen on a bed in a resident room and stated she has had to work the floor several nights as a charge nurse and has had to be a CNA on the floor when the facility was short staffed. The DON stated she knew she was not supposed to work the floor in a building of more than 60 average residents. The DON stated she would take the citation because she was not leaving the residents with no care and there was no one else to work. The DON stated she was the monitor for the infection control system, the weight system, the skin system, the antibiotic stewardship system, and the gradual dose reduction system. The DON stated she had ADONs to assist her but ultimately the responsibilities were hers. The DON stated she had not had time to keep up with all the systems because she was working the floor. The DON stated she was responsible for checking behind the nurses for clean oxygen equipment, making sure admission orders were checked, making sure admission assessments were done, making sure everyone was on the correct antibiotic, and making sure interventions were in place for weight loss and skin breakdown. The DON listed the dates she had worked the floor totaling 3 shifts in August, 3 shifts in September and 4 shifts in October 2023.<BR/>Record review of sign in sheets for August, September and October had not listed the DON as the floor nurse on any of the days.<BR/>During an interview with the Administrator on 11/02/2023 at 3:00 p.m., the Administrator stated the DON had worked the floor several shifts. The Administrator stated the DON was salary, so she did not have to clock in and out when working the floor, so there was no way to track what days and hours she worked the floor. The Administrator stated she was sure working night shifts sometimes put the DON a little behind because she had many systems she oversaw, but a lot can be done on the night shift because it was a slower time of day. The Administrator stated all the department head nurses took turns working the floor when someone called in. She said they each had responsibilities to keep the facility functioning well and it was her expectation that they keep up with their work.<BR/>A policy was requested on 11/02/2023 at 10:00 a.m. from the Administrator and none was provided prior to exit.