AVIR AT FREDERICKSBURG

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents had the right to be informed of, and participate in, their treatments, for 1 of 8 residents (Resident #29) reviewed for antipsychotic medication administration. <BR/>Resident #29 was prescribed and received the antipsychotic medication Haldol for disorganized schizophrenia without evidence in her medical record of the state consent form 3713. <BR/>The deficient practices could place residents at risk for side effects for which they did not consent.<BR/> The findings included:<BR/>Record review of Resident #29's admission record revealed Resident #29 was a [AGE] year-old female admitted on [DATE] with diagnoses to include schizophrenia (mental health condition that affects how people think, feel, and behave), anxiety disorder, psychosis (state of impaired reality), and restlessness and agitation. <BR/>Record review of Resident #29's admission MDS assessment, dated 05/20/25, reflected Resident #29 had a BIMS score of 0 out of 15, indicating severe cognitive impairment. It further reflected Resident #29 did not exhibit behavioral symptoms (physical or verbal behavioral symptoms directed towards others). It revealed Resident #29 rejected care daily. <BR/>Record review of Resident #29's care plan reflected a focus of at risk for complications due to refusing care refusing medication, initiated on 06/10/25, with interventions to include If resident refuses care, try another staff member or approach, Notify family as needed, Notify MD as needed, Provide alternate approaches/settings in accordance with resident preferences, It further reflected a focus of risk for harm: self directed or other-directed, initiated 06/16/25, to include interventions administer medications as prescribed, encourage resident to verbalize cause for aggression, if resident poses a potential threat to injure self or others notify provider. And it further reflected a focus of The resident has a behavior problem (schizoaffective disorder) r/t (refusal to comply with medication regimen, refusing to comply with standard tasks, becoming verbally aggressive with staff), initiated 06/09/25, with intervention Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. dated 06/09/25.<BR/>Record review of Resident #29's June MAR reflected Haldol Injection Solution 5 MG/ML Inject 5 mg intramuscularly one time only related to DISORGANIZED SCHIZOPHRNIA, with start date 06/02/25, was given on 06/02/25 at 07:10PM by LVN B. <BR/>Interview on 06/20/25 at 10:59 AM, Resident #29's RP (and guardian) revealed he gave written permission and verbal permission to give Resident #29 medication prescribed by the psychiatric NP. The RP revealed the facility always communicated with him about giving her these medications and he always gave them permission because it helped the resident. <BR/>Attempted interview with Resident #29 on 06/20/25 at 12:36PM was unsuccessful, the resident refused the interview.<BR/>Interview on 06/20/25 at 04:20PM, the DON revealed Resident #29 did not have form 3713 completed for the antipsychotic Haldol. She revealed she did not realize it was not signed. She revealed it was important because it went back to resident safety and resident rights.<BR/>Record review of facility's policy, revised April 2019, reflected 22. The individual administering the medication initials the resident's MAR and the appropriate line after giving each medication and before administering the next ones.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience, and that were not required to treat the resident's medical symptoms for 1 of 8 residents (Resident #29) reviewed for freedom from physical and chemical restraints.<BR/>The facility failed to ensure Resident #29 was free from physical restraint when nursing staff physically restrained her for medication administration on 06/02/25, 06/04/25, and 06/17/25.<BR/>These deficient practices could place residents at risk of unnecessary restriction of their freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control). <BR/>The findings include:<BR/>Record review of Resident #29's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses which included schizophrenia (mental health condition that affects how people think, feel, and behave), anxiety disorder, psychosis (state of impaired reality), and restlessness and agitation. <BR/>Record review of Resident #29's admission MDS assessment, dated 05/20/25, reflected Resident #29 had a BIMS score of 0 out of 15, which indicated severe cognitive impairment. Resident #29 did not exhibit behavioral symptoms (physical or verbal behavioral symptoms directed towards others). Resident #29 rejected care daily. <BR/>Record review of Resident #29's care plan reflected a focus of at risk for complications due to refusing care refusing medication, initiated on 06/10/25, with interventions to include If resident refuses care, try another staff member or approach, Notify family as needed, Notify MD as needed, Provide alternate approaches/settings in accordance with resident preferences. It further reflected a focus of Behavior Management, initiated on 06/10/25, with interventions to include educated resident/representative on necessity of care attempted to provide .ensure the safety of resident and others. Resident #29's care plan further reflected a focus of risk for harm: self-directed or other-directed, initiated 06/16/25, to include interventions administer medications as prescribed, encourage resident to verbalize cause for aggression, if resident poses a potential threat to injure self or others notify provider. It further reflected a focus of The resident has a behavior problem (schizoaffective disorder (mental health condition)) r/t (refusal to comply with medication regimen, refusing to comply with standard tasks, becoming verbally aggressive with staff), initiated 06/09/25, with intervention Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. dated 06/09/25.<BR/>Record review of Resident #29's care plan did not reflect anything about Resident #29 needing a therapeutic hold for medication administration.<BR/>Record review of Resident #29's June MAR reflected Haldol Injection Solution 5 MG/ML. Inject 5 mg intramuscularly one time only related to Disorganized Schizophrenia, with start date 06/02/25, was given on 06/02/25 at 07:10 PM by LVN B. <BR/>Record review of Resident #29's June MAR reflected RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG Inject 50 mg intramuscularly at bedtime every 14 day(s) related to Disorganized Schizophrenia, with start date 06/04/25 and D/C date 06/09/25, was blank on 06/04/25 at 08:00 PM.<BR/>Record review of Resident #29's June MAR reflected RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG. Inject 50 mg intramuscularly every day shift every 14 day(s) related to Disorganized Schizophrenia, with start date 06/17/25, was blank on 06/17/25 Day. <BR/>Record review of Order Granting Leave to Resign and Appointing Succesor Guardian of the Person, dated 06/18/20, reflected [Resident #29's RP] is appointed as the successor guardian of the person of [Resident #29], an Incapacitated Person. [Resident #29] is found to be incapacitation and lacks the necessary capacity to care for herself as a reasonable prudent person would do, and a full guardianship of the person is hereby granted with all the rights, duties, and powers granted to a successor guardian by law. [Resident #29] is declared fully incapacitated without the authority to exercise any rights or powers over herself.<BR/>Record review of nurse's note, dated 06/17/25 at 10:30 PM and authored by LVN C, reflected [Resident #29] informed of ordered IM Risperidone 50mg injection, increased agitation noted, resident quickly stated, no you will not! Get out of my room! Several attempts to educate the resident regarding the medication were unsuccessful, four employees assisted to ensure safety and protect the resident from hurting herself or others. Safety techniques effectively applied by staff, IM Risperidone 50mg administered to the right upper outer gluteal quadrant without incident. Resident voiced frustration and yelled, I said get out of my room, staff exited room, visual safety checks applied and continued monitoring throughout the night to ensure safety and monitor for any possible side effects<BR/>Interview on 06/20/25 at 10:45 AM, the DON revealed she was present on June 2nd when Resident #29 was throwing things and being verbally aggressive to staff when they needed to give Resident #29 a medication, so they called the psychiatric NP, who ordered Haldol on 06/02/25. The DON revealed Resident #29 was not allowing staff to administer Haldol. The DON revealed she tried to explain to Resident #29 the RP and NP wanted them to give her the injection and gave Resident #29 options to sit in bed or in a chair to receive the injection. The DON revealed they tried to give the medication when Resident #29 was in the chair, but the resident physically swung. The DON revealed the psychiatric NP and attending physician said the nursing staff could hold the resident for medication administration. The RP gave verbal permission to hold Resident #29 for medication administration. The DON revealed they had 4 staff members hold Resident #29, 1 staff member for each limb, while LVN C gave the injection. She further revealed no nursing staff were trained or practiced doing a therapeutic hold for a resident. She revealed it was important for resident safety and Resident #29 sustained no injuries.<BR/>Interview on 06/20/25 at 10:59 AM, Resident #29's RP (and guardian) revealed he gave written permission and verbal permission to give Resident #29 medication prescribed by the psychiatric NP. He revealed when the shot was wearing off for Resident #29, Resident #29 did not have reason and was combative. The RP revealed the facility always communicated with him about giving her these medications and he always gave them permission because it helped the resident. He further revealed he had been in contact with her psychiatrist, and they were all in agreeance that this helped the resident. He was okay the facility had to physically restrain her because it was for her benefit, health wise.<BR/>Interview on 06/20/25 at 12:18 PM, the DON revealed Resident #29's use of restraints was not care planned and there was no assessment to show the need for physical restraints for the resident. She revealed the use of restraints was a verbal order from the doctor, but it needed to be signed and entered into the resident's medical record. She revealed when they entered the doctor's order, they would add what health condition it was used for in the additional comments. She revealed it was important for resident safety because restraints could lead to injury.<BR/>Attempted interview with Resident #29 on 06/20/25 at 12:36PM was unsuccessful, the resident refused the interview. <BR/>Interview on 06/20/25 at 12:57 PM, the DON revealed there was not an assessment available to complete for using restraints on Resident #29 for medication administration. She revealed the facility had created an assessment so they could complete this assessment before doing a therapeutic hold on Resident #29 for medication administration. She revealed when they used a therapeutic hold on Resident #29 on 06/17/25 and monitored Resident #29 every 5 to 15 minutes. The DON revealed she sat with Resident #29 for about 2 hours to ensure resident safety. She revealed after each therapeutic hold for medication administration, Resident #29 had no injuries and did not appear to be affected by the therapeutic hold.<BR/>Interview on 06/20/25 at 02:01 PM, the MD revealed he was called before the nursing staff held Resident #29 down for medication administration. He revealed Resident #29 was on a special psychiatric medication and she has had, on more than one occasion, been held because she was yelling and throwing items. He revealed the facility called and asked him if this was appropriate to hold Resident #29 for medication administrator. He revealed for resident's comfort and well-being, medication was vital because there could be an emergency room trip if she had not received these medications. He revealed Resident #29 was not harmed in anyway, because the medication was administered in a respectful and non-violent manner. He revealed his orders were done verbally because the medication administration needed to be done quickly. He revealed there should be a doctor's order afterward. He revealed his order would have read: With familial consent and doctor approval, okay to hold patient for medication administration to improve uncontrolled symptoms of aggression and allow time for new medication to take effect. He revealed he may revise this order and have it read more eloquently. He revealed this should be a one-time thing and if the facility wanted to do it again, he would be contacted. He revealed this was not a long-term solution. He revealed they might need to adjust Resident #29's medication regimen to have Resident #29 be participate with staff more. He revealed Resident #29 had a psychiatric disturbance with aggressive behaviors. He revealed there needed to be monitoring after a therapeutic hold for medication administration for Resident #29 to watch the resident for any injuries every few hours or every shift. He revealed it was important for these components to be in place so Resident #29 was not scared in the facility and felt comfortable, learning what it's like to not be scared or agitated.<BR/>Interview on 06/20/25 at 04:20 PM, the DON revealed form 3713 (consent for antipsychotic or neuroleptic medication treatment) should be completed for Haldol. She revealed it was important because it went back to resident safety and resident rights. She revealed before they went into Resident #29's room they had a safety plan if resident was not cooperative with receiving the shot. She revealed each staff member were all assigned an extremity to hold. She revealed they did not practice. She revealed she instructed the nursing staff to hold the resident to make sure they would not cause a fracture. She revealed on June 17th Resident #29 sat on the edge of bed and this was all Resident #29 would comply. She revealed they tried non-pharmacologically interventions first. She revealed Haldol was given on June 2nd and RisperDAL was given on June 4th and June 17th, confirming the MAR was not filled out accurately on June 4th and June 17th. She revealed it was important to fill out these administration times so nursing staff knew what medications were given. <BR/>Interview on 06/20/25 at 04:37 PM, the ADON revealed she helped with Resident #29's medication administration on June 2nd and June 4th. She revealed the facility approached Resident #29 in a gentle manner and tried to educate her about the importance of her medications. She revealed after contacting Resident #29's doctor and RP, they were able to do a therapeutic hold for medication administration. She revealed the nursing staff spoke about what they were going to do before they entered Resident #29's room to make sure the staff and resident remained safe. She revealed they did not practice a therapeutic hold for medication administration.<BR/>Interview on 06/20/25 at 05:17 PM, LVN C revealed she was never trained on restraining a resident for medication administration. She revealed Resident #29 had to be held down for their safety (to include not harming herself or the nursing staff) since the medication administration was an injection and involved a needle. She revealed Resident #29 had to be held down so the needle would not break when being injected. <BR/>Interview with LVN B was attempted. A voicemail was left on 06/20/25 at 05:16PM for LVN. <BR/>Record review of the facility's, undated, policy, Restraint Policy, reflected The use of restraints is expressly forbidden unless it is prescribed as a measure of treatment for the resident and issued by the treating physician. Physical Restraint is any method or device used to restrict the movement or to keep a resident in a certain position while sitting or lying down . A restraint may only be placed on a resident if it has been determined by the Licensed Staff and the Treating Physician that it is medically necessary and the order is include in the Care Plan of a resident . The LVN or RN may receive a verbal order and consent from the physician and approval by the resident's responsible party but for a period not to exceed 24 hours. A written order must be received by the facility before the 24-hour period expires.

**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 for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 4 of 8 residents (Resident #2, #32, #28, and #7) reviewed for care plans in that:<BR/>Residents #32 and #7 did not have a comprehensive person-centered care plan in their resident file.<BR/>Residents #2 and #28 did not have a comprehensive care plan that met a resident's medical needs. <BR/>These failures could place residents at risk of receiving inadequate interventions not individualized to their care needs. <BR/>The findings were:<BR/>- <BR/>Record review of Resident #32's face sheet dated 3/23/23, revealed an [AGE] year-old female admitted on [DATE] with diagnosis that include malignant neoplasm of brain (a fast-growing tumor in the brain), gastro-esophageal reflux disease (a condition where acidic gastric fluid flows backward into the esophagus), and depression. <BR/>- <BR/>Record review of Resident #32's most recent MDS dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills. <BR/>- <BR/>Record review of Resident #32's EHR reflected no evidence of a comprehensive person-centered care plan. <BR/>- <BR/>Record review of Reside #7's face sheet dated 3/23/23, revealed a [AGE] year-old female admitted on [DATE] with diagnosis that include Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves), Stage 3 pressure ulcer (an injury to skin resulting from prolonged pressure), and Dysphasia (impairment in speech due to brain disease or damage). <BR/>- <BR/>Record review of Resident #7's most recent MDS dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills. <BR/>- <BR/>Record review of Resident #7's EHR reflected no evidence of a comprehensive person-centered care plan. <BR/>- <BR/>Record review of Resident #28's face sheet dated 3/23/23, revealed an [AGE] year-old male admitted on [DATE] with diagnosis that include Gout (a form of arthritis), Oropharyngeal dysphagia (swallowing problems occurring in the mouth/throat), Aphasia (language disorder that affects the ability to communicate) and open wounds to forearm and left ankle.<BR/>- <BR/>Record review of Resident #28's most recent MDS dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills. <BR/>- <BR/>Record review of Resident #28's care notes from the dietician dated 9/19/22 indicate that the resident had lost 8.1% of their total body weight in 1 month. Stated there were current orders for protein shakes.<BR/>- <BR/>Record review or Resident #28's care notes from the dietician dated 315/23 indicate that the resident had lost 7.8% of their total body weight in 1 month. The care note also states that the resident should be on a fortified meal plan. <BR/>- <BR/>Record review of Resident #28's comprehensive person-centered care plan revealed there were no interventions present for the resident's weight loss as recommended by the dietician. <BR/>- <BR/>Record review of facility policy on care planning revealed that comprehensive care plans for each resident must be developed within seven days of completion of the MDS. <BR/>- <BR/>Record review of facility policy on care planning revealed that a change in condition that will not resolve itself without intervention is required to be reviewed by an interdisciplinary team and revised on the care plan. <BR/>- <BR/>In an interview on 3/24/23 at 10:55 AM, ADON stated she is teaching herself the facilities EHR system and has recently taught herself how to do Care Plans in the system. The ADON stated that she was not aware Resident #32 and Resident #7 did not have record of a care plan in the EHR. The ADON also stated that she was not aware that Resident #28's care plan did not accurately reflect his medical needs. <BR/>- <BR/>In an interview on 3/24/23 at 1:06 PM, Administrator stated he was not aware care plans were not being completed adequately. Administrator stated there were care plan meetings but that there were not RNs at these meetings. The administrator stated he does not know why Residents #32, #7, and #28 do not have accurate care plans.<BR/>Resident #2<BR/>A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care.<BR/>A record review of Resident #2's hospital discharge records, dated 02/26/2023, revealed history of present illness; chief complaint; altered mental status, low oxygen level, and foreign body(dentures) in esophagus . this is a [AGE] year-old white female brought by emergency medical services 2[name of hospital] emergency room on the evening of 02/21/2023 for recurrent episodes of aspiration associated with shortness of breath for two days prior to presentation. the patient is unable to provide any history due to cognitive impairment at baseline . the patient was sent 2 . emergency room by care staff at the skilled nursing facility where the patient resides for two episodes of food aspiration for two days prior to presentation. the patient had one episode of food aspiration on 02/20/2023 and a second episode of food aspiration on 02/21/2023. her second episode was more severe and associated with significant coughing and choking. care staff reports gradual onset of worsening shortness of breath for approximately 2 days prior to presentation . the patient was noted to meet criteria for sepsis with elevated heart rate, elevated temperature, and elevated white blood cell count. the patient was found to have a bacterial source in the form of bilateral aspiration pneumonia . X-ray of the soft tissues of the neck performed at the emergency room showed a U-shaped foreign body noted within the cervical esophagus consistent with dentures. upon further inspection of the patient, the patient's upper dentures were accounted for but the patient's lower dentures were not. because of these findings, the patient . has been transferred to a higher-level of care for further medical management and evaluation, including an ear nose and throat specialist consultation findings of foreign body and cervical esophagus . foreign body dentures removed by medical doctor and ear nose and throat specialist this morning after locating object in hypopharynx and extending into the cervical esophagus <BR/>A record review of Resident #2's re-entry and quarterly MDS's, dated 02/27/2023 revealed the Regional MDS LVN documented in section A0310 type of assessment 99 which indicated none of the above. Further review of section A0310 revealed the choices were 01. Admission, 02. Quarterly, 03. Annual, 04. Significant Change in Status, 05. Significant Correction to prior comprehensive assessment, 06. Significant correction to prior quarterly assessment, and 99. None of the above. Further review revealed the MDS assessment was not signed by a RN. <BR/>A record review of Resident #2's quarterly MDS's, dated 03/01/2022, revealed the Regional DON assessed Resident #2 as returned from an acute care hospital on [DATE]. The MDS assessment revealed Resident #2 was severely impaired for cognition and was assessed as needing limited assistance and supervision during meals. Resident #2 was diagnosed with pneumonia, loss of liquids/solids from mouth when eating or drinking and required a change in textures of food and liquids. Review of the MDS Section L revealed no documentation for the assessment broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose). <BR/>A record review of Resident #2's physical paper chart revealed a Care Plan worksheet, dated 01/11/2023, which documented the attendees as the Activities Director [AD] and the Director of Rehabilitation [DOR]. The document revealed there was a concern made by Resident #2's representative for Resident #2's bottom dentures. Further review revealed no documents to reveal any subsequent care plan meetings. <BR/>A record review of Resident #2's Care Plan, dated, 01/13/2023, revealed no focuses, interventions, and/or care instructions for Resident #2's needs for dentures. Review of Resident #2's care plan revealed 1 care instruction, Resident [#2] is at risk for falls due to amputation and weakness . Resident [#2] will be free of falls through next review . encourage call light usage . increased staff supervision with intensity based on Resident [#2] need. Further review of Resident #2's medical records evidenced no further care plans other than the 01/13/2023 care plan. <BR/>During an interview on 03/22/2023 at 02:15 PM CNA D and CNA E, who were the CNAs for Resident #2 revealed the CNAs stated they were not aware Resident #2 had top and bottom dentures and believed she only had top dentures. The CNAs stated they had no care instructions for Resident #2 in their version of the care plan, the [NAME] . The CNA's stated they had no training or care instructions for Resident #2's denture care.<BR/>During an interview on 03/23/2023 at 01:55 PM, the Regional MDS LVN stated she was the MDS coordinator for the facility intermittingly. The Regional MDS LVN stated she had been helping periodically per the facility's needs with Resident assessments and would be alerted by the facility for the need for an MDS assessment. The Regional MDS LVN stated she had completed the MDS assessment for Resident #2 on 02/27/2023 and documented the assessment section as 99 and did not document the assessment as a change of status. The Regional MDS LVN stated she was not aware of Resident #2's change of status and her hospitalization for swallowing her dentures with a diagnosis of sepsis pneumonia. The Regional MDS LVN stated she was not assigned to follow the MDS with care plans and the duty was assigned to someone at the facility by the Administrator possibly ADON S [ADON S from another facility] who helped at the facility or the Regional DON. <BR/>During an interview on 03/24/2023 at 04:50 PM, the Regional DON stated a care plan is prepared by the Interdisciplinary Team [IDT] per the MDS assessment within 7 days of the completed MDS assessment. The Regional DON stated she had completed the quarterly MDS for Resident #2 on 03/01/2023 and did not document an assessment for Resident #2's oral / dental status under section L, broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose) mouth or facial pain, discomfort or difficulty with chewing. The Regional DON stated she did not know if Resident #2's dentures were or were not loose fitting and after her discharge from the hospital there were no reports of Resident #2 having swallowing issues. The Regional DON stated she was responsible for 5 other facility's and was on call for all 5. The Regional DON stated she was not in the facility for 40 hrs. a week. The Regional DON stated she had not coordinated a care plan for Resident #2's change of status for her needs with dentures and assistance supervision during meals within 7 days of the 02/27/2023 re-admission from the hospital or within 7 days of the 03/01/2023 quarterly MDS assessment . The Regional DON stated there should have been care instructions in Resident #2's care plan to reflect Resident #2's needs for support with her dentures and assistance with meals to include diet textures and swallow studies as assessed by the Speech Language pathologist [SLP] who was an IDT member. <BR/>During an interview on 03/24/2023 at 04:32 PM the Administrator stated the ex-DON resigned in October 2022 and since then the corporate regional nursing support staff, to include the Regional DON, the Regional DON I, the Regional Director of Quality, and the Regional MDS nurse, were all involved with the facility's nursing services while the search for a replacement DON ensued. The administrator stated he relied on the corporate regional nursing support staff for the daily continuation of nursing services. The administrator stated the facility policy is to provide an accurate and comprehensive MDS assessments to include care plan development and implementation upon admission, change in conditions, and at a minimum, quarterly. The Administrator stated this was not done as evidenced by Resident #2's MDS assessments and care plan which do not support Resident #2 with her denture needs. The Administrator stated if he had been given a report from nursing staff, that MDS assessments were incomplete, care plans were not performed as required, he would have ensured gaps in nursing services were addressed. <BR/>A record review of the facility's policy Care Planning - Interdisciplinary Team, dated February 2014, revealed, policy statement: our facilities care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each Resident. a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment MDS. the care plan is based on the residence comprehensive assessment and is developed by a care planning interdisciplinary team which includes but is not necessarily limited to the following personnel: the residents attending physician; the registered nurse who has responsibility for the Resident; the activities director coordinator; therapist speech; occupational; recreational; etcetera as applicable; consultants; the director of nursing; the charge nurse responsible for the Resident; nursing assistants responsible for residents care; others as appropriate. the Resident, the residents family and or the residents legal representative guardian are encouraged to participate in the development of and revisions to the residents care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 4 (Residents #6, #16, #26, and #134) of 20 residents reviewed for competent nursing care.<BR/>1. CNA G failed to spread and cleaned within Resident #6's labial folds after an incontinent episode. <BR/>2. CNA A applied barrier cream to Resident #16's open wounds. CNA A reapplied Resident #16's wound dressing that had fallen off into the soiled brief.<BR/>3. LVN D failed to follow facility procedure when she instilled eye drops for Residents #26. <BR/>4. LVN C crushed medications for Resident #134, that were noted to be Do Not Crush.<BR/>These deficient practices affect residents who depend on nursing care and could place residents at risk for injury, infection, and harm.<BR/>The findings included: <BR/>1. Record review of Resident # 6's electronic face sheet dated 05/17/2024 reflected she was admitted to the facility on [DATE]. The resident's diagnoses included: cerebral infarction (damage to tissues on the brain due to a loss of oxygen to the area), dementia (loss of memory, language, problem-solving, and other thinking abilities that were severe), hypothyroidism (thyroid gland does not make enough thyroid hormone), neuropathy (weakness, numbness, and pain form nerve damage), and glaucomatous flecks (disease that damages eye). <BR/>Record review of Resident #6's quarterly MDS, dated [DATE], indicated she did not have a BIMS score which she had impaired cognition. The MDS also indicated Resident #6 was always incontinent for bladder and bowel. <BR/>Observation on 05/15/2024 at 4:55 p.m. revealed while providing incontinent care for Resident #6, CNA G cleaned the perineal area and did not separate and clean between the labial folds. <BR/>In an interview on 05/15/2024 at 5:14 p.m. CNA G revealed she was supposed to open and clean the labia (labia minor-inner fold) and confirmed she did not. CNA G stated she was supposed to clean between the folds to remove germs and prevent infections. <BR/>In an interview with the RNC on 05/15/2024 at 5:20 p.m., the RNC said that during incontinent care the labial folds need to be cleaned to make sure they are properly cleaned and to remove any bacteria in the area. <BR/>Record Review of annual skills check for CNA G revealed CNA G passed competency for Perineal care/incontinent care on 03/27/2024.<BR/>Record review of the facility policy, titled Perineal care, revised 10/2010, revealed Steps in the Procedure . 9. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back (1) Separate labia and wash area downward from front to back.<BR/>2. Record review of Resident #16's electronic face sheet dated 05/15/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to general deterioration of brain), age related osteoporosis (deterioration in bone mass, increasing risk for fracture), contracture (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) right and left shoulder and psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality).<BR/>Record review of Resident #16's quarterly MDS assessment with an ARD of 02/24/2024 reflected she was not a candidate for a BIMS which signified she was severely cognitively impaired. She could rarely understand and rarely be understood. She required extensive assistance with her ADL's. She was always incontinent of bowel and bladder.<BR/>Record review of Resident #16's comprehensive person-centered care plan dated 09/29/2016 reflected Problem, Urinary Incontinence. <BR/>Record review of Resident #16's Active Orders as of 04/01/2024 to 04/30/2024 did not reflect an order for barrier cream.<BR/>Observation on 05/15/2024 at 01:45 PM during incontinent care for Resident #16, her wound dressing which was a 4X4 inch dressing with 4 strips of adhesive tape fell off into the dirty brief. CNA A picked up the dirty wound dressing and placed it back onto Resident #16's wound area after putting barrier cream over the open wound areas.<BR/>During an interview with CNA A on 05/16/2024 at 2:00 PM she stated she screwed up, and she was not supposed to put the dirty dressing back onto Resident #16's bottom. She stated she was supposed to call the nurse when the dressing came off, and she did not think, and placed it back onto the resident. She stated her job was to tell the nurse if the dressing came off. She stated she did not know there was not an order for barrier cream. <BR/>During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated CNA A needed to call the nurse when Resident #16's wound dressing fell off, and not to put it back onto the resident. She stated the barrier cream required an order, because it was noted to be a treatment, and the wound may not heal with other solutions not ordered. She stated she needed to report any changes that were nursing care related to the licensed nurse. She stated she was not trained to put the dressing back on or to apply ointment to wound areas because that was not in her job description.<BR/>Record review of the facility Job Description, Certified Nursing Assistant (CNA) dated February 2024 rflected Essential functions, assist residents with all aspects of activities of daily living, no nursing duties were in the job description.<BR/>Record review of the facilityNurse Aide Performance record dated 06/28/2022 reflected she was trained on applies principles of standard precautions. No where on the skills training checklist related to applying a dressing to a resident.<BR/>3. Record review of Resident #16's electronic face sheet dated 05/15/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to general deterioration of brain), age related osteoporosis (deterioration in bone mass, increasing risk for fracture), contracture (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) of right and left shoulder, and psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality).<BR/>Record review of Resident #16's quarterly MDS assessment with an ARD of 02/24/2024 reflected she was not a candidate for a BIMS score which signified she was severely cognitively impaired. She could rarely understand and rarely be understood. She required extensive assistance with her ADL's. She was always incontinent of bowel and bladder.<BR/>Record review of Resident #16's comprehensive person-centered care plan dated 09/29/2016 reflected Problem, Urinary Incontinence. <BR/>Observation on 05/15/2024 at 03:13 PM of RN F performed wound care for Resident #16 and revealed she did not wear a gown. <BR/>Observation on 05/15/2024 at 01:45 PM during incontinent care for Resident #16, her wound dressing which was a 4X4 inch dressing with 4 strips of adhesive tape fell off into the dirty brief. CNA A picked up the dirty wound dressing and placed it back onto Resident #16's wound area after putting barrier cream over the open wound areas.<BR/>During an interview with CNA A on 05/16/2024 at 2:00 PM she stated she screwed up, and she was not supposed to put the dirty dressing back onto Resident #16's bottom. She stated she was supposed to call the nurse when the dressing came off, and she did not think, and placed it back onto the resident. She stated her job was to tell the nurse if the dressing came off. She stated she did not know there was not an order for barrier cream and the wound would get infected.<BR/>During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated CNA A needed to call the nurse when Resident #16's wound dressing fell off, and not to put it back onto the resident. She stated the barrier cream required an order, because it was noted to be a treatment, and the wound may not heal with other solutions not ordered. She stated she needed to report any changes that were nursing care related to the licensed nurse. She stated she was not trained to put the dressing back on or to apply ointment to wound areas because that was not in her job description. This could cause harm for the resident.<BR/>Record review of the facility Job Description, Certified Nursing Assistant (CNA) dated February 2024 reflected Essential functions, assist residents with all aspects of activities of daily living, no nursing duties were in the job description.<BR/>Record review of the facility Nurse Aide Performance record dated 06/28/2022 reflected she was trained on applies principles of standard precautions. Nothing on the skills training checklist related to the application of a dressing to a resident.<BR/>4. Record review of Resident #26's electronic face sheet dated 05/16/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: cognitive communication deficit (trouble participating in conversations), adult failure to thrive (loss of interest, depressive symptoms), and social exclusion and rejection (detaching from individuals, groups, and social relationships).<BR/>Record review of Resident #26's quarterly MDS assessment with an ARD of 02/27/2024 reflected he scored a 05/15 for his BIMS score which signified he was severely cognitively impaired. He could sometimes understand and sometimes be understood. He required moderate amount of assistance with his ADL's.<BR/>Record review of Resident #26's comprehensive person-centered care plan dated 09/28/2023 reflected Problem, ADL's, self-care deficit, administer medications and treatments as ordered.<BR/>Record review of Resident #26's Active Orders as for 04/01/2024 to 04/30/2024 reflected he received artificial tears, one gtt ou, twice a day.<BR/>Observation on 05/16/2024 at 07:30 a.m. of LVN D applying artificial tears for Resident #16 revealed, she did not wear gloves, and had the resident tilt his head a little bit and she placed the drops of artificial tears directly into one eye and then the other.<BR/>In an interview on 05/16/2024 at 3:00 PM, with LVN D she stated she was not aware that was not the way to administer eye drops. She stated she was not familiar with the facility policy and procedure on eye drop administration, but she knew she was trained. She stated she understood after the procedure was explained to her, that Resident #26's eye drops would not provide the most therapeutic effect if most of the solution ran out of the eyes after administration.<BR/>During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated LVN D did not follow the facility policy and procedure for administering eye drops and she would retrain her. She stated the resident would not get the effectiveness of the medication if the medication was not administered properly, and in this situation. Resident #26's eyes could be irritated and dry.<BR/>Record review of LVN D's Skills checklist-Licensed Nurse dated 03/24/2024 reflected she completed med pass.<BR/>Record review of the facility policy and procedure titled Instillation of Eye Drops revised January 2014 reflected put on gloves, have resident tilt head back slightly, gently pull the lower eyelid down, instruct resident to look up, drop the medication into the mid lower eyelid to allow even distribution of the drops. Instruct the resident not to blink or squeeze the eyelids shut, which forces the medicine out of the eye.<BR/>5. Record review of Resident #134's electronic face sheet dated 05/15/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: encephalopathy, chronic obstructive pulmonary disease, poisoning by cardiac-stimulant glycosides and drugs of similar action, congestive heart failure, and cognitive communication deficit.<BR/>Record review of Resident #134's EMR reflected he was not at the facility long enough for an MDS assessment.<BR/>Record review of Resident #134's baseline care plan dated 05/13/2024 reflected Resident admitted for skilled care, cognition, require orientation to surroundings reminders, and assistance with medication management.<BR/>Record review of Resident #134 physician orders dated 05/16/2024 reflected potassium chloride (to treat or prevent low amounts of potassium in the blood) tablet extended release; 20meq; 1 tablet oral once a day, tamsulosin (treatment for men with large prostate gland) capsule; 0.4mg; 1 tablet 0.4mg, oral one time a day and omeprazole capsule, delayed release (DR/EC) (indicated for short-term treatment of active benign gastric ulcer); 40mg, 1 capsule oral one time a day with start dates of 05/11/2024.<BR/>Record review of the medication cards for 3 of the medications: potassium chloride (to treat or prevent low amounts of potassium in the blood) tablet extended release; 20meq; 1 tablet oral once a day, tamulosin (treatment for men with large prostate gland) capsule; 0.4mg; 1 tablet 0.4mg, oral one time a day and omeprazole capsule, delayed release (DR/EC) (indicated for short-term treatment of active benign gastric ulcer); 40mg, 1 capsule oral one time a day had blue stickers which read Warning DO NOT CRUSH on the front of the packet.<BR/>Observation on 05/16/2024 at 08:34 a.m. of LVN C during medication pass for Resident #134 revealed she took Resident #134's medications into his room in a cup and was ready to administer them, when she asked the resident, would you like these crushed? Resident #134 responded yes, and LVN C departed the resident's room, crushed the tablets, opened the capsules, and mixed the crushed contents into in a medication cup with applesauce. LVN C administered the applesauce and medications to Resident #134 with water.<BR/>During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated LVN C needed to check the medication card for the do not crush and check the Do Not Crush List. She stated LVN C should have called the physician or pharmacist, as she was trained. <BR/>In an interview with LVN C on 05/16/2024 at 1:00 PM she stated she crushed Resident #134's medications before, and had not noticed the warning, do not crush sticker. She stated that too much of a dose could taste bad or cause too much medication to be released too soon and cause distress. She stated she was trained to not crush medications unless the provider had an order to crush, and she had medication skills review annually.<BR/>Record review of LVN C's Skills checklist-Licensed Nurse dated 03/24/2024 reflected she completed med pass.<BR/>Record review of the facility Medications Not to Be Crushed list dated revised 12/22 reflected Omeprazole, Potassium Chloride, and Tamsulosin were on the list. <BR/>Record review of the facility policy and procedure titled Medication Administration, Oral dated 2007 reflected Check for specific prescriber order to crush medications if required by state regulation. Crush medications if indicated for this resident only after referring to the Medications Not to Be Crushed List. For products that appear on the Medication Not to Be Crushed List, check with the pharmacist regarding a suitable alternative, and request a new prescriber order if appropriate.

Based on observation, interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal spa: the failure to ensure residents were made aware of how to obtain a snack when desired for 4 of 9 residents (confidential residents in group) reviewed for frequency of meals.<BR/>The facility failed to ensure residents were offered snacks at bedtimes as required due to mealtimes being more than 14 hours apart.<BR/>This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. <BR/>Findings included: <BR/>Record review of the resident snack list, no date was provided by the DM. There were 27 residents that received morning and afternoon snacks. There was no resident list with HS snacks provided.<BR/>Record review of the resident rooster dated on 5/14/2024 reflected a census of 31 residents. <BR/>Observation on 5/14/2024 at 9:50 AM, of the posted Meal Service Times in the dining room revealed the following:<BR/>Breakfast - 7:30 -7:45 AM <BR/>Lunch - 11:30-11:45 AM <BR/>Evening meal - 5:30 -5:45 PM- There is no posting to advise any resident a snack or availability of type of snack after specified times. <BR/>During interview on 5/14/2024 at 1:35 PM with residents in group of 6 residents, it was brought to the attention of the state surveyors that they have not been made aware of options of a snack which are available to residents. Residents said they were not offered any HS snacks . <BR/>Interview on 5/16/2024 at 10:48 AM with dietary consultant stated he was not aware of residents not offered snacks after dinner. The Dietary consultant stated the effects of residents not offered snacks by staff would he a potential for weight loss, the resident might be diabetic, resident blood sugar levels and resident morale.<BR/>Interview on 5/14/2024 at 4:00 PM the DM stated the resident that received snacks had orders and or have some weight loss. The DM provided a list of 27 out of 31 residents that received snacks . <BR/>Interview on 5/14/2024 at 4:15 PM the ADM stated they give snacks to the residents and snacks are available when resident ask the nurse. The ADM stated the residents that were diabetic or have an order get snacks from kitchen. The ADM stated that residents were provided snacks by the nurse if they ask for snacks.<BR/>Interview on 5/15/2024 at 5:15 PM LVN G stated resident get snacks at the nurse's station. LVN G stated when residents ask for snacks, they provide residents with snacks. <BR/>Interview on 5/15/2024 at 5:24 PM with CNA I who worked the 6 AM to 6 PM shift during the week. CNA I stated not all resident get snacks when they come out from the kitchen. CNA I stated the resident that are offered snacks are residents with physician orders and diabetic residents . CAN I stated the snack that had labels were brought out by kitchen and the nurses' stations always had snacks for residents, at resident request. CNA I stated the residents had refrigerators that had snacks they bought our was brought in by the family. <BR/>Record Review of Facility Policies and Procedures Snacks dated September 2017, reflected The purpose of this procedure is to provide the resident with adequate nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized, for 1 of 24 residents (Resident #30) reviewed for accurate medical records, in that:<BR/>LVN A failed to document an order for a urinalysis laboratory test ordered for Resident #30.<BR/>This failure could place residents at risk for harm by inaccurate records.<BR/>The findings included:<BR/>A record review of Resident #30's Face Sheet, dated 03/22/2023, revealed an admission date of 01/06/2022, with diagnosis which included obstructive and reflux uropathy [a condition when the passage of urine from the kidneys to the exterior is blocked by an obstruction anywhere along the urinary tract].<BR/>A record review of Resident #30's quarterly MDS, dated [DATE], revealed Resident #30 was an [AGE] year-old female assessed with severe mental cognition impairment, as evidenced by a Brief Interview for Mental status score of 05 out of 15. Resident #15 was assessed with the need for total assistance with activities of daily life to include toileting. Further review revealed Resident #30 was assessed as always incontinent of bowel and bladder. <BR/>A record review of Resident #30's care plan, dated 03/22/2023, revealed, problem activities of daily life self-care deficit: requires assistance; total staff performs / provides total assistance; will be clean, dry and free form odors with dignity maintained throughout next quarter; approach document activities of daily life performance staff assistance as per policy, notify charge nurse of change in ability . <BR/>During an observation on 03/21/2023 at 12:16 PM, revealed an empty 4 oz. specimen cup with Lids & ID Label, on the sink counter of Resident #30's bedroom. Further observation revealed the specimen cup label read, UA [urinalysis] 03/20/2023, [Resident #30], [Dr. T ].<BR/>A record review of Resident #30's physician's order summary, dated 03/22/2023, revealed no order for a urinalysis laboratory for Resident #30.<BR/>During an interview on 03/22/2023 at 01:10 PM, LVN A stated she called Dr. T, on 03/20/2023, and gave a SBAR for Resident #30's change of condition with a fever and altered mental status. LVN A stated Dr. T gave her an order to obtain a urinalysis for Resident #30. LVN A stated she failed to document the order in Resident #30's medical record . LVN A stated the failure placed Resident #30 at risk for inaccurate records. LVN A stated inaccurate records denied interdisciplinary team members information needed for quality care for residents. <BR/>During an interview on 03/24/2023 at 04:40 PM the ADON stated physician's orders should always be documented in the resident's medical record as soon as the order had been received. The ADON stated the documentation of the order was critical to quality care for residents. The AND stated the nurses needed orders documented to ensure nursing practice within their scope of duty. The ADON stated inaccurate records denied interdisciplinary team members information needed for quality care for residents.<BR/>A record review of the facility's policy regarding recording/documenting physicians' orders was requested, from the Administrator, on 03/22/2023 at 02:16 PM. As of 03/26/2023 at 04:30 PM a policy was not provided and the Regional DON stated the facility followed the CMS and state regulations/guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #1) whose records were reviewed for infections.<BR/>The facility failed to follow protocols when Resident #1 was diagnosed with Salmonella:<BR/>a. There was not a physician's order or a sign on Resident #1's room to inform nursing staff and others he was on contact precautions for an infection.<BR/>b. The ADM and DON did not contact the local state authority or HHSC to report Resident #1 was diagnosed with Salmonella.<BR/>These deficient practices could affect any resident and contribute to the spread of infections.<BR/>The findings were:<BR/>Review of Resident #1's face sheet, dated 3/7/24, revealed he was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation (an irregular and often very rapid heart rhythm.) and Hyperlipidemia (elevated lipid levels within the human body). Further review revealed Resident #1 was discharged from the facility on 3/1/24.<BR/>Review of Resident #1's admission MDS, dated [DATE], revealed Resident #1's BIMS was 11 reflecting moderate cognitive impairment. Further review did not reveal he had an existing infection.<BR/>Review of Resident #1's Care Plan, dated, 1/28/24, revealed Resident #1 had diarrhea related to Salmonella (most commonly cause diarrhea illness). and was on contact precautions.<BR/>Review of Resident #1's consolidated physician orders for February 2024 did not reveal an order for isolation or contact precautions related to diagnosis of Salmonella. <BR/>Review of hospital lab report dated, 12/24/23 revealed Resident #1 was detected with Salmonella sp (most commonly cause diarrhea illness. Other types of Salmonella - Salmonella Typhi and Salmonella Paratyphi - cause typhoid fever and paratyphoid fever).<BR/>Review of hospital lab report dated, 2/24/23 revealed Resident #1 was detected with Salmonella sp.<BR/>Review of an Infection Event Summary Report [DATE] to [DATE] revealed Resident #1 was diagnosed with Gastroenteritis infection on 12/27/23 and resolved on 12/28/23; then again on 2/26/24. Further review revealed there were no other residents with same the same diagnosis during this time period.<BR/>Review of progress notes from December 2023 to February 2024 revealed the following: <BR/>*12/24/23 at 12:07 PM written by LVN E, indicated Resident #1 had lose stools and sent out to the hospital. <BR/>*12/27/23 at 1440 (2:40 PM) written by LVN F, revealed a new order for Cefpodoxime related to salmonella infection. <BR/>*1/9/24 at 2050 (8:50 PM) written by LVN G indicated Resident #1 received ABT. The MD indicated he did not re-test because Resident #1 did not have any more lose stools and he completed the ABT. Further review revealed Resident #1's family member mentioned Resident #1 was not getting better on the medication. <BR/>*2/18/24 at 2128 (9:28 PM), revealed Resident #1 had signs and symptoms of nausea and diarrhea again. <BR/>*2/20/24 at 13:43 (1:43 PM) written by LVN F, revealed Resident #1 did not have any lose stools. <BR/>*2/21/24 at 1342 (1:42 PM) written by LVN F, revealed NP A assessed Resident #1, and Resident #1's family member requested IV therapy for dehydration and NP A agreed and provided an order. There was also new orders for Zofran (used alone or with other medications to prevent nausea and vomiting) and Loperamide (treat sudden diarrhea) to be administered until 2/29/24. <BR/>Interview on 3/5/24 at 3:30 PM with the DON revealed NP A ordered a stool sample per protocol after Resident #1 had a few episodes of diarrhea upon admission. She stated the diarrhea subsided and then about 1 week later it started again. It was more persistent and lasted for about 4 to 5 days. The DON stated NP A ordered Resident #1 with a full treatment of antibiotics. She further stated the signs/symptoms cleared and then last week or the week before Resident #1 had diarrhea again. The DON stated Resident #1 was diagnosed with salmonella. She stated she learned most recently she was supposed to report it to the local state authority after she received a call from a representative from the local state authority. She was provided with a document with a list of reportable infections and Salmonella was on the list. The DON stated she had been the facility DON as of June 2023 and it was her first DON position. The DON provided the document and further stated it also reflected they should also report the incident to HHSC. She stated it would be the ADM who would report the incident. <BR/>Interview on 3/5/24 at 4:35 PM with the ADM revealed she was responsible for reporting all reportable incidents to HHSC but did not know she had to report a positive infection for salmonella. She stated in the 20 years as an ADM she had never had experienced residents with Salmonella. <BR/>Interview on 3/5/24 at 4:38 PM with CNA B revealed she had worked at the facility for 25 years and remembered Resident #1. She stated Resident #1 had a few episodes of diarrhea upon admission and learned he was diagnosed with an infection: food poisoning. She stated she did not remember Resident #1 being on isolation. <BR/>Interview on 3/5/24 at 5 PM with the DON revealed she was the Infection Preventionist. She stated the purpose for reporting contagious infections to their local health authority would be for accountability, tracking infections in the city that could spread and the local state health department would be able to provide guidance. She stated Resident #1 was placed on contact precautions; placed a sign on the door and a cart with PPE outside of his room. <BR/>Interview on 3/5/24 at 5:27 PM with LVN C revealed she worked 2 to 10 PM for about 1 year. LVN C stated Resident #1 was diagnosed with Salmonella during February 2024. She stated Resident #1 was not placed on contact isolation but stated he was on contact precautions; standard precautions. However, there were no signs on Resident #1's door he was on contact precautions.<BR/>Interview on 3/7/24 at 11:38 AM with the DON revealed she provided nursing staff a verbal order that Resident #1 was on contact precautions but she did not enter it into Resident #1's consolidated orders which would let nursing staff he was on contact precautions. The DON stated she should have entered the orders to ensure nursing staff that were not present at the time were aware and would take the necessary precautions. <BR/>Interview on 3/5/24 at 12:41 PM with LVN D revealed she had worked in the facility for 33 years. She stated Resident #1 was tested after he started having diarrhea and was diagnosed with food poisoning, Salmonella. He was put on antibiotic. LVN D stated Resident #1 was on standard precautions but there was not a sign on the door reflecting he was on standard precautions related to an infection. She stated nursing staff protocol was to always use standard precautions. However, it was protocol required a sign to let nursing staff Resident #1 had an active infection. This also served the purpose to letting nursing staff to monitor and document on the resident's condition.<BR/>Review of facility policy, Infection Prevention and Control Program, revised on 1/1/24 read: This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precaution, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. Surveillance: b. The infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings to the facility's Quality Assessment and Assurance Committee. c. The RNs and LPs participate in surveillance through assessment of residents and reporting changes in condition to the resident's physician and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. <BR/>Review of Texas Notifiable Conditions-2024 provided by the Texas Department of State Health Services revised 11/28/23 read Report all Confirmed and Suspected cases, Salmonellosis, including typhoid fever within 1 week.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the Resident's assessment accurately reflected the resident's status, for 1 of 24 residents (Resident #2) reviewed for lack of assessment for dentures, in that:<BR/>1. <BR/>Resident #2 was admitted and assessed without documenting her need for dentures after a hospitalization where Resident #2 was treated for having swallowed her dentures.<BR/>This failure could have placed residents at risk for harm by unidentified dentures and lack of care and support for the dentures.<BR/>The findings included:<BR/>A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 11/22/2022 and 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care.<BR/>A record review of Resident #2's hospital discharge records, dated 02/26/2023, revealed history of present illness; chief complaint; altered mental status, low oxygen level, and foreign body (dentures) in esophagus . this is a [AGE] year-old white female brought by emergency medical services 2[name of hospital] emergency room on the evening of 02/21/2023 for recurrent episodes of aspiration associated with shortness of breath for two days prior to presentation. the patient is unable to provide any history due to cognitive impairment at baseline . the patient was sent 2 . emergency room by care staff at the skilled nursing facility where the patient resides for two episodes of food aspiration for two days prior to presentation. the patient had one episode of food aspiration on 02/20/2023 and a second episode of food aspiration on 02/21/2023. her second episode was more severe and associated with significant coughing and choking. care staff reports gradual onset of worsening shortness of breath for approximately 2 days prior to presentation . the patient was noted to meet criteria for sepsis with elevated heart rate, elevated temperature, and elevated white blood cell count. the patient was found to have a bacterial source in the form of bilateral aspiration pneumonia . X-ray of the soft tissues of the neck performed at the emergency room showed a U-shaped foreign body noted within the cervical esophagus [back of the throat] consistent with dentures. upon further inspection of the patient, the patient's upper dentures were accounted for, but the patient's lower dentures were not. because of these findings, the patient . has been transferred to a higher-level of care for further medical management and evaluation, including an ear nose and throat specialist consultation findings of foreign body and cervical esophagus . foreign body dentures removed by medical doctor and ear nose and throat specialist this morning after locating object in hypopharynx [back of the throat] and extending into the cervical esophagus .<BR/>A record review of Resident #2's re-entry and quarterly MDS's, dated 02/27/2023 revealed the Regional MDS LVN documented in section A0310 type of assessment 99 which indicated none of the above. Further review of section A0310 revealed the choices were 01. Admission, 02. Quarterly, 03. Annual, 04. Significant Change in Status, 05. Significant Correction to prior comprehensive assessment, 06. Significant correction to prior quarterly assessment, and 99. None of the above. Further review revealed the MDS assessment was not signed by a RN.<BR/>A record review of Resident #2's quarterly MDS's, dated 03/01/2022, revealed the Regional DON assessed Resident #2 as returned from an acute care hospital on [DATE]. The MDS assessment revealed Resident #2 was severely impaired for cognition and was assessed as needing limited assistance and supervision during meals. Resident #2 was diagnosed with pneumonia, loss of liquids/solids from mouth when eating or drinking and required a change in textures of food and liquids. Review of the MDS Section L revealed no documentation for the assessment broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose). <BR/>A record review of Resident #2's physical paper chart revealed a Care Plan worksheet, dated 01/11/2023, which reflected the attendees as the AD and the DOR. The document revealed there was a concern made by Resident #2's representative for Resident #2's bottom dentures. Further review revealed no documents to reveal any subsequent care plan meetings. <BR/>A record review of Resident #2's Care Plan, dated, 01/13/2023, revealed no focuses, interventions, and/or care instructions for Resident #2's needs for dentures. Further review of Resident #2's medical records evidenced no further care plans other than the 01/13/2023 care plan. <BR/>During an interview on 03/23/2023 at 01:55 PM, the Regional MDS LVN stated she was the MDS coordinator for the facility intermittingly. The Regional MDS LVN stated she had been helping periodically per the facility's needs with resident assessments and would be alerted by the facility of the need for an MDS assessment. The Regional MDS LVN stated she had completed the MDS assessment for Resident #2 on 02/27/2023 and documented the assessment section as 99 and did not document the assessment as a change of status . The Regional MDS LVN stated she was not aware of Resident #2's change of status and her hospitalization for swallowing her dentures with a diagnosis of sepsis pneumonia. The Regional MDS LVN stated she was not assigned to follow the MDS with care plans and the duty was assigned to someone at the facility by the Administrator possibly ADON S [ADON S from another facility] who helped at the facility or the Regional DON. <BR/>During an interview on 03/24/2023 at 04:50 PM, the Regional DON stated a care plan was prepared by the IDT per the MDS assessment within 14 days of the completed MDS assessment. The Regional DON stated she had completed the quarterly MDS for Resident #2 on 03/01/2023 and did not document an assessment for Resident #2's oral/dental status under Section L, broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose) mouth or facial pain, discomfort or difficulty with chewing. The Regional DON stated she did not know if Resident #2's dentures were or were not loose fitting and after her discharge from the hospital there were no reports of Resident #2 having swallowing issues. The Regional DON stated she was responsible for 5 other facility's and was on call for all 5. The Regional DON stated she was not in the facility for 40 hrs. a week. The Regional DON stated she had not coordinated a care plan for Resident #2's change of status for her needs with dentures and assistance supervision during meals within 14 days of the 02/27/2023 re-admission from the hospital or within 14 days of the 03/01/2023 quarterly MDS assessment . The Regional DON stated there should have been care instructions in Resident #2's care plan to reflect Resident #2's needs for support with her dentures and assistance with meals to include diet textures and swallow studies as assessed by the SLP who was an IDT member.<BR/>During an interview on 03/24/2023 at 04:32 PM the Administrator stated the ex-DON resigned in October 2022 and since then the corporate regional nursing support staff, to include the Regional DON, the Regional DON I, the Regional Director of Quality, and the Regional MDS nurse, were all involved with the facility's nursing services while the search for a replacement DON ensued. The administrator stated he relied on the corporate regional nursing support staff for the daily continuation of nursing services. The administrator stated the facility policy is to provide an accurate and comprehensive MDS assessments to include care plan development and implementation upon admission, change in conditions, and at a minimum, quarterly. The Administrator stated this was not done as evidenced by Resident #2's MDS assessments and care plan which do not support Resident #2 with her denture needs. The Administrator stated if he had been given a report from nursing staff, that MDS assessments were incomplete, care plans were not performed as required, he would have ensured gaps in nursing services were addressed. <BR/>A record review of the facility's policy admission Assessment and Follow Up: Role of the Nurse, dated December 2012, revealed, The purpose of this procedure is to gather information about the residents physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the Resident, initiating the care plan, and completing required assessment instruments, including the MDS . steps in the procedure . conduct a physical assessment, including the following systems: eyes, ears, nose, throat; teeth and gums . contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtained admission orders that are based on these findings . notify the supervisor and the attending physician of immediate needs that the resident may have . report other information in accordance with facility policy and professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services to meet the needs for 5 of 9 residents (Residents #4, #5, #9, #15, and #134), and the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconcilitation for 1 of 9 residents (Resident #4) reviewed for medication administration. <BR/>1. <BR/>The facility failed to ensure accurate documentation of medications administered to Resident #134. <BR/>2. <BR/>The facility failed to ensure Residents #4, #5, #9, and #15 received medications as ordered by the physician.<BR/>3. <BR/>The facility failed to prevent the loss of 2 tablets of Resident #4's hydrocodone-acetaminophen, a narcotic pain <BR/>medication. <BR/>4. <BR/>The facility failed to discard expired insulin for Resident #15. <BR/>These failures could lead to inaccurate administration of medications, ineffective therapeutic effects, and injury or illness. <BR/>Findings included: <BR/>1. Record review of Resident #134's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE], with relevant diagnoses including type 2 diabetes mellitus with hyperglycemia (elevated blood sugar levels resulting from the body's inability to self-regulate glucose) and chronic pulmonary embolism (a blood clot in the lung). Record review of Resident #134's admission MDS, submitted on [DATE], indicated a BIMS score could not be assessed due to the cognitive status of the resident. <BR/>Record review of Resident #134's EMR contained the following medication orders:<BR/>a. Insulin lispro injection solution 100 unit/mL, inject as per sliding scale . subcutaneously before meals and at bedside related to type 2 diabetes mellitus with hyperglycemia (order date [DATE])<BR/>b. Eliquis oral tablet 2.5mg (apixaban), given 1 tablet via PEG-tube every morning and at bedside related to chronic pulmonary embolism (order date [DATE])<BR/>Record review of Resident #134's MAR revealed no documentation on [DATE] for 8:00 PM administration of medication Eliquis and 8:00 PM administration of subcutaneous insulin. <BR/>In an interview on [DATE] at 4:00 PM, LVN E stated he was responsible for administering the above listed medications. He stated Resident #134 received both medications, and the missing documentation was the result of a computer error. LVN E reported potential the possible harm of incorrect medication documentation was potential overdose or other staff not knowing what medications a resident had received. <BR/>2. Record review of Resident #4's facesheet, printed [DATE], reflected a [AGE] year-old female, originally admitted to the facility on [DATE]. Resident #4 had a relevant diagnosis of dementia, unspecified (a progress that impairs the thought processes). Record review of Resident #4's quarterly MDS, submitted [DATE], did not include a BIMS score assessment due to the resident's cognitive status at the time of the assessment. <BR/>Record review of Resident #4's EMR contained the following physician's order: <BR/>Divalproex sodium DR 125 mg tab, given 1 tablet orally two times a day related to unspecified dementia (order <BR/>date [DATE])<BR/>While observing routine medication administration on [DATE] at 7:32 AM, the DON was observed crushing the divalproex DR tablet before mixing it with pudding to administer to Resident #4 orally. <BR/>In a telephone interview on [DATE] at 8:20 AM, the RPh stated Resident #4's divalproex DR should not be crushed prior to administration, as crushing it would affect the absorption and cause the medication to become absorbed more quickly. The RPh also stated that he was unaware Resident #4 required medications to be crushed, and if he would have known, he would have contacted the facility to recommend a different formulation of the medication. The RPh then stated the potential harm to Resident #134 by receiving the medication crushed inappropriately was ineffective therapeutic effect due to quicker absorption. <BR/>The DON was interviewed on [DATE] at 14:20. She stated the divalproex DR should not have been crushed. She then stated the divalproex had been discussed with the RPh, and the order was modified to the alternate formulation appropriate for crushed medications. She reported the potential harm to Resident #4 from receiving the improperly crushed medication was the resident not getting the intended therapeutic effect or seizures. <BR/>Record review of Resident #5's facesheet, printed [DATE], reflected a [AGE] year-old male, originally admitted to the facility on [DATE], and with a relevant diagnosis of drug induced subacute dyskinesia (a movement disorder that develops as a result of starting or increasing the dosage of certain medications). Record review of Resident #5's quarterly MDS, submitted [DATE], revealed a BIMS score of 9, indicating moderately impaired cognition. <BR/>Resident #5's EMR contained the following order:<BR/>Austedo XR oral tablet extended release 24 hour 6mg (Deutetrabenazine) give 6mg by mouth at bedtime for <BR/>tardive dyskinesia related to unsteadiness on feet (order state [DATE] 20:00 [8:00 PM])<BR/>Review of Resident #5's MAR for [DATE], printed [DATE], reflected the following documentation for Austedo XR:<BR/>a. <BR/>[DATE] 8:00 PM: no documentation/blank<BR/>b. <BR/>[DATE] 8:00 PM: code 9 documented by LVN C<BR/>c. <BR/>[DATE] 8:00 PM: code 9 documented by CMA A<BR/>d. <BR/>[DATE] 8:00 PM: code 9 documented by LVN C<BR/>e. <BR/>[DATE] 8:00 PM: documented as administered by LVN C<BR/>f. <BR/>[DATE] 8:00 PM: code 9 documented by CMA A<BR/>g. <BR/>[DATE] 8:00 PM: code 9 documented by CMA A<BR/>h. <BR/>[DATE] 8:00 PM: code 9 documented by CMA A<BR/>i. <BR/>[DATE] 8:00 PM: code 9 documented by LVN C<BR/>j. <BR/>[DATE] 8:00 PM: code 9 documented by LVN C<BR/>k. <BR/>[DATE] 8:00 PM: code 9 documented by ADON<BR/>l. <BR/>[DATE] 8:00 PM: code 9 documented by ADON<BR/>The code key for the MAR revealed 9 indicated other/see progress notes. Record review of Resident #5's progress notes for [DATE] did not reveal any documentation related to the administration of the Austedo XR.<BR/>CMA A was interviewed on [DATE] at 5:05 PM. She stated she was responsible for administering medications to Resident #5 on [DATE]. She explained the Austedo XR was not able to be administered to Resident #5 because it was not available in the facility and did not arrive until [DATE]. She explained if a medication is not in stock, the process was to inform the charge nurse or the ADON or DON, if they were available. She stated she informed the charge nurse and the DON of the need for the Austedo XR and the pharmacy told the staff it would be delivered. She was unsure why the administration scheduled for 8:00 PM on [DATE] did not contain any documentation, as the facility policy for medications not administered was to use code 9 and type a progress note, if needed.<BR/>In an attempted interview on [DATE] at 5:29 PM, LVN C was contacted by telephone but there was no answer, and the voicemail recording indicated the mailbox was full.<BR/>The ADON was interviewed on [DATE] at 5:15 PM. She stated she noticed on [DATE] the medication was not in stock, so she contacted the pharmacy personally to request the medication. She said the pharmacy was unaware of the new order, and they delivered it on [DATE]. <BR/>An interview on [DATE] at 5:20 PM revealed the DON was not aware that Resident #5 had not received 11 doses of the Austedo XR. She did not recall being notified by any staff member during that time. She stated Austedo XR was not contained with the facility emergency stock of medications, so the documentation of Resident #5 receiving the medication on [DATE] was likely charted in error. She then said her expectation of staff was they would notify her and the Admin of any medications that were out of stock. <BR/>Record review of Resident #9's face sheet, printed [DATE], reflected a [AGE] year-old male, initially admitted to the facility on [DATE], with a relevant diagnosis of cognitive impairment of uncertain or unknown etiology. Record review of Resident #9's quarterly MDS submitted on [DATE] revealed a BIMS score of 11, indicating moderately impaired cognition. <BR/>Record review of Resident #9's EMR revealed the following physician's order:<BR/>Memantine HCl oral tablet 5mg, give 5mg by mouth at bedside related to mild cognitive impairment of uncertain <BR/>or unknown etiology for 7 days (start date [DATE] 20:00 [8:00 PM]). <BR/>Record review of Resident #9's [DATE] MAR, printed [DATE], revealed the following documentation for Memantine HCl:<BR/>a. <BR/>[DATE] 8:00 PM: no documentation/blank<BR/>b. <BR/>[DATE] 8:00 PM: no documentation/blank<BR/>c. <BR/>[DATE] 8:00 PM: no documentation/blank<BR/>d. <BR/>[DATE] 8:00 PM: no documentation/blank<BR/>CMA A was interviewed on [DATE] at 5:05 PM. She stated she was responsible for administering medications to Resident #9 on [DATE] and [DATE]. She stated the order for administration of the Memantine HCl was not present on [DATE] or [DATE], as she did not remember seeing an alert. <BR/>Per the staffing schedule, LVN C was responsible for administering Resident #9's medications on [DATE] and [DATE]. LVN C was contacted by telephone on [DATE] at 5:29 PM, but there was no answer, and the voicemail recording indicated the mailbox was full.<BR/>Record review of Resident #15's facesheet, printed [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE], with a relevant diagnosis of schizoaffective disorder, bipolar type (a chronic mental health condition that causes difficulty distinguishing reality with frequent mood swings). Record review of Resident #9's admission MDS submitted [DATE] reflected a BIMS score of 13, indicating intact cognition. <BR/>Record review of Resident #15's EMR revealed the following physician's order:<BR/>Quetiapine fumarate oral tablet, give 12.5 mg by mouth in the morning related to schizoaffective disorder, <BR/>bipolar type for 7 days (start date [DATE] 08:00 [AM]). <BR/>Record review of Resident #15's [DATE] MAR, printed [DATE], reflected the following documentation for Quetiapine:<BR/>a. <BR/>[DATE] 8:00 AM: no documentation/blank<BR/>b. <BR/>[DATE] 8:00 AM: no documentation/blank<BR/>Per the staffing schedule, LVN D was responsible for administering Resident #15's Quetiapine on [DATE] and [DATE]. <BR/>LVN D was contacted by telephone on [DATE] at 4:20 PM, and a voicemail with contact information was left to obtain an interview. LVN D did not contact the state survey team prior to exit. <BR/>In an interview with the ADON on [DATE] at 5:33 PM, she explained that Resident #9 did not receive the ordered Memantine HCl and Resident #15 did not receive the ordered Quetiapine because the electronic orders were pending confirmation from the nursing staff administering the medication in the EMR. She further explained that both orders were confirmed late (after the ordered start date), so the MARs populated with the missed doses. She reported the potential harm to residents as missed doses of medication. She reported there was no formal process for confirming medication orders and that this needed to be addressed by herself and the DON. <BR/>Record review of the facility's policy titled Administering Medications (2001, revised [DATE]) revealed the following:<BR/>a. <BR/>Medications are administered in accordance with prescriber orders, including any required time frame<BR/>b. <BR/>If a drug is withheld . the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. <BR/>3. As noted previously, record review of Resident #4's facesheet, printed [DATE], reflected a [AGE] year-old female, originally admitted to the facility on [DATE]. Resident #4 had a relevant diagnosis of dementia, unspecified (a progress that impairs the thought processes). Record review of Resident #4's quarterly MDS, submitted [DATE], did not include a BIMS score assessment due to the resident's cognitive status at the time of the assessment. <BR/>Record review of Resident #4's EMR revealed the following physician's order:<BR/>Hydrocodone-acetaminophen oral tablet 10-325mg<BR/>Give 1 tablet by mouth four times a day related to pain, unspecified<BR/>(Order date [DATE])<BR/>Record review of the facility's investigation report included copies of the individual narcotic record dated [DATE] through [DATE], in which 2 tablets of the medication were not dated or signed as administered by nursing staff. <BR/>During an observation of medication administration on [DATE] at 7:00 AM, Resident #4's hydrocodone-acetaminophen tablets (45) were verified to match the documentation on the individual narcotic record (45). <BR/>LVN E was interviewed on [DATE] at 12:26 PM,. she stated a discrepancy of 4 tablets was discovered during the routine narcotic count on the [DATE] morning shift handoff between LVN F and herself. She stated she counted the actual tablets present, and LVN F read the number she recorded in the book during her overnight shift, and the numbers did not match. She reported signing the paper to indicate the number of tablets on hand and notified the DON later that day. She stated Resident #4 did not appear to be in pain during her shift or to have suffered any harm because of the missing medication. LVN E denied knowledge of the missing hydrocodone-tablets.<BR/>LVN F was interviewed on [DATE] at 2:06 PM. She reported no medication was missing on the handoff that occurred on the morning of [DATE], and she was unsure why she was questioned about the missing tablets, as the handoff was recorded by herself and the oncoming nurse which indicated a proper count of actual tablets versus recorded amount. She denied any knowledge of Resident #4's misappropriated hydrocodone-acetaminophen. She stated she was no longer employed at the facility.<BR/>In an interview with the DON on [DATE] at 9:03 AM. She explained the process for narcotic counts at shift change was the off-going and oncoming would review the narcotics and the documentation in the binder containing the individual narcotic records to verify the documentation was correct. The two nurses would then sign the front page of the binder to indicate mutual verification. When asked about Resident #4, she explained initially four tablets of the hydrocodone-acetaminophen were missing, but her investigation and audit revealed two of the four tablets were administered by LVN F on the PM shift of [DATE] and not documented properly . She reported 2 tablets were not able to be reconciled, despite the investigation.<BR/>Record review of the facility's policy titled Controlled Substances (dated 2001, revised [DATE]) revealed the following:<BR/>The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.<BR/>The director of nursing services documents irreconcilable discrepancies in a report to the administrator. <BR/>4. Record review of Resident #15's facesheet, printed [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE], with a relevant diagnosis of type 2 diabetes mellitus without complications (inability of the body to regulate blood glucose levels.) <BR/>Record review of Resident #15's admission MDS submitted [DATE] reflected a BIMS score of 13, indicating intact cognition. <BR/>Record review of Resident #15's EMR contained the following physician's order:<BR/>Insulin lispro infection solution 100 unit/mL . subcutaneously before meals and at bedside related to Type 2 <BR/>diabetes mellitus without complications (order date [DATE])<BR/>In an observation on [DATE] at 4:03 PM of the medication cart used for the 200 and 300 residence halls, two multi-dose insulin vials affixed with pharmacy labels for Resident #15 were observed in the drawer. Both multi-dose vials were labeled as opened on [DATE]. LVN B explained during this observation that the facility process was to discard insulin after 29 days and Resident #15's insulin should be thrown away. LVN B had just arrived for his shift and was unsure if Resident #15 had been administered the expired insulin. LVN B reported the potential harm to residents receiving expired insulin was hyperglycemia as the expired insulin may be less effective. <BR/>In an interview with the DON on [DATE] at 4:17 PM, she reported the facility policy was to keep insulin for 28 days after removing from the fridge. The DON stated unlabeled insulin in the medication cart should be discarded and not administered.<BR/>Review of the facility policy titled Medication Labeling and Storage (dated 2001, revised February 2023), revealed the following:<BR/>Multi-dose vials that have been opened or accessed . are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to have drugs and biologicals used in the facility labeled in accordance with currently accepted professional principles and the expiration date when applicable for 1 of 2 medication carts (200-300 halls cart) reviewed for medication storage. <BR/>The facility failed to label the expiration dates of opened/unrefrigerated insulin stored in the medication cart for Resident #2.<BR/>This failure could lead to ineffective insulin therapy, hyperglycemia, and illness. <BR/>Findings included:<BR/>Record review of Resident #2's facesheet, printed [DATE], revealed a [AGE] year-old female, originally admitted to the facility on [DATE] with a relevant diagnosis of type 2 diabetes mellitus with hyperglycemia (the body's inability to self-regulate blood sugar leading to elevated levels). Review of the quarterly MDS, submitted [DATE], revealed a BIMS score of 8, indicating moderately impaired cognition. <BR/>Record review of Resident #2's EMR contained the following physician's order:<BR/>Lantus Solostar 100 unit/mL<BR/>Inject 10 unit subcutaneously at bedtime related to type 2 diabetes mellitus with hyperglycemia<BR/>(Order date [DATE])<BR/>In an observation on [DATE] at 4:03 PM of the medication cart used for the 200 and 300 residence halls, an insulin pen affixed with a pharmacy label for Resident #2 was observed in the drawer. The insulin pen was not labeled with any additional dates other than the information printed by the pharmacy. <BR/>LVN B assisted with the observation and was interviewed concurrently. LVN B was unsure of when Resident #2's insulin pen was removed from the fridge and opened, and he denied administering insulin to the resident using that device on [DATE] as her insulin was not due until the evening. He stated the facility process is to label insulin pens and vials with the date they are removed from the fridge and opened. He also stated the insulin can be kept for 29 days once removed from the fridge and then must be discarded. LVN B had just arrived for his shift and was unsure if Resident #2 had been administered the unlabeled insulin. LVN B reported the potential harm to residents was hyperglycemia as the insulin may expired and may be less effective. <BR/>In an interview with the DON on [DATE] at 4:17 PM, she reported the facility policy was to apply a date when the insulin is opened and to keep insulin for 28 days after removing from the fridge.<BR/>Review of the facility policy titled Medication Labeling and Storage (dated 2001, revised February 2023), revealed the following:<BR/>Multi-dose vials that have been opened or accessed . are dated and discarded within 28 days unless the <BR/>manufacturer specifies a shorter or longer date for the open vial.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #1) whose records were reviewed for infections.<BR/>The facility failed to follow protocols when Resident #1 was diagnosed with Salmonella:<BR/>a. There was not a physician's order or a sign on Resident #1's room to inform nursing staff and others he was on contact precautions for an infection.<BR/>b. The ADM and DON did not contact the local state authority or HHSC to report Resident #1 was diagnosed with Salmonella.<BR/>These deficient practices could affect any resident and contribute to the spread of infections.<BR/>The findings were:<BR/>Review of Resident #1's face sheet, dated 3/7/24, revealed he was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation (an irregular and often very rapid heart rhythm.) and Hyperlipidemia (elevated lipid levels within the human body). Further review revealed Resident #1 was discharged from the facility on 3/1/24.<BR/>Review of Resident #1's admission MDS, dated [DATE], revealed Resident #1's BIMS was 11 reflecting moderate cognitive impairment. Further review did not reveal he had an existing infection.<BR/>Review of Resident #1's Care Plan, dated, 1/28/24, revealed Resident #1 had diarrhea related to Salmonella (most commonly cause diarrhea illness). and was on contact precautions.<BR/>Review of Resident #1's consolidated physician orders for February 2024 did not reveal an order for isolation or contact precautions related to diagnosis of Salmonella. <BR/>Review of hospital lab report dated, 12/24/23 revealed Resident #1 was detected with Salmonella sp (most commonly cause diarrhea illness. Other types of Salmonella - Salmonella Typhi and Salmonella Paratyphi - cause typhoid fever and paratyphoid fever).<BR/>Review of hospital lab report dated, 2/24/23 revealed Resident #1 was detected with Salmonella sp.<BR/>Review of an Infection Event Summary Report [DATE] to [DATE] revealed Resident #1 was diagnosed with Gastroenteritis infection on 12/27/23 and resolved on 12/28/23; then again on 2/26/24. Further review revealed there were no other residents with same the same diagnosis during this time period.<BR/>Review of progress notes from December 2023 to February 2024 revealed the following: <BR/>*12/24/23 at 12:07 PM written by LVN E, indicated Resident #1 had lose stools and sent out to the hospital. <BR/>*12/27/23 at 1440 (2:40 PM) written by LVN F, revealed a new order for Cefpodoxime related to salmonella infection. <BR/>*1/9/24 at 2050 (8:50 PM) written by LVN G indicated Resident #1 received ABT. The MD indicated he did not re-test because Resident #1 did not have any more lose stools and he completed the ABT. Further review revealed Resident #1's family member mentioned Resident #1 was not getting better on the medication. <BR/>*2/18/24 at 2128 (9:28 PM), revealed Resident #1 had signs and symptoms of nausea and diarrhea again. <BR/>*2/20/24 at 13:43 (1:43 PM) written by LVN F, revealed Resident #1 did not have any lose stools. <BR/>*2/21/24 at 1342 (1:42 PM) written by LVN F, revealed NP A assessed Resident #1, and Resident #1's family member requested IV therapy for dehydration and NP A agreed and provided an order. There was also new orders for Zofran (used alone or with other medications to prevent nausea and vomiting) and Loperamide (treat sudden diarrhea) to be administered until 2/29/24. <BR/>Interview on 3/5/24 at 3:30 PM with the DON revealed NP A ordered a stool sample per protocol after Resident #1 had a few episodes of diarrhea upon admission. She stated the diarrhea subsided and then about 1 week later it started again. It was more persistent and lasted for about 4 to 5 days. The DON stated NP A ordered Resident #1 with a full treatment of antibiotics. She further stated the signs/symptoms cleared and then last week or the week before Resident #1 had diarrhea again. The DON stated Resident #1 was diagnosed with salmonella. She stated she learned most recently she was supposed to report it to the local state authority after she received a call from a representative from the local state authority. She was provided with a document with a list of reportable infections and Salmonella was on the list. The DON stated she had been the facility DON as of June 2023 and it was her first DON position. The DON provided the document and further stated it also reflected they should also report the incident to HHSC. She stated it would be the ADM who would report the incident. <BR/>Interview on 3/5/24 at 4:35 PM with the ADM revealed she was responsible for reporting all reportable incidents to HHSC but did not know she had to report a positive infection for salmonella. She stated in the 20 years as an ADM she had never had experienced residents with Salmonella. <BR/>Interview on 3/5/24 at 4:38 PM with CNA B revealed she had worked at the facility for 25 years and remembered Resident #1. She stated Resident #1 had a few episodes of diarrhea upon admission and learned he was diagnosed with an infection: food poisoning. She stated she did not remember Resident #1 being on isolation. <BR/>Interview on 3/5/24 at 5 PM with the DON revealed she was the Infection Preventionist. She stated the purpose for reporting contagious infections to their local health authority would be for accountability, tracking infections in the city that could spread and the local state health department would be able to provide guidance. She stated Resident #1 was placed on contact precautions; placed a sign on the door and a cart with PPE outside of his room. <BR/>Interview on 3/5/24 at 5:27 PM with LVN C revealed she worked 2 to 10 PM for about 1 year. LVN C stated Resident #1 was diagnosed with Salmonella during February 2024. She stated Resident #1 was not placed on contact isolation but stated he was on contact precautions; standard precautions. However, there were no signs on Resident #1's door he was on contact precautions.<BR/>Interview on 3/7/24 at 11:38 AM with the DON revealed she provided nursing staff a verbal order that Resident #1 was on contact precautions but she did not enter it into Resident #1's consolidated orders which would let nursing staff he was on contact precautions. The DON stated she should have entered the orders to ensure nursing staff that were not present at the time were aware and would take the necessary precautions. <BR/>Interview on 3/5/24 at 12:41 PM with LVN D revealed she had worked in the facility for 33 years. She stated Resident #1 was tested after he started having diarrhea and was diagnosed with food poisoning, Salmonella. He was put on antibiotic. LVN D stated Resident #1 was on standard precautions but there was not a sign on the door reflecting he was on standard precautions related to an infection. She stated nursing staff protocol was to always use standard precautions. However, it was protocol required a sign to let nursing staff Resident #1 had an active infection. This also served the purpose to letting nursing staff to monitor and document on the resident's condition.<BR/>Review of facility policy, Infection Prevention and Control Program, revised on 1/1/24 read: This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precaution, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. Surveillance: b. The infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings to the facility's Quality Assessment and Assurance Committee. c. The RNs and LPs participate in surveillance through assessment of residents and reporting changes in condition to the resident's physician and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. <BR/>Review of Texas Notifiable Conditions-2024 provided by the Texas Department of State Health Services revised 11/28/23 read Report all Confirmed and Suspected cases, Salmonellosis, including typhoid fever within 1 week.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 3 (Residents #11, #15, and #18) of 20 residents reviewed for dignity.<BR/>1. Resident #11's wheelchair on 05/14/2024 at 10:00 a.m. had the left armrest vinyl torn and sharp and appeared worn and damaged.<BR/>2. Resident #15's wheelchair on 05/14/2024 at 10:12 a.m., had both armrests vinyl torn and worn on the edges.<BR/>3. Resident #18's wheelchair on 05/14/2024 at 10:15 a.m. had both armrests vinyl torn and worn. The left side armrest was missing vinyl and foam and the baseboard was exposed. <BR/>These deficient practices affect residents who rely on facility equipment for mobilization and could result in loss of self-esteem, dignity, and increased lack of self-worth.<BR/>The findings included:<BR/>1. Record review of Resident #11's electronic face sheet dated 05/14/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: abnormalities of gait and mobility (any deviations from normal walking or gait), thyrotoxicosis (a condition that happens when there is too much thyroid hormone in the body and can cause rapid weight loss and a rapid heartbeat), paroxysmal atrial fibrillation (type of irregular heartbeat), and adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability).<BR/>Record review of Resident #11's quarterly MDS assessment with an ARD of 04/02/2024 reflected he scored a 10/15 for his BIMS score which signified he was moderately cognitively impaired. He could understand and be understood. He required a manual wheelchair, and he could roll 150 feet once seated in the chair.<BR/>Record review of Resident #11's comprehensive person-centered plan of care 09/29/2023 reflected Problem, ADL's Functional Status/Rehabilitation Potential, Approach, promote dignity, assist with ADL's as needed.<BR/>Observation on 05/14/2024 at 10:00 a.m., Resident #11 was sitting in his wheelchair and the left armrest vinyl was torn with sharp ragged edges and appeared worn and damaged.<BR/>During an interview on 05/17/2024 at 1:30 p.m. with Resident #11, he stated he had the wheelchair for as long as he could remember. When asked why he did not ask the staff to repair it, he stated what good would it do? He stated he did not want to bother anyone. He stated the worn and torn armrest made him feel depressed.<BR/>2. Record review of Resident #15's electronic face sheet dated 05/14/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: hypothyroidism (the thyroid gland cannot make enough thyroid hormone to keep the body running normally), dementia (a loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and muscle weakness (when full effort does not produce a normal muscle contraction or movement).<BR/>Record review of Resident #15's quarterly MDS review with an ARD of 03/25/2024 reflected he scored a 09/15 for his BIMS score which signified he was moderately cognitively impaired. He could usually understand and could usually be understood. He required a manual wheelchair, and he could move independently.<BR/>Record review of Resident #15's comprehensive person-centered care plan dated 03/24/2024 reflected Problem, ADLs Functional Status/Rehabilitation Potential, Approach, promote dignity, assist with ADL's as needed.<BR/>Observation and interview on 05/14/2024 at 10:12 a.m., Resident #15 was sitting in his wheelchair and both the armrests vinyl was torn and worn which caused him to feel a loss of dignity.<BR/>During an observation and interview on 05/17/2024 at 2:00 p.m. with Resident #15, who was sitting in his wheelchair in the 300 hallway, he had new armrests on his wheelchair which were replaced on 05/16/2024 after the state surveyor spoke with the RNC. He stated the old armrests made him feel bad. When asked why he did not mention the worn and torn armrests to the staff, he stated he did not want to bother anyone. He stated he had the wheelchair since he was admitted to the facility.<BR/>3. Record review of Resident #18's electronic face sheet dated 05/14/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and mood issues), weakness (lacking strength), unspecified abnormalities of gait (any deviations from normal walking or gait), and mobility and spinal stenosis (space inside the backbone is too small and can cause pain, tingling, and weakness).<BR/>Record review of Resident #18's quarterly MDS assessment with an ARD of 03/21/2024 reflected he scored a 10/15 for his BIMS score which signified he was moderately cognitively impaired. He could understand and be understood. He required a manual wheelchair and could move independently.<BR/>Record review of Resident #18's comprehensive person-centered care plan dated 08/14/2023 reflected Problem, ADLs Functional Status/Rehabilitation Potential, Approach, promote dignity, assist with ADL's as needed.<BR/>Observation on 05/14/2024 at 10:15 a.m. of Resident #18, he was sitting in his wheelchair, and both the armrests had torn and worn vinyl and the left armrest was missing foam which exposed the baseboard.<BR/>During an interview on 05/14/2024 at 10:17 a.m. with Resident #18, he stated he had the wheelchair since his admission and the vinyl wore and tore. He stated he did not want to bother the staff and did not complain. He stated the torn and worn vinyl and missing foam on the armrests bothered him and made him feel down and not dignified.<BR/>Observation on 05/17/2024 of Resident #18 at 3:00 p.m. sitting in his wheelchair in the 300 hall, he had new armrests. The new armrests were the result of the state surveyor intervention, who spoke with the RNC on 05/16/2024 about the torn and worn armrests.<BR/>During an interview on 05/17/2024 at 3:02 p.m. with Resident #18, he stated the new armrests on his wheelchair were soft and comfortable, and he felt much better.<BR/>During an interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated worn and torn armrests on resident's wheelchairs were a safety and dignity issue. She stated she had been at the facility for less than a year and the company just hired a DON who had not started work. She stated she was not aware and had not noticed the resident wheelchairs needed armrests replaced or repaired. She stated if staff saw something that required repair, they needed to write it down in the Maintenance book at the nurse's station, and she presumed no one had noticed since the residents did not complain. She stated she would get them replaced right away. She stated a resident could feel embarrassed, undignified, or have a lack of self-esteem because of the torn armrests.<BR/>Record review of the facility policy and procedure titled Quality of Life-Dignity, dated revised August 2009 reflected Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, Treated with dignity means that residents will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the Resident's assessment accurately reflected the resident's status, for 1 of 24 residents (Resident #2) reviewed for lack of assessment for dentures, in that:<BR/>1. <BR/>Resident #2 was admitted and assessed without documenting her need for dentures after a hospitalization where Resident #2 was treated for having swallowed her dentures.<BR/>This failure could have placed residents at risk for harm by unidentified dentures and lack of care and support for the dentures.<BR/>The findings included:<BR/>A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 11/22/2022 and 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care.<BR/>A record review of Resident #2's hospital discharge records, dated 02/26/2023, revealed history of present illness; chief complaint; altered mental status, low oxygen level, and foreign body (dentures) in esophagus . this is a [AGE] year-old white female brought by emergency medical services 2[name of hospital] emergency room on the evening of 02/21/2023 for recurrent episodes of aspiration associated with shortness of breath for two days prior to presentation. the patient is unable to provide any history due to cognitive impairment at baseline . the patient was sent 2 . emergency room by care staff at the skilled nursing facility where the patient resides for two episodes of food aspiration for two days prior to presentation. the patient had one episode of food aspiration on 02/20/2023 and a second episode of food aspiration on 02/21/2023. her second episode was more severe and associated with significant coughing and choking. care staff reports gradual onset of worsening shortness of breath for approximately 2 days prior to presentation . the patient was noted to meet criteria for sepsis with elevated heart rate, elevated temperature, and elevated white blood cell count. the patient was found to have a bacterial source in the form of bilateral aspiration pneumonia . X-ray of the soft tissues of the neck performed at the emergency room showed a U-shaped foreign body noted within the cervical esophagus [back of the throat] consistent with dentures. upon further inspection of the patient, the patient's upper dentures were accounted for, but the patient's lower dentures were not. because of these findings, the patient . has been transferred to a higher-level of care for further medical management and evaluation, including an ear nose and throat specialist consultation findings of foreign body and cervical esophagus . foreign body dentures removed by medical doctor and ear nose and throat specialist this morning after locating object in hypopharynx [back of the throat] and extending into the cervical esophagus .<BR/>A record review of Resident #2's re-entry and quarterly MDS's, dated 02/27/2023 revealed the Regional MDS LVN documented in section A0310 type of assessment 99 which indicated none of the above. Further review of section A0310 revealed the choices were 01. Admission, 02. Quarterly, 03. Annual, 04. Significant Change in Status, 05. Significant Correction to prior comprehensive assessment, 06. Significant correction to prior quarterly assessment, and 99. None of the above. Further review revealed the MDS assessment was not signed by a RN.<BR/>A record review of Resident #2's quarterly MDS's, dated 03/01/2022, revealed the Regional DON assessed Resident #2 as returned from an acute care hospital on [DATE]. The MDS assessment revealed Resident #2 was severely impaired for cognition and was assessed as needing limited assistance and supervision during meals. Resident #2 was diagnosed with pneumonia, loss of liquids/solids from mouth when eating or drinking and required a change in textures of food and liquids. Review of the MDS Section L revealed no documentation for the assessment broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose). <BR/>A record review of Resident #2's physical paper chart revealed a Care Plan worksheet, dated 01/11/2023, which reflected the attendees as the AD and the DOR. The document revealed there was a concern made by Resident #2's representative for Resident #2's bottom dentures. Further review revealed no documents to reveal any subsequent care plan meetings. <BR/>A record review of Resident #2's Care Plan, dated, 01/13/2023, revealed no focuses, interventions, and/or care instructions for Resident #2's needs for dentures. Further review of Resident #2's medical records evidenced no further care plans other than the 01/13/2023 care plan. <BR/>During an interview on 03/23/2023 at 01:55 PM, the Regional MDS LVN stated she was the MDS coordinator for the facility intermittingly. The Regional MDS LVN stated she had been helping periodically per the facility's needs with resident assessments and would be alerted by the facility of the need for an MDS assessment. The Regional MDS LVN stated she had completed the MDS assessment for Resident #2 on 02/27/2023 and documented the assessment section as 99 and did not document the assessment as a change of status . The Regional MDS LVN stated she was not aware of Resident #2's change of status and her hospitalization for swallowing her dentures with a diagnosis of sepsis pneumonia. The Regional MDS LVN stated she was not assigned to follow the MDS with care plans and the duty was assigned to someone at the facility by the Administrator possibly ADON S [ADON S from another facility] who helped at the facility or the Regional DON. <BR/>During an interview on 03/24/2023 at 04:50 PM, the Regional DON stated a care plan was prepared by the IDT per the MDS assessment within 14 days of the completed MDS assessment. The Regional DON stated she had completed the quarterly MDS for Resident #2 on 03/01/2023 and did not document an assessment for Resident #2's oral/dental status under Section L, broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose) mouth or facial pain, discomfort or difficulty with chewing. The Regional DON stated she did not know if Resident #2's dentures were or were not loose fitting and after her discharge from the hospital there were no reports of Resident #2 having swallowing issues. The Regional DON stated she was responsible for 5 other facility's and was on call for all 5. The Regional DON stated she was not in the facility for 40 hrs. a week. The Regional DON stated she had not coordinated a care plan for Resident #2's change of status for her needs with dentures and assistance supervision during meals within 14 days of the 02/27/2023 re-admission from the hospital or within 14 days of the 03/01/2023 quarterly MDS assessment . The Regional DON stated there should have been care instructions in Resident #2's care plan to reflect Resident #2's needs for support with her dentures and assistance with meals to include diet textures and swallow studies as assessed by the SLP who was an IDT member.<BR/>During an interview on 03/24/2023 at 04:32 PM the Administrator stated the ex-DON resigned in October 2022 and since then the corporate regional nursing support staff, to include the Regional DON, the Regional DON I, the Regional Director of Quality, and the Regional MDS nurse, were all involved with the facility's nursing services while the search for a replacement DON ensued. The administrator stated he relied on the corporate regional nursing support staff for the daily continuation of nursing services. The administrator stated the facility policy is to provide an accurate and comprehensive MDS assessments to include care plan development and implementation upon admission, change in conditions, and at a minimum, quarterly. The Administrator stated this was not done as evidenced by Resident #2's MDS assessments and care plan which do not support Resident #2 with her denture needs. The Administrator stated if he had been given a report from nursing staff, that MDS assessments were incomplete, care plans were not performed as required, he would have ensured gaps in nursing services were addressed. <BR/>A record review of the facility's policy admission Assessment and Follow Up: Role of the Nurse, dated December 2012, revealed, The purpose of this procedure is to gather information about the residents physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the Resident, initiating the care plan, and completing required assessment instruments, including the MDS . steps in the procedure . conduct a physical assessment, including the following systems: eyes, ears, nose, throat; teeth and gums . contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtained admission orders that are based on these findings . notify the supervisor and the attending physician of immediate needs that the resident may have . report other information in accordance with facility policy and professional standards of practice.

**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 for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 4 of 8 residents (Resident #2, #32, #28, and #7) reviewed for care plans in that:<BR/>Residents #32 and #7 did not have a comprehensive person-centered care plan in their resident file.<BR/>Residents #2 and #28 did not have a comprehensive care plan that met a resident's medical needs. <BR/>These failures could place residents at risk of receiving inadequate interventions not individualized to their care needs. <BR/>The findings were:<BR/>- <BR/>Record review of Resident #32's face sheet dated 3/23/23, revealed an [AGE] year-old female admitted on [DATE] with diagnosis that include malignant neoplasm of brain (a fast-growing tumor in the brain), gastro-esophageal reflux disease (a condition where acidic gastric fluid flows backward into the esophagus), and depression. <BR/>- <BR/>Record review of Resident #32's most recent MDS dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills. <BR/>- <BR/>Record review of Resident #32's EHR reflected no evidence of a comprehensive person-centered care plan. <BR/>- <BR/>Record review of Reside #7's face sheet dated 3/23/23, revealed a [AGE] year-old female admitted on [DATE] with diagnosis that include Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves), Stage 3 pressure ulcer (an injury to skin resulting from prolonged pressure), and Dysphasia (impairment in speech due to brain disease or damage). <BR/>- <BR/>Record review of Resident #7's most recent MDS dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills. <BR/>- <BR/>Record review of Resident #7's EHR reflected no evidence of a comprehensive person-centered care plan. <BR/>- <BR/>Record review of Resident #28's face sheet dated 3/23/23, revealed an [AGE] year-old male admitted on [DATE] with diagnosis that include Gout (a form of arthritis), Oropharyngeal dysphagia (swallowing problems occurring in the mouth/throat), Aphasia (language disorder that affects the ability to communicate) and open wounds to forearm and left ankle.<BR/>- <BR/>Record review of Resident #28's most recent MDS dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills. <BR/>- <BR/>Record review of Resident #28's care notes from the dietician dated 9/19/22 indicate that the resident had lost 8.1% of their total body weight in 1 month. Stated there were current orders for protein shakes.<BR/>- <BR/>Record review or Resident #28's care notes from the dietician dated 315/23 indicate that the resident had lost 7.8% of their total body weight in 1 month. The care note also states that the resident should be on a fortified meal plan. <BR/>- <BR/>Record review of Resident #28's comprehensive person-centered care plan revealed there were no interventions present for the resident's weight loss as recommended by the dietician. <BR/>- <BR/>Record review of facility policy on care planning revealed that comprehensive care plans for each resident must be developed within seven days of completion of the MDS. <BR/>- <BR/>Record review of facility policy on care planning revealed that a change in condition that will not resolve itself without intervention is required to be reviewed by an interdisciplinary team and revised on the care plan. <BR/>- <BR/>In an interview on 3/24/23 at 10:55 AM, ADON stated she is teaching herself the facilities EHR system and has recently taught herself how to do Care Plans in the system. The ADON stated that she was not aware Resident #32 and Resident #7 did not have record of a care plan in the EHR. The ADON also stated that she was not aware that Resident #28's care plan did not accurately reflect his medical needs. <BR/>- <BR/>In an interview on 3/24/23 at 1:06 PM, Administrator stated he was not aware care plans were not being completed adequately. Administrator stated there were care plan meetings but that there were not RNs at these meetings. The administrator stated he does not know why Residents #32, #7, and #28 do not have accurate care plans.<BR/>Resident #2<BR/>A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care.<BR/>A record review of Resident #2's hospital discharge records, dated 02/26/2023, revealed history of present illness; chief complaint; altered mental status, low oxygen level, and foreign body(dentures) in esophagus . this is a [AGE] year-old white female brought by emergency medical services 2[name of hospital] emergency room on the evening of 02/21/2023 for recurrent episodes of aspiration associated with shortness of breath for two days prior to presentation. the patient is unable to provide any history due to cognitive impairment at baseline . the patient was sent 2 . emergency room by care staff at the skilled nursing facility where the patient resides for two episodes of food aspiration for two days prior to presentation. the patient had one episode of food aspiration on 02/20/2023 and a second episode of food aspiration on 02/21/2023. her second episode was more severe and associated with significant coughing and choking. care staff reports gradual onset of worsening shortness of breath for approximately 2 days prior to presentation . the patient was noted to meet criteria for sepsis with elevated heart rate, elevated temperature, and elevated white blood cell count. the patient was found to have a bacterial source in the form of bilateral aspiration pneumonia . X-ray of the soft tissues of the neck performed at the emergency room showed a U-shaped foreign body noted within the cervical esophagus consistent with dentures. upon further inspection of the patient, the patient's upper dentures were accounted for but the patient's lower dentures were not. because of these findings, the patient . has been transferred to a higher-level of care for further medical management and evaluation, including an ear nose and throat specialist consultation findings of foreign body and cervical esophagus . foreign body dentures removed by medical doctor and ear nose and throat specialist this morning after locating object in hypopharynx and extending into the cervical esophagus <BR/>A record review of Resident #2's re-entry and quarterly MDS's, dated 02/27/2023 revealed the Regional MDS LVN documented in section A0310 type of assessment 99 which indicated none of the above. Further review of section A0310 revealed the choices were 01. Admission, 02. Quarterly, 03. Annual, 04. Significant Change in Status, 05. Significant Correction to prior comprehensive assessment, 06. Significant correction to prior quarterly assessment, and 99. None of the above. Further review revealed the MDS assessment was not signed by a RN. <BR/>A record review of Resident #2's quarterly MDS's, dated 03/01/2022, revealed the Regional DON assessed Resident #2 as returned from an acute care hospital on [DATE]. The MDS assessment revealed Resident #2 was severely impaired for cognition and was assessed as needing limited assistance and supervision during meals. Resident #2 was diagnosed with pneumonia, loss of liquids/solids from mouth when eating or drinking and required a change in textures of food and liquids. Review of the MDS Section L revealed no documentation for the assessment broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose). <BR/>A record review of Resident #2's physical paper chart revealed a Care Plan worksheet, dated 01/11/2023, which documented the attendees as the Activities Director [AD] and the Director of Rehabilitation [DOR]. The document revealed there was a concern made by Resident #2's representative for Resident #2's bottom dentures. Further review revealed no documents to reveal any subsequent care plan meetings. <BR/>A record review of Resident #2's Care Plan, dated, 01/13/2023, revealed no focuses, interventions, and/or care instructions for Resident #2's needs for dentures. Review of Resident #2's care plan revealed 1 care instruction, Resident [#2] is at risk for falls due to amputation and weakness . Resident [#2] will be free of falls through next review . encourage call light usage . increased staff supervision with intensity based on Resident [#2] need. Further review of Resident #2's medical records evidenced no further care plans other than the 01/13/2023 care plan. <BR/>During an interview on 03/22/2023 at 02:15 PM CNA D and CNA E, who were the CNAs for Resident #2 revealed the CNAs stated they were not aware Resident #2 had top and bottom dentures and believed she only had top dentures. The CNAs stated they had no care instructions for Resident #2 in their version of the care plan, the [NAME] . The CNA's stated they had no training or care instructions for Resident #2's denture care.<BR/>During an interview on 03/23/2023 at 01:55 PM, the Regional MDS LVN stated she was the MDS coordinator for the facility intermittingly. The Regional MDS LVN stated she had been helping periodically per the facility's needs with Resident assessments and would be alerted by the facility for the need for an MDS assessment. The Regional MDS LVN stated she had completed the MDS assessment for Resident #2 on 02/27/2023 and documented the assessment section as 99 and did not document the assessment as a change of status. The Regional MDS LVN stated she was not aware of Resident #2's change of status and her hospitalization for swallowing her dentures with a diagnosis of sepsis pneumonia. The Regional MDS LVN stated she was not assigned to follow the MDS with care plans and the duty was assigned to someone at the facility by the Administrator possibly ADON S [ADON S from another facility] who helped at the facility or the Regional DON. <BR/>During an interview on 03/24/2023 at 04:50 PM, the Regional DON stated a care plan is prepared by the Interdisciplinary Team [IDT] per the MDS assessment within 7 days of the completed MDS assessment. The Regional DON stated she had completed the quarterly MDS for Resident #2 on 03/01/2023 and did not document an assessment for Resident #2's oral / dental status under section L, broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose) mouth or facial pain, discomfort or difficulty with chewing. The Regional DON stated she did not know if Resident #2's dentures were or were not loose fitting and after her discharge from the hospital there were no reports of Resident #2 having swallowing issues. The Regional DON stated she was responsible for 5 other facility's and was on call for all 5. The Regional DON stated she was not in the facility for 40 hrs. a week. The Regional DON stated she had not coordinated a care plan for Resident #2's change of status for her needs with dentures and assistance supervision during meals within 7 days of the 02/27/2023 re-admission from the hospital or within 7 days of the 03/01/2023 quarterly MDS assessment . The Regional DON stated there should have been care instructions in Resident #2's care plan to reflect Resident #2's needs for support with her dentures and assistance with meals to include diet textures and swallow studies as assessed by the Speech Language pathologist [SLP] who was an IDT member. <BR/>During an interview on 03/24/2023 at 04:32 PM the Administrator stated the ex-DON resigned in October 2022 and since then the corporate regional nursing support staff, to include the Regional DON, the Regional DON I, the Regional Director of Quality, and the Regional MDS nurse, were all involved with the facility's nursing services while the search for a replacement DON ensued. The administrator stated he relied on the corporate regional nursing support staff for the daily continuation of nursing services. The administrator stated the facility policy is to provide an accurate and comprehensive MDS assessments to include care plan development and implementation upon admission, change in conditions, and at a minimum, quarterly. The Administrator stated this was not done as evidenced by Resident #2's MDS assessments and care plan which do not support Resident #2 with her denture needs. The Administrator stated if he had been given a report from nursing staff, that MDS assessments were incomplete, care plans were not performed as required, he would have ensured gaps in nursing services were addressed. <BR/>A record review of the facility's policy Care Planning - Interdisciplinary Team, dated February 2014, revealed, policy statement: our facilities care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each Resident. a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment MDS. the care plan is based on the residence comprehensive assessment and is developed by a care planning interdisciplinary team which includes but is not necessarily limited to the following personnel: the residents attending physician; the registered nurse who has responsibility for the Resident; the activities director coordinator; therapist speech; occupational; recreational; etcetera as applicable; consultants; the director of nursing; the charge nurse responsible for the Resident; nursing assistants responsible for residents care; others as appropriate. the Resident, the residents family and or the residents legal representative guardian are encouraged to participate in the development of and revisions to the residents care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 (residents #21, and #22) of 20 residents reviewed for care plans.<BR/>1. Resident #21's comprehensive person-centered care plan was not revised after her quarterly MDS assessment with an ARD of 03/17/24 to reflect she had taken antianxiety medication.<BR/>2. Resident #22's comprehensive person-centered care plan was not revised or updated based on the facility policy to not use chair and bed alarms for prevention of fall, but the care plan reflected continually using chair and bed alarms. <BR/>These deficient practices affect residents who receive assessments and could result in an inaccurate comprehensive person-centered care plan and missed care.<BR/>The findings included:<BR/>1. Record review of Resident #21's electronic face sheet dated 05/14/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: edema (swelling caused by too much fluid trapped in the body's tissue), acute respiratory failure (occurs when the lungs cannot release enough oxygen into the blood), anxiety (a feeling of worry, nervousness, or unease), peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), and spinal stenosis (space inside the backbone is too small and can cause pain, tingling and weakness).<BR/>Record review of Resident #21's quarterly MDS assessment with an ARD of 03/17/2024 reflected she scored a 09/15 for her BIMS score which signified she was moderately cognitively impaired. She could understand and be understood. She required moderate to extensive assistance with her ADL's. Review of Section N0415, High-Risk Drug Classes: Use and Indication. An area checked Is taking and indication noted was antianxiety.<BR/>Record review of Resident #21's comprehensive person-centered care plan revised dated 04/09/2024 did not reflect Resident #21's antianxiety medication she took three times a day.<BR/>Record review of Resident #21's Physician Order Report: 03/01/2024 - 04/30/2024 reflected she took an antianxiety medication during the week of 03/12/2024 to 03/17/2024. Ativan (antianxiety medication) 0.5mg TID, with a start date of 02/09/2024. <BR/>Record review of Resident #21's EMAR dated 03/01/2024 - 03/31/2024 reflected she received Ativan (antianxiety medication) 0.5mg TID, with a start date of 02/09/2024.<BR/>During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated Resident #21's antianxiety medication ordered in February and indicated on the March 17 MDS assessment. This needed to be updated on her care plan and it was not. She stated a resident's care plan was a map of how a resident gets what care they need and without it, they may miss or receive inappropriate care.<BR/>In an interview on 05/17/2024 at 05:22 PM with the Corporate MDS Nurse, she stated she was so busy with MDS's and care plans, she did not know how the psychoactive medication, Ativan, was not updated on the care plan after her quarterly assessment dated [DATE]. Could result in care missed.<BR/>2. Record review of Resident # 22's electronic face sheet dated 05/17/2024 reflected he was admitted to the facility on [DATE]. The resident's diagnoses included: hypokalemia (low level of potassium in the blood), cerebral infarction (damage to tissues on the brain due to a loss of oxygen to the area), reduced mobility, abnormalities of gait and mobility (change to walking pattern), history of falling, anxiety disorder (persistent feeling of anxiety or dread), and impaired vision (poor vision to blindness).<BR/>Record review of Resident #22's quarterly MDS assessment with an ARD of 04/29/2024 reflected he scored an 8/15 for his BIMS score which signified he was moderately cognitively impaired. He could understand and be understood.<BR/>Record review of Resident #22' comprehensive person-centered plan of care, dated 03/01/2024, reflected Evaluate need for bed/chair alarms for prevention of fall.<BR/>In an interview with CNA A on 05/16/2024 at 8:14 a.m. she stated, Per our facility policy, we never use chair or bed alarms.<BR/>In an interview with LVN D on 05/16/2024 at 8:24 a.m. she stated He [Resident #22] did not have chair or bed alarms because we never use chair or bed alarms per our policy.<BR/>In an interview with MDS consultant RN B on 05/16/2024 at 9:21 a.m. confirmed the facility did not use chair or bed alarms per their policy. Resident #22' comprehensive person-centered plan of care for Evaluate need for bed/chair alarms for prevention of fall should have revised or updated based on the facility policy. She stated it was very important that the care plan was revised or updated correctly to reflect current Resident #22's status because the care plan was the blueprint regarding how to provide correct care to residents. <BR/>Record review of the facility policy and procedure titled Care Planning - Interdisciplinary Team revised September 2013 reflected A comprehensive care plan is developed within 7 days of completion of the resident MDS assessment .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan.<BR/>Record review of the facility policy, titled Quality of Life - Homelike environment, revised 02/2014, revealed The facility staff and management shall minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include Chair and bed alarms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 9 residents (Resident #2) reviewed for reviewed for neglect for denture care and supervision at meals, in that:<BR/>The facility failed to identify care or support for Resident #2's dentures. During 3 meals, on 02/20/2023 and 02/21/2023, Resident #2 choked on food and aspirated food. Resident #2 swallowed her lower dentures which became lodged in the back of her throat during the 2nd meal and was served the third meal in this condition. [Choking occurs when the airway is blocked by food, drink, or foreign objects. Aspiration occurs when food, drink, or foreign objects are breathed into the lungs (going down the wrong tube).]<BR/>An IJ was identified on 03/24/2023. The IJ template was provided to the facility on [DATE] at 05:15 PM. While the IJ was removed on 03/25/2023, the facility remained out of compliance at a scope of IJ and a severity level of J because of the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure placed Residents at risk for death by a blocked airway and secondary pulmonary infection by aspirated food/vomit. <BR/>The findings included:<BR/>A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 11/22/2022 and 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care.<BR/>A record review of Resident #2's admission notes, 11/22/2022 to 02/20/2023, failed to reveal any assessments for dentures or oral dentition. <BR/>A record review of Resident #2's admission MDS, dated [DATE], revealed the Regional MDS LVN prepared the assessment and failed to assess Resident #2 was admitted with and used dentures. Further review revealed Regional DON I signed the MDS. <BR/>A record review of Resident #2's Care Plan, dated, 03/22/2023, revealed no focuses, interventions, and/or care instructions for Resident #2's needs for dentures. <BR/>A record review of Resident #2's nursing progress notes revealed LVN H documented on 02/20/2023 at 06:30 PM, Approximately 1730 [05:30 PM] resident was eating dinner in the dining room when she aspirated [inhaled food and/or vomit into lungs] while eating her meal. Writer and staff acted quickly and was able to assist Resident to clear what was caught in her throat. Writer contacted the physician and was told to monitor resident for fever and shortness of breath. Resident [family member] was contacted and let known of the situation. Resident vitals are stable and Resident has been placed back in her bed in high fowlers position to prevent any further aspiration. will continue to monitor.<BR/>A record review of Resident #2's nursing progress notes revealed LVN A documented on 02/21/2023 at 01:53 PM, To dining room for meals for supervision. Pureed diet served today due to sore and hoarse throat. Resident began coughing on first bite of food. Resident able to clear and then slowly ate pureed food. X-ray ordered with two views.<BR/>A record review of Resident #2's final X-ray Report, dated 02/21/2023 , revealed, examination: chest . findings: . a metallic foreign body projects over the neck <BR/>A record review of Resident #2's nursing progress notes revealed the ADON documented on 02/21/2023 at 06:11 PM, Patient presenting increased SOB using ABDM muscles, cold, clammy to touch, pale, diaphoretic [excessive sweating], speech therapist here tried to feed patient at this time patient did not tolerate but one bite of mashed potatoes. Drooling and discharge from nose called. [Resident #2's representative] and doctor [name] on call for [Resident #2's doctor] send to ED for evaluation and treatment .<BR/>A record review of Resident #2's hospital medical records revealed a History of Present Illness, dated 02/22/2023, authored by Dr. T, chief complaint: altered mental status, low oxygen level, and foreign body (dentures) in esophagus [throat] . is a [AGE] year old white female brought by EMS to [local hospital] hospital emergency room on the evening of 02/21/2023 for recurrent episodes of aspiration associated with shortness of breath for two days prior to presentation. The patient is unable to provide any history due to cognitive impairment at baseline. As a result, history is obtained exclusively from review of hard copy medical records provided by the transferring facility. The patient was sent to the outside emergency room by care staff at the skilled nursing facility where the patient resides for two episodes of food aspiration for two days prior to presentation. The patient had one episode of food aspiration on 02/20/2023 and a second episode of food aspiration on 02/21/2023. Her second episode was more severe and associated with significant coughing and choking. Care staff reports gradual onset of worsening shortness of breath for approximately 2 days prior to presentation. Her shortness of breath was worse if she laid flat and improves if she sat up. At the outside emergency room, the patient's initial vital signs were remarkable for blood pressure 131/72, heart rate 106, respiratory rate 18, temperature 101.4, and 90% oxygen saturation on room air. Labs were remarkable for white blood cell count 25.4, hemoglobin 13.1, hematocrit 40.2, platelet count 270, sodium 138, potassium 4.3, creatinine 0.73, glucose 170, lactic acid 1.35, negative troponin, BNP 37, lipase 22, phosphorus 3.5, magnesium 1.7, TSH 1.06, PT 12.4, INR 1.1, PTT 30.4, and negative urinalysis. The patient was noted to meet criteria for sepsis with elevated heart rate, elevated temperature, an elevated white blood cell count. the patient was found to have a bacterial source in the form of bilateral aspiration pneumonia. CTA of chest was negative for PPE but did show acute findings consistent with bilateral aspiration pneumonia. CT of abdomen and pelvis with IV contrast performed at the outside emergency room showed fecal impaction with wall thickening and adjacent stranding. X-ray of the soft tissues of the neck performed at the outside of emergency room showed a U-shaped foreign body noted within the cervical esophagus consistent with dentures. upon further inspection of the patient, the patient's upper dentures were accounted for, but the patient's lower dentures were not. As a result of these findings, the patient has been transferred to [out of town specialty hospital] to a higher-level care for further medical management and evaluation, including ear nose and throat specialist consultation.<BR/>A record review of Resident #2's hospital records revealed a patient assessment document Bedside Swallowing Evaluation, dated 02/22/2023, authored by Dr. U, medical history diagnosis, date of onset: patient is a [AGE] year-old female admitted with hypoxemia, concern for aspiration pneumonia, findings of foreign body and cervical esophagus. her are in, history of renal cancer. chest X-ray 02/22: segmental atelectasis vs RRL pneumonia. foreign body dentures removed by medical doctor and ear nose and throat specialist this morning after locating object in hypopharynx and extending into the cervical esophagus. per emergency medical record documented dysphasia at nursing facility.<BR/>During an interview on 03/22/2023 at 10:23 AM, the ADON stated on her 2nd day of employment at the facility, Resident #2 aspirated during the evening dinner on 2/20/2023. The ADON stated LVN H was assigned to supervise the residents at the evening meal and was absent from his duty. The ADON stated she heard the commotion and calls from the dining room when she ran to the dining room and assessed Resident #2, pale, cyanotic [blue skin], cold, tearing eyes and anxiously attempting to breath. The ADON stated she performed the Heimlich maneuver [performed by wrapping your arms around a person, making a fist with one hand and clasping it with the other. You place your fists between the person's ribcage and belly button and thrust your hands into their abdomen until the object is freed], swept Resident #2's oral cavity and expelled food from Resident #2's oral cavity. The ADON stated she was not familiar with Resident #2 and did not know Resident #2 had dentures. The ADON stated she did not feel or visualize Resident #2's dentures in her mouth. The ADON stated she could not access Resident #2's care plan due to her lack of training on the facility's electronic record. The ADON stated she now understood, even if she had access to Resident #2's care plan there were no interventions to alert anyone to Resident #2's dentures. The ADON stated Resident #2 was assessed with vital signs within normal limits, her physician was given a report and was assisted to bed for the evening. The ADON stated the physician was not given any report regarding her dentures. <BR/>During an interview on 03/22/2023 at 02:15 PM CNA D and CNA E, who were the CNAs for Resident #2 to include the dinner meal on 02/20/2023 and 02/21/2023, the CNAs stated they were not aware Resident #2 had top and bottom dentures and believed she only had top dentures. The CNAs stated they had no training or care instructions for Resident #2's denture care.<BR/>During an interview on 03/23/2023 at 02:00 PM, LVN H stated he was the nurse on duty on 02/20/2022 and that Resident #2 had aspirated and had recovered. LVN H stated he called the on-call physician, gave report of the incident, and received new orders for monitoring Resident #2 for signs and symptoms of aspiration complications . LVN H stated he did not document the SBAR or the new orders received. LVN H stated he was not aware Resident #2 had dentures. LVN H stated Resident #2 was assisted to bed for the evening and was not in distress. LVN H stated he had no knowledge if Resident #2 had her lower dentures lodged in her airway that evening. LVN H stated there was a miscommunication as to his duty to supervise the dining room meal that evening. <BR/>During an interview on 03/23/2023 at 02:05 PM the ADON stated Resident #2 refused the breakfast meal on 02/21/2023. The ADON stated Resident #2 was receiving mechanical soft diet and the diet was discontinued on 02/21/2023 and a pureed diet was ordered . The ADON stated Resident #2 was assisted with the lunch meal by LVN A and Resident #2 began to aspirate on pureed foods. The ADON received the report of the 2nd aspiration episode and SBAR'ed the physician and received a new order for a chest x-ray. The ADON stated the image was captured shortly afterward, and the facility awaited the results of the image. The ADON stated Resident #2 was assisted by the SLP with the evening meal on 02/21/2023 when Resident #2 began to aspirate a 3rd time and was sent to the hospital for treatment and evaluation. The ADON stated the facility received the image result of the x-ray at 10:00 PM. The ADON stated the x-ray revealed a foreign object in the airway. <BR/>During an interview on 03/23/2023 at 02:00 PM the NP stated he was a NP who worked for the PCP responsible for Resident #2. The NP stated he had reviewed Resident #2's medical records to include her admitting nursing assessments and was not aware of Resident #2 using dentures. The NP stated if the nursing staff had assessed and documented Resident #2's dentures he could have had an opportunity to review her assessments, he may have possibly ordered a referral for Resident #2 to see a dentist to assess for Resident #2's dentures for proper fit. The NP stated often, as people age, the lower jaw changed shape and dentures became loose fitting. The NP stated Resident #2 could have died when she was not provided support while eating with dentures, such as proper care for dentures, instructions for wearing dentures, proper supervision for proper fitting dentures prior to meals. The NP stated the danger for aspiration was still in place due to the floor staff not having access to a complete and accurate care plan developed to support Resident #2's nutritional needs, and assistance with meals and dentures.<BR/>During an interview on 03/24/2023 at 04:32 PM the Administrator stated the ex-DON resigned in October 2022 and since then the corporate regional nursing support staff, to include the Regional DON, Regional DON I, the Regional Director of Quality, and the Regional MDS nurse, were all involved with the facility's nursing services while the search for a replacement DON ensued. The Administrator stated he relied on the corporate regional nursing support staff for the daily continuation of nursing services. The Administrator stated the facility policy was to provide an accurate and comprehensive MDS assessments to include care plan development and implementation upon admission, change in conditions, and at a minimum, quarterly. The Administrator stated this was not done as evidenced by Resident #2's MDS assessments and care plan which did not support Resident #2 with her denture needs. The Administrator stated if he had been given a report from nursing staff, that MDS assessments were incomplete, care plans were not performed as required, he would have ensured gaps in nursing services were addressed . <BR/>A record review of the facility's policy admission Assessment and Follow Up: Role of the Nurse, dated December 2012, revealed, The purpose of this procedure is to gather information about the residents physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the Resident, initiating the care plan, and completing required assessment instruments, including the MDS . steps in the procedure . conduct a physical assessment, including the following systems: eyes, ears, nose, throat; teeth and gums . contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtained admission orders that are based on these findings . notify the supervisor and the attending physician of immediate needs that the resident may have . report other information in accordance with facility policy and professional standards of practice.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/24/20223 at 05:17 PM. The Administrator was notified. The Administrator was provided with the IJ template on 03/24/2023. The following Plan of Removal was accepted on 03/25/2023 at 3:00 PM.<BR/>Plan of Removal Verification 03/26/2023<BR/>Resident # 2 assessed by the RN for any s/s of discomfort/pain or changes in condition, physician was notified of the alleged deficiency on 3/24/23. There were no new orders obtained. The affected resident's responsible party was notified by the Administrator of alleged deficiencies and plan of correction. Resident was evaluated by SLP, clarification on diet received, new orders for speech treatment and swallow study ordered by physician.<BR/>A record review of Resident #2's medical record revealed a progress note authored by the Regional DON, dated 03/24/2023, revealed, resident in the dining room without dentures, oral cavity without signs and symptoms of pain or discomfort. no redness or irritation noted.<BR/>A record review of the facility's ad-hoc QAPI attendee sign in log, dated 03/24/2023, revealed attendees to include the Regional DON, Medical Director, Administrator, ADON, and RDO<BR/>A record review of Resident #2's order summary revealed new orders on 03/25/2023, for: the mechanical soft diet to be discontinued and for a pureed diet with thin liquids to begin, denture care to include monitoring daily for comfort and fit, an order for a modified barium swallow test, and an order for speech language to evaluate and treat.<BR/>A record review of Resident #2's speech therapy notes, dated 03/25/2023, revealed Resident #2 was evaluated by the SLP, clarification on diet received, new orders for speech treatment and a swallow study was ordered by the physician.<BR/>A record review of Resident #2's progress notes revealed a note authored by the ADON on 03/25/2023, [family member] called and informed there was an active and investigation from state surveyors on the incident with his [Resident #2's] dentures . <BR/>Residents with dentures were assessed by the RN (Regional DON) on 3/24/2023, the plan of care was updated and POC was updated to reflect patients' dentures utilization.<BR/>A record review of the facility's daily census report revealed 9 residents (Residents #2, #5, #6, #10, #16, #20, #21, #28, and #88) were assessed for their needs for dentures. <BR/>A record review of Resident #2's care plan, dated 03/26/2023, revealed a focus on denture care with interventions for denture supports, Problem: Resident has dental concerns AEB: (x ) resident without dentures currently, pt refuses to wear.<BR/>A record review of Resident #5's care plan, dated 03/26/2023, revealed a focus on denture care with interventions for denture supports, Problem: Resident has dental concerns AEB: (x ) resident without dentures currently, pt refuses to wear.<BR/>Residents will be identified on admission, by the charge nurse, if dentures are in place. The ADON will enter the information in the Matrix EMR and Point of Care mechanism. The ADON will also initiate dental care plan.<BR/>During an interview on 03/26/2023 at 10:33 AM the ADON stated she had reviewed all residents for needs for dentures and has assessed 9 residents with dentures to include Residents #2, #5, #6, #10, #16, #20, #28, and #88. The ADON stated she reviewed their care plans for accurate assessment and nursing interventions for the residents related to their needs for dentures. <BR/>Staff have been educated on abuse and neglect, changes in condition by the Administrator and ADON starting on 3/24/2023. IDT has been in-serviced starting on 3/24/2023 by the RNC on Care Planning, MDS completion, and communication with staff on interventions/Point of care EHR documentation. Nursing staff has been educated on denture care, refusals, instructions for wearing dentures and notification of any issues with dentures/missing dentures starting on 3/24/2023 by ADON. Staff will not be allowed to work until they receive training.<BR/>A record review of the facility's in-service titled Change of Condition, dated 03/24/2023, revealed 43 employees were educated for, facility policy title change in the residence condition or status policy statement our facility shall promptly notify the Resident, his or her attending physician, and representative of changes in the Resident's mechanical, mental condition and or status . policy interpretation and implementation; the nurse surveyor charge nurse will notify the resident's attending physician or alcohol physician when there has been . discovery of injuries of unknown source, . a significant change in the residence physical, emotional mental condition .<BR/>A record review of the facility's in-service titled Abuse and Neglect, dated 03/24/2023, revealed 43 employees were educated for, abuse and neglect clinical protocol the nurse will assess the individual and document related findings, assessment data will include injury assessment, all current medications, vital signs . the nurse who report findings to the physician as needed the physicians well let's ask the resident to verify or clarify such finding . reporting abuse to the facility management, policy statement, it is the responsibility of our employees, facility consultants, attending physicians, family members, visitors etcetera, to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to the facility management.<BR/>A record review of the facility's in-service titled Care Planning IDT, dated 03/24/2023, revealed 43 employees were educated for, policy statement her facilities care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each Resident . policy interpretation and implementation . a comprehensive care plan for each resident is developed within seven days have a completion of the resident assessment MDS. the care plan is based on the resident's comprehensive assessment and is developed by care planning introducing [NAME] team which includes, but it's not necessarily limited to the following personnel: the resident attending physician: the registered nurse who has responsibility for the Resident: the dietary manager dietitian: the social services worker responsible for the Resident: the activity director coordinator: therapist speech, occupational, recreational, etcetera, as applicable: the charge nurse responsible for resident care: nursing assistants responsible for the residents care: and others as appropriate or necessary to meet the needs of the Resident. comprehensive care plan . policy statement; an individualized comprehensive care plan that includes measurable objective objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each Resident. policy interpretation and implementation; are facilities care planning in the disciplinary team in coordination with the Resident, is her family or representative, develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning and resident may be expected to attain . the comprehensive care plan is based on a thorough assessment that includes, but it's not limited to the MDS. <BR/>A record review of the facility's in-service titled denture Cleaning and Storing, dated 03/24/2023, revealed 43 employees were educated for, the purpose of this procedure are two cleans and freshen the residents mount, to clean the residence dentures, to prevent infections of the mouth, to protect the residents dentures from breakage when dentures are out of the residents mouth, and to store dentures at bedtime . review the residents care plan to assess for any special needs of the Resident. assemble the equipment and supplies needed loose or poor fitting dentures can cause gum sores and prevent the resident from chewing his or her food properly. if a resident is not chewing his or her food thoroughly report it to your supervisor. encourage the resident to keep dentures in his or her mouth as much as possible. when dentures are left out of the mouth for several days, the bone structure to the mouth changes and the gums will shrink causing the dentures to fit improperly . <BR/>During an interview on 03/26/2023 at 11:10 AM the Human Resources Manager stated she reviewed the employee roster and compared the roster to the in-service roster and stated it was accurate for all of the facility's employees, to include employees who worked during the IJ up to midnight on 03/25/2023. <BR/>Nursing staff received in-service training on documenting physician team contact in the progress notes for each resident as appropriate. Notification to physician of any changes of condition will be noted on the 24-hour report and the facility activity report and will be reviewed by the IDT team at the morning meetings Monday-Friday, and by the Manager on Duty on weekends.<BR/>During an interview on 03/26/2023 at 10:33 AM the ADON stated she received in-service education from the facility's Regional DON to include reporting to the physician and documenting in residents' medical records, the 24- hour report, the facility activity report, any notification to physicians of any changes of conditions, and would be noted on the 24-hour report and the facility activity report, and would be reviewed by the IDT team at the morning meetings Monday-Friday, and by the Manager on Duty on weekends. The ADON stated she and the Regional DON provided in-service training education for all of the facility's, 43 staff, to include reporting to the physician and documenting in residents' medical records, the 24- hour report, the facility activity report, any notification to physicians of any changes of conditions, and will be noted on the 24-hour report and the facility activity report, and will be reviewed by the IDT team at the morning meetings Monday-Friday, and by the Manager on Duty on weekends. The ADON stated the weekend RN and the ADON would in-service staff as needed, new staff, since all staff had been in-serviced by 03/25/2023. <BR/>Upon reporting to work the appropriate in-service will be given to staff before they can begin work. All staff will complete Abuse/Neglect in-service by the Administrator and verified by the RDO. Nursing staff will also complete denture care, requirement for a nurse to be in dining room during meals, physician notification of change of condition, access to care plan in matrix, and update to Point of Care mechanism for CNA/nurse documentation of denture care from the ADON and verified by the Administrator.<BR/>During an interview on 03/26/2023 at 10:11 AM, RN K stated she was the facility's weekend RN supervisor and worked from 06:00 AM to 10:00 PM. RN K stated she had received in-service education to include abuse and neglect, residents' changes in condition, care planning, MDS completion, and communication with staff on interventions/Point of care EHR documentation. RN K stated she and nursing staff had been educated on denture care, refusals, instructions for wearing dentures and notification of any issues with dentures/missing dentures starting on 3/24/2023 by ADON. RN K stated staff would not be allowed to work until they received training. RN K stated she and the ADON would in service staff as needed, new staff, since all staff had been in- serviced by 03/25/2023. <BR/>During an interview on 03/26/2023 at 10:58 AM, the BOM/HR, and MOD as assigned, stated the in-service roster was accurate for employees who worked from the date of the IJ to midnight on 03/25/2023 to include all of the facility's 43 employees. <BR/>During an interview on 03/26/2023 at 11:18 AM, CNA L stated she assisted residents with dressing, eating, toileting and activities of daily life. CNA L stated she received education/in-services for dentures, clean make sure they have them in, don't fit right, refuse, change of condition, refusal to eat drink, s/s of aspiration, and to report everything. <BR/>During an interview on 03/26/2023 at 12:30 PM CNA M stated she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA M stated the facility's electronic record for resident care now included an area where CNAs could now document denture care for residents. <BR/>During an interview on 03/26/2023 at 3:20 PM LVN N stated she worked the 02:00 PM to 10:00 PM shift and occasionally the 10:00 PM to 06:00 AM shift. LVN N stated she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the ADON and/or DON any complications and or concerns with residents and their dentures. LVN N stated the facility's electronic record for resident care now included an area where CNA's could now document denture care for residents and LVN N would inspect the documentation for accuracy and assess residents with dentures prior to and after meals. <BR/>During an interview on 03/26/2023 at 04:53 PM CNA O stated she worked the 10:00 PM to 06:00 PM shift, received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA O stated the facility's electronic record for resident care now included n area where CNA's could now document denture care for residents. CNA O stated she was trained to assess all residents at the beginning of her shift, and throughout the shift for resident's skin conditions, and overall wellbeing, and to focus on residents needs for dentures and denture care to include well-fitting dentures and to report to the nurse any resident's refusal to wear dentures. <BR/>During an interview on 03/26/2023 at 04:54 PM CNA P stated worked she worked 02:00 to 10 :00 PM and she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA P stated the facility's electronic record for resident care now included an area where CNA's could now document denture care for residents. CNA P stated she was trained to assess all residents at the beginning of her shift, and throughout the shift for residents' skin conditions, and overall wellbeing, and to focus on residents needs for dentures and denture care to include well-fitting dentures and to report to the nurse any resident's refusal to wear dentures. <BR/>During an interview on 03/26/2023 at 05:01 PM CNA Q stated she worked 06:00 PM to 06:00 AM and she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA Q stated the facility's electronic record for resident care now included an area where CNAs could now document denture care for residents. CNA Q stated she was trained to assess all residents at the beginning of her shift, and throughout the shift for residents' skin conditions, and overall wellbeing, and to focus on residents needs for dentures and denture care to include well-fitting dentures and to report to the nurse any resident's refusal to wear dentures. <BR/>During an interview on 03/26/2023 at 06:00 PM LVN R stated she has been in serviced for main issue to assess residents for dentures, and to assess residents for refusals to eat and assess for ill-fitting dentures, and to inspect delegation of care to CNAs for resident denture care. LVN R stated she would assess CNAs for assistance with resident care to include eating and oral care. LVN R stated she had worked double shifts from 06:00 AM to 10:00 PM, but usually worked the 06:00 AM to 2:00 PM shift. <BR/>During an interview on 03/26/2023 at 06:10 PM LVN B stated she had been in service for main issue to assess residents for dentures, and to assess residents for refusals to eat and assess for ill-fitting dentures, and to inspect delegation of care to CNAs for Resident denture care. LVN B stated she would assess CNAs for assistance with Resident care to include eating, and oral care. LVN R stated she has worked double shifts from 06:00 AM to 10:00 PM, but usually works the 06:00 to 2:00 PM shift. also, in serviced on documenting SBARS and reviewing residents care plans for accuracy, also to report all allegations of suspected ANE and/or mistreatment. <BR/>During an interview on 03/26/2023 at 06:16 PM CNA E stated she had been in-serviced for has received education in services any changes of conditions and report to the charge nurse, the ADON, and if ANE, mistreatment, and or injuries of unknown origin to the nurse, ADON, and to include the Administrator. CNA E stated the CNA documentation screen for residents now included a care plan for residents who had dentures. CNA E stated she usually worked the 02:00 PM to 10:00 PM shift and had worked the 10:00 PM to 06:00 AM shift. <BR/>All in-service and training will be completed by 3/25.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 4 (Residents #6, #16, #26, and #134) of 20 residents reviewed for competent nursing care.<BR/>1. CNA G failed to spread and cleaned within Resident #6's labial folds after an incontinent episode. <BR/>2. CNA A applied barrier cream to Resident #16's open wounds. CNA A reapplied Resident #16's wound dressing that had fallen off into the soiled brief.<BR/>3. LVN D failed to follow facility procedure when she instilled eye drops for Residents #26. <BR/>4. LVN C crushed medications for Resident #134, that were noted to be Do Not Crush.<BR/>These deficient practices affect residents who depend on nursing care and could place residents at risk for injury, infection, and harm.<BR/>The findings included: <BR/>1. Record review of Resident # 6's electronic face sheet dated 05/17/2024 reflected she was admitted to the facility on [DATE]. The resident's diagnoses included: cerebral infarction (damage to tissues on the brain due to a loss of oxygen to the area), dementia (loss of memory, language, problem-solving, and other thinking abilities that were severe), hypothyroidism (thyroid gland does not make enough thyroid hormone), neuropathy (weakness, numbness, and pain form nerve damage), and glaucomatous flecks (disease that damages eye). <BR/>Record review of Resident #6's quarterly MDS, dated [DATE], indicated she did not have a BIMS score which she had impaired cognition. The MDS also indicated Resident #6 was always incontinent for bladder and bowel. <BR/>Observation on 05/15/2024 at 4:55 p.m. revealed while providing incontinent care for Resident #6, CNA G cleaned the perineal area and did not separate and clean between the labial folds. <BR/>In an interview on 05/15/2024 at 5:14 p.m. CNA G revealed she was supposed to open and clean the labia (labia minor-inner fold) and confirmed she did not. CNA G stated she was supposed to clean between the folds to remove germs and prevent infections. <BR/>In an interview with the RNC on 05/15/2024 at 5:20 p.m., the RNC said that during incontinent care the labial folds need to be cleaned to make sure they are properly cleaned and to remove any bacteria in the area. <BR/>Record Review of annual skills check for CNA G revealed CNA G passed competency for Perineal care/incontinent care on 03/27/2024.<BR/>Record review of the facility policy, titled Perineal care, revised 10/2010, revealed Steps in the Procedure . 9. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back (1) Separate labia and wash area downward from front to back.<BR/>2. Record review of Resident #16's electronic face sheet dated 05/15/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to general deterioration of brain), age related osteoporosis (deterioration in bone mass, increasing risk for fracture), contracture (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) right and left shoulder and psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality).<BR/>Record review of Resident #16's quarterly MDS assessment with an ARD of 02/24/2024 reflected she was not a candidate for a BIMS which signified she was severely cognitively impaired. She could rarely understand and rarely be understood. She required extensive assistance with her ADL's. She was always incontinent of bowel and bladder.<BR/>Record review of Resident #16's comprehensive person-centered care plan dated 09/29/2016 reflected Problem, Urinary Incontinence. <BR/>Record review of Resident #16's Active Orders as of 04/01/2024 to 04/30/2024 did not reflect an order for barrier cream.<BR/>Observation on 05/15/2024 at 01:45 PM during incontinent care for Resident #16, her wound dressing which was a 4X4 inch dressing with 4 strips of adhesive tape fell off into the dirty brief. CNA A picked up the dirty wound dressing and placed it back onto Resident #16's wound area after putting barrier cream over the open wound areas.<BR/>During an interview with CNA A on 05/16/2024 at 2:00 PM she stated she screwed up, and she was not supposed to put the dirty dressing back onto Resident #16's bottom. She stated she was supposed to call the nurse when the dressing came off, and she did not think, and placed it back onto the resident. She stated her job was to tell the nurse if the dressing came off. She stated she did not know there was not an order for barrier cream. <BR/>During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated CNA A needed to call the nurse when Resident #16's wound dressing fell off, and not to put it back onto the resident. She stated the barrier cream required an order, because it was noted to be a treatment, and the wound may not heal with other solutions not ordered. She stated she needed to report any changes that were nursing care related to the licensed nurse. She stated she was not trained to put the dressing back on or to apply ointment to wound areas because that was not in her job description.<BR/>Record review of the facility Job Description, Certified Nursing Assistant (CNA) dated February 2024 rflected Essential functions, assist residents with all aspects of activities of daily living, no nursing duties were in the job description.<BR/>Record review of the facilityNurse Aide Performance record dated 06/28/2022 reflected she was trained on applies principles of standard precautions. No where on the skills training checklist related to applying a dressing to a resident.<BR/>3. Record review of Resident #16's electronic face sheet dated 05/15/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to general deterioration of brain), age related osteoporosis (deterioration in bone mass, increasing risk for fracture), contracture (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) of right and left shoulder, and psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality).<BR/>Record review of Resident #16's quarterly MDS assessment with an ARD of 02/24/2024 reflected she was not a candidate for a BIMS score which signified she was severely cognitively impaired. She could rarely understand and rarely be understood. She required extensive assistance with her ADL's. She was always incontinent of bowel and bladder.<BR/>Record review of Resident #16's comprehensive person-centered care plan dated 09/29/2016 reflected Problem, Urinary Incontinence. <BR/>Observation on 05/15/2024 at 03:13 PM of RN F performed wound care for Resident #16 and revealed she did not wear a gown. <BR/>Observation on 05/15/2024 at 01:45 PM during incontinent care for Resident #16, her wound dressing which was a 4X4 inch dressing with 4 strips of adhesive tape fell off into the dirty brief. CNA A picked up the dirty wound dressing and placed it back onto Resident #16's wound area after putting barrier cream over the open wound areas.<BR/>During an interview with CNA A on 05/16/2024 at 2:00 PM she stated she screwed up, and she was not supposed to put the dirty dressing back onto Resident #16's bottom. She stated she was supposed to call the nurse when the dressing came off, and she did not think, and placed it back onto the resident. She stated her job was to tell the nurse if the dressing came off. She stated she did not know there was not an order for barrier cream and the wound would get infected.<BR/>During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated CNA A needed to call the nurse when Resident #16's wound dressing fell off, and not to put it back onto the resident. She stated the barrier cream required an order, because it was noted to be a treatment, and the wound may not heal with other solutions not ordered. She stated she needed to report any changes that were nursing care related to the licensed nurse. She stated she was not trained to put the dressing back on or to apply ointment to wound areas because that was not in her job description. This could cause harm for the resident.<BR/>Record review of the facility Job Description, Certified Nursing Assistant (CNA) dated February 2024 reflected Essential functions, assist residents with all aspects of activities of daily living, no nursing duties were in the job description.<BR/>Record review of the facility Nurse Aide Performance record dated 06/28/2022 reflected she was trained on applies principles of standard precautions. Nothing on the skills training checklist related to the application of a dressing to a resident.<BR/>4. Record review of Resident #26's electronic face sheet dated 05/16/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: cognitive communication deficit (trouble participating in conversations), adult failure to thrive (loss of interest, depressive symptoms), and social exclusion and rejection (detaching from individuals, groups, and social relationships).<BR/>Record review of Resident #26's quarterly MDS assessment with an ARD of 02/27/2024 reflected he scored a 05/15 for his BIMS score which signified he was severely cognitively impaired. He could sometimes understand and sometimes be understood. He required moderate amount of assistance with his ADL's.<BR/>Record review of Resident #26's comprehensive person-centered care plan dated 09/28/2023 reflected Problem, ADL's, self-care deficit, administer medications and treatments as ordered.<BR/>Record review of Resident #26's Active Orders as for 04/01/2024 to 04/30/2024 reflected he received artificial tears, one gtt ou, twice a day.<BR/>Observation on 05/16/2024 at 07:30 a.m. of LVN D applying artificial tears for Resident #16 revealed, she did not wear gloves, and had the resident tilt his head a little bit and she placed the drops of artificial tears directly into one eye and then the other.<BR/>In an interview on 05/16/2024 at 3:00 PM, with LVN D she stated she was not aware that was not the way to administer eye drops. She stated she was not familiar with the facility policy and procedure on eye drop administration, but she knew she was trained. She stated she understood after the procedure was explained to her, that Resident #26's eye drops would not provide the most therapeutic effect if most of the solution ran out of the eyes after administration.<BR/>During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated LVN D did not follow the facility policy and procedure for administering eye drops and she would retrain her. She stated the resident would not get the effectiveness of the medication if the medication was not administered properly, and in this situation. Resident #26's eyes could be irritated and dry.<BR/>Record review of LVN D's Skills checklist-Licensed Nurse dated 03/24/2024 reflected she completed med pass.<BR/>Record review of the facility policy and procedure titled Instillation of Eye Drops revised January 2014 reflected put on gloves, have resident tilt head back slightly, gently pull the lower eyelid down, instruct resident to look up, drop the medication into the mid lower eyelid to allow even distribution of the drops. Instruct the resident not to blink or squeeze the eyelids shut, which forces the medicine out of the eye.<BR/>5. Record review of Resident #134's electronic face sheet dated 05/15/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: encephalopathy, chronic obstructive pulmonary disease, poisoning by cardiac-stimulant glycosides and drugs of similar action, congestive heart failure, and cognitive communication deficit.<BR/>Record review of Resident #134's EMR reflected he was not at the facility long enough for an MDS assessment.<BR/>Record review of Resident #134's baseline care plan dated 05/13/2024 reflected Resident admitted for skilled care, cognition, require orientation to surroundings reminders, and assistance with medication management.<BR/>Record review of Resident #134 physician orders dated 05/16/2024 reflected potassium chloride (to treat or prevent low amounts of potassium in the blood) tablet extended release; 20meq; 1 tablet oral once a day, tamsulosin (treatment for men with large prostate gland) capsule; 0.4mg; 1 tablet 0.4mg, oral one time a day and omeprazole capsule, delayed release (DR/EC) (indicated for short-term treatment of active benign gastric ulcer); 40mg, 1 capsule oral one time a day with start dates of 05/11/2024.<BR/>Record review of the medication cards for 3 of the medications: potassium chloride (to treat or prevent low amounts of potassium in the blood) tablet extended release; 20meq; 1 tablet oral once a day, tamulosin (treatment for men with large prostate gland) capsule; 0.4mg; 1 tablet 0.4mg, oral one time a day and omeprazole capsule, delayed release (DR/EC) (indicated for short-term treatment of active benign gastric ulcer); 40mg, 1 capsule oral one time a day had blue stickers which read Warning DO NOT CRUSH on the front of the packet.<BR/>Observation on 05/16/2024 at 08:34 a.m. of LVN C during medication pass for Resident #134 revealed she took Resident #134's medications into his room in a cup and was ready to administer them, when she asked the resident, would you like these crushed? Resident #134 responded yes, and LVN C departed the resident's room, crushed the tablets, opened the capsules, and mixed the crushed contents into in a medication cup with applesauce. LVN C administered the applesauce and medications to Resident #134 with water.<BR/>During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated LVN C needed to check the medication card for the do not crush and check the Do Not Crush List. She stated LVN C should have called the physician or pharmacist, as she was trained. <BR/>In an interview with LVN C on 05/16/2024 at 1:00 PM she stated she crushed Resident #134's medications before, and had not noticed the warning, do not crush sticker. She stated that too much of a dose could taste bad or cause too much medication to be released too soon and cause distress. She stated she was trained to not crush medications unless the provider had an order to crush, and she had medication skills review annually.<BR/>Record review of LVN C's Skills checklist-Licensed Nurse dated 03/24/2024 reflected she completed med pass.<BR/>Record review of the facility Medications Not to Be Crushed list dated revised 12/22 reflected Omeprazole, Potassium Chloride, and Tamsulosin were on the list. <BR/>Record review of the facility policy and procedure titled Medication Administration, Oral dated 2007 reflected Check for specific prescriber order to crush medications if required by state regulation. Crush medications if indicated for this resident only after referring to the Medications Not to Be Crushed List. For products that appear on the Medication Not to Be Crushed List, check with the pharmacist regarding a suitable alternative, and request a new prescriber order if appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 11.54%, based on 3 errors out of 26 opportunities which involved 1 of 6 residents (Resident #134) reviewed for medication administration and medication errors.<BR/>LVN C crushed 3 medications, 2 capsules and 1 tablet that were on the Do Not Crush list during medication pass for Resident #134.<BR/>This deficient practice places residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. <BR/>The findings included:<BR/>Record review of Resident #134's electronic face sheet dated 05/15/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: encephalopathy (a group of conditions that cause brain dysfunction), chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), poisoning by cardiac-stimulant glycosides and drugs of similar action, congestive heart failure (the heart cannot pump or fill adequately), and cognitive communication deficit (difficulty communicating).<BR/>Record Review of Resident #134's baseline care plan dated 5/13/24 revealed, Resident #134 was not at the facility long enough for an MDS assessment.<BR/>Record review of Resident #134's baseline care plan dated 05/13/2024 reflected Resident admitted for skilled care, cognition, require orientation to surroundings reminders, and assistance with medication management.<BR/>Record review of Resident #134 physician orders dated 05/16/2024 reflected potassium chloride (to treat or prevent low amounts of potassium in the blood) tablet extended release; 20meq; 1 tablet oral once a day, Tamsulosin (treatment for men with large prostate gland) capsule; 0.4mg; 1 tablet 0.4mg, oral one time a day, and omeprazole capsule, delayed release (DR/EC) (indicated for short-term treatment of active benign gastric ulcer); 40mg, 1 capsule oral one time a day with start dates of 05/11/2024.<BR/>Record review of the medication cards for 3 of the medications: potassium chloride (to treat or prevent low amounts of potassium in the blood) tablet extended release; 20meq; 1 tablet oral once a day, tamulosin (treatment for men with large prostate gland) capsule; 0.4mg; 1 tablet 0.4mg, oral one time a day and omeprazole capsule, delayed release (DR/EC) (indicated for short-term treatment of active benign gastric ulcer); 40mg, 1 capsule oral one time a day had blue stickers which read Warning DO NOT CRUSH on the front of the packet.<BR/>Observation on 05/16/2024 at 08:34 a.m. of LVN C during medication pass for Resident #134 revealed she took Resident #134's medications into his room in a cup and was ready to administer them, when she asked the resident, would you like these crushed? Resident #134 responded yes, and LVN C departed the resident's room, crushed the tablets, opened the capsules, and mixed the crushed contents into in a medication cup with applesauce. LVN C administered the applesauce and medications to Resident #134 with water.<BR/>During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated LVN C needed to check the medication card for the do not crush and check the Do Not Crush List. She stated LVN C should have called the physician or pharmacist, as she was trained. <BR/>Interview on 05/16/2024 with LVN C, at 1:00 PM she stated she crushed Resident #134's medications before, and had not noticed the warning, do not crush sticker. She stated that too much of a dose could taste bad or cause too much medication to be released too soon and cause distress. She stated she was trained to not crush medications unless the provider had an order to crush, and she had medication skills review annually.<BR/>Record review of the facility Medications Not to Be Crushed list dated revised 12/22 reflected Omeprazole, Potassium Chloride and Tamsulosin were on the list. <BR/>Record review of the facility policy and procedure titled Medication Administration, Oral dated 2007 reflected Check for specific prescriber order to crush medications if required by state regulation. Crush medications if indicated for this resident only after referring to the Medications Not to Be Crushed List. For products that appear on the Medication Not to Be Crushed List, check with the pharmacist regarding a suitable alternative, and request a new prescriber order if appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure 1 out of 6 residents (Resident #134) were free of any significant medication errors whenobserved for medication pass.<BR/>LVN C crushed 3 medications for Resident #134 that had Do Not Crush labeled on them during medication administration pass.<BR/>This deficient practice affects residents with medications that are not recommended to be crushed and could result in physical harm or distress.<BR/>The findings included:<BR/>Record review of Resident #134's electronic face sheet dated 05/15/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: encephalopathy, chronic obstructive pulmonary disease, poisoning by cardiac-stimulant glycosides and drugs of similar action, congestive heart failure and cognitive communication deficit.<BR/>Resident #134 was not at the facility long enough for an MDS assessment.<BR/>Record review of Resident #134's baseline care plan dated 05/13/2024 reflected Resident admitted for skilled care, Cognition, require orientation to surroundings reminders, and assistance with medication management.<BR/>Record review of Resident #134 physician orders dated 05/16/2024 reflected potassium chloride (to treat or prevent low amounts of potassium in the blood) tablet extended release; 20meq; 1 tablet oral once a day, tamulosin (treatment for men with large prostate gland) capsule; 0.4mg; 1 tablet 0.4mg, oral one time a day and omeprazole capsule, delayed release (DR/EC) (indicated for short-term treatment of active benign gastric ulcer); 40mg, 1 capsule oral one time a day with start dates of 05/11/2024.<BR/>Observation on 05/16/2024 at 08:34 a.m. of LVN C during medication pass for Resident #134 revealed she took Resident #134's medications into his room in a cup and was ready to administer them, when she asked the resident, would you like these crushed? Resident #134 responded yes, and LVN C departed the resident's room, crushed the tablets, opened the capsules, and mixed the crushed contents into in a medication cup with applesauce. LVN C administered the applesauce and medications to Resident #134 with water.<BR/>Record review of the medication cards for 3 of the medications: potassium chloride (to treat or prevent low amounts of potassium in the blood) tablet extended release; 20meq; 1 tablet oral once a day, tamulosin (treatment for men with large prostate gland) capsule; 0.4mg; 1 tablet 0.4mg, oral one time a day and omeprazole capsule, delayed release (DR/EC) (indicated for short-term treatment of active benign gastric ulcer); 40mg, 1 capsule oral one time a day had blue stickers which read Warning DO NOT CRUSH on the front of the packet.<BR/>During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated LVN C needed to check the medication card for the do not crush and check the Do Not Crush List. She stated LVN C should have called the physician or pharmacist, as she was trained. <BR/>Interview on 05/16/2024 with LVN C, at 1:00 PM she stated she crushed Resident #134's medications before, and had not noticed the warning, do not crush sticker. She stated that too much of a dose could taste bad or cause too much medication to be released too soon and cause distress. She stated she was trained to not crush medications unless the provider had an order to crush, and she had medication skills review annually.<BR/>Record review of the facility Medications Not to Be Crushed list dated revised 12/22 reflected Omeprazole, Potassium Chloride and Tamsulosin were on the list. <BR/>Record review of the facility policy and procedure titled Medication Administration, Oral dated 2007 reflected Check for specific prescriber order to crush medications if required by state regulation. Crush medications if indicated for this resident only after referring to the Medications Not to Be Crushed List. For products that appear on the Medication Not to Be Crushed List, check with the pharmacist regarding a suitable alternative, and request a new prescriber order if appropriate.<BR/>Record review of https://journals.lww.com/nursing/fulltext/2004/10000/don_t_crush_these_drugs.46.aspx, Lippincott's Nursing2024 Do Not Crush reflected Many drug forms, such as slow-release, enteric-coated, and encapsulated beads are made to release their active ingredients over a certain period of time or at preset points after administration. the disruptions caused by crushing or chewing these drug forms can dramatically affect the absorption rate and increase risk of adverse reactions. Other reasons not to crush or chew these drug forms include such considerations as tase, tissue irritation and unusual formulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure Menus and nutritional adequacy. Menus must Meet the nutritional needs of residents in accordance with established national guidelines.; Be prepared in advance; Be followed for 1 of 1 kitchen, in that:<BR/>1. Food items were not in the kitchen, pasteurized eggs or shelled eggs, bananas, bread and onions. Resident #29 and #17 preferred fried eggs. Resident group stated they would prefer fried eggs (#17, #24, #13) and Resident #18 preferred hard-boiled eggs for chef salad . <BR/>2. Kitchen cook J served residents for breakfast 1 slice of bacon, instead to two slices. Resident #2, #4, #13, #24, #29 had 1 slice of bacon for breakfast. <BR/>3. The facility failed to post of the weekly at a glance menu.<BR/>This could affect all residents that eat in the dining area and could result in residents not aware of what will be on menu for the week. This could affect all residents that eat from the kitchen and place them at risk of improper food handling.<BR/>The Findings were:<BR/>Record review of Breakfast menu for Wednesday and Friday included scrambled eggs and bacon portion size, 2 slices. <BR/>Record review of Lunch menu included peas with saut&eacute;ed onions and peaches and bananas for dessert. <BR/>1. Observation on 5/14/2024 at 9:50 AM in the kitchen with the DM revealed no pasteurized eggs or shelled eggs in refrigerator. <BR/>Interview on 5/14/2024 at 1:35 PM group, Resident #13, #17, #24 and #29 stated they preferred fried eggs and Resident #18 preferred hard-boiled eggs for his chef salad. Residents stated they had discussed this with the kitchen but had not listened to them. <BR/>Record review of Resident #2's face sheet dated 5/16/2204 reflected she was admitted on [DATE], age was 71. Her diagnoses included polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body) in disease, muscle weakness, dysphagia (difficulty or discomfort in swallowing, as a symptom of disease.), feeding difficulties, cognitive communications deficit. Record review of Resident #2's consolidated physician orders for May 2024 reflected her diet, regular mechanical soft, ground meat and pureed fruits and vegetables, diagnoses Dysphagia. Record review of Resident #2's quarterly MDS dated [DATE] reflected she was moderately cognitively impaired, she required a manual wheelchair to mobilize, and she required partial/moderate assistance with eating. Record review of Resident #2's care plan dated 3/31/2024 reflected to serve diet and fluids as ordered. <BR/>Record review of Resident #13's face sheet dated 5/16/2024 reflected she was admitted on [DATE], re-admitted on [DATE] she was [AGE] years old. Resident #13 Quarterly MDS dated [DATE] reflected she had a BIMS score of 9/15 (moderate cognitive impairment). Record review of Resident #13's food preference assessment was dated 9/29/2021, reflected no preference at this time. Record review of Resident #13's care plan dated 2/27/2024 reflected no food preferences. Record review of Resident # #13's diet card reflected under notes section no eggs. <BR/>Record review of Resident #17's face sheet dated 5/16/2024 reflected she was admitted on [DATE], re-admitted on [DATE], she was [AGE] years old. Resident #17's Quarterly MDS dated [DATE] reflected she has a BIMS score of 12/15 (moderate cognitive impairment). Record review of Resident #17's care plan dated 2/27/2024 reflected no food preferences. Record review of #17's chart revealed no food preference assessment. Record review of Resident # #17's diet card reflected under notes section: fried eggs. <BR/>Record review of Resident #18's face sheet dated 5/14/2024 reflected he was admitted to the facility on [DATE]. Record review of Resident #18's Quarterly MDS assessment was dated 3/21/2024 reflected his BIMS scored was 10/15 (moderate cognitive impairment). Record review of Resident #18's care plan dated 5/16/2024 reflected no food preferences for eggs. Resident #18's chart revealed no food preference assessment. Record review of Resident # #18's diet card reflected under notes section extra eggs.<BR/>Record review of Resident #24's face sheet dated 5/16/204 reflected she was admitted on [DATE], re-admitted on [DATE], she was [AGE] years old. Resident #24's quarterly MDS dated [DATE] reflected she had a BIMS score of 9/15 (moderate cognitive impairment). Record review of Resident #24's care plan dated 2/27/2024 chart revealed no food preference assessment. Record review of Resident # #24's diet card reflected under notes section, no preferences. <BR/>Record review of Resident #29 face sheet dated 5/16/2024 reflected he was admitted on [DATE], he was [AGE] years old. Resident #29's admission MDS dated [DATE] reflected he had a BIMS score was 9/15 (moderate cognitive impairment). Record review of Resident #29's care plan reflected no food preferences for eggs. Resident #29's chart revealed no food preference assessment. Record review of Resident # #29's diet card reflected under notes section scrambled eggs. <BR/>Observation on 5/14/2024 11:51 AM of Resident #2 at lunch time revealed she had pureed potatoes, peas and peaches. No bananas or saut&eacute;ed onions were seen with any of the resident trays. Residents did not voice a concern about the missing items.<BR/>Observation on 5/14/2024 at 12:03 PM revealed Resident #24's plate had meatloaf, potatoes, peas (no onion), peaches, 2 drinks, she had no bread or bananas today . <BR/>Observation on 5/14/2024 at 12:12 PM in Resident # 29's room revealed he was eating lunch in his room. Resident # 29's plate had peas (no onions), meatloaf, potatoes, coffee, drinks, water, and no bread on plate. <BR/>Observation on 5/14/2024 at 3:55 PM in the kitchen with DM revealed he had no bananas, no bread and no onions for the meals for this day. <BR/>Observation on 5/15/24 at 7:46 AM breakfast service: Resident #2 plate had 1 small scoop of scrambled eggs, one slice of toast and one slice of bacon or small serving of ground sausage . Nurse D appeared to be checking the trays and handing them out. <BR/>Observation on 5/15/24 at 10:13 AM with Resident #13 revealed her plate had no bread and no onions. <BR/>Interview on 5/14/24 at 12:04 PM revealed Resident #24's stated she had no onions in peas, no bread or bananas today. <BR/>interview on 5/15/24 at 10:14 AM with Resident #13 stated too many green beans and spinach, potatoes, she did not get bread in every meal. Resident #13 stated she would like boiled eggs or fried eggs and staff excuse was they cannot go over the budget .<BR/>2. <BR/> Record review of Resident #19's face sheet dated 5/16/2024 reflected he was admitted on [DATE], he was [AGE] years old. Resident #19 Quarterly MDS dated [DATE] reflected he had a BIMS score of 13/15 (cognition intact). Record review of Resident #19's care plan dated 5/16/2024 reflected no food preferences. Resident #19's chart revealed no food preference assessment. Record review of Resident # #19's diet card reflected under notes section no preferences. <BR/>Observations on 5/17/24 at 7:25 AM in the kitchen during breakfast service, cook J was serving breakfast and served 1 slice of bacon on each resident plate. [NAME] J looked at the menu for the day and observed to serve resident 2 slices of bacon. [NAME] J stated she was not aware that she was supposed to serve residents 2 slices of bacon. <BR/>Observations on 5/17/24 7:40 AM Resident #24 had 1 slice of bacon a never received 2 strips of bacon. <BR/>Observations on 5/17/24 7:42 AM Resident #13 had 1 slice of bacon on her plate. res ident stated she never gets 2 slices of bacon.<BR/>. <BR/>Observations on 5/17/24 7:48 AM Resident #19 had 1 slice of bacon on her plate. Resident stated he could not remember the last time he was served 2 bacon slices for breakfast. <BR/>Interview on 5/14/2024 at 3:56 PM in the kitchen with DM revealed he had no bananas, no bread and no onions for the meals for this day. The DM stated he had to discuss with the dietary consultant for the out-of-stock items. The DM stated he was not trained on ordering food for the kitchen menu food items. <BR/>Interview on 5/14/2024 at 9:51 AM with the DM revealed no pasteurized eggs in refrigerator. The DM stated he did not have pasteurized eggs for the last 3 days. The DM stated there were 2 (#29, #17) residents that he could think of that prefer fried eggs for breakfast. The DM stated that he did not get the order in on time for the delivery service. The DM stated they get their food delivery every Wednesday. The DM stated he did not do any Resident Food Preference assessments, since he started working on 2/1/2024. <BR/>Interview on 5/14/2024 at 3:40 PM the ADM stated she was not aware of food items missing for a meal. The ADM stated the Dietary manager could use the credit card to get food items from the store. The ADM stated she will do some training.<BR/>Interview on 5/16/2024 at 11 AM the ADM stated no concerns with supplies, she orders extra, if they are out of any supplies they can always go to the local store. The ADM stated she was not made aware that some food items were not delivered. She stated the dietary manager was required to be certified. The ADM stated dietary manger was promoted on 2/1/2024. <BR/>Interview on 5/17/24 at 7:50 AM the ADM stated the regional staff and she had gone in kitchen at random times and has trained the dietary manager. <BR/>Record review of the Facility policy Resident Nutrition Services dated November 2010 reflected, Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance. 2. Nursing personnel will ensure that residents are served the correct food tray. 3. Prior to service the food tray, the nurse aide/feeding assistant must check the tray card to ensure that the correct food tray is being served to the resident. <BR/>3. Observation on 5/15/2024 at 9:50 AM no week at a glance menu's posted and no breakfast posted. <BR/>Observation on 5/15/2024 at 8:59 AM no week at glance menus posted, no breakfast menu posted.<BR/>Interview on 5/15/2024 at 9:00 AM with ADM stated she did not see a weekly menu posted and no breakfast menu posted.<BR/>Interview on 5/15/2024 at 11:54 AM with DM confirmed no weekly or breakfast menu posted. The DM stated the ADM let him know that he was required to post a week at a glance menu and have all 3 meals posted, so residents can see it, this day. The risk would be residents not knowing what they would eat. <BR/>Interview on 5/16/24 at 10:48 AM with the dietary consultant stated the DM was taking classes and was hired on 2/1/2024, he stated he did talk to the DM about posting the weekly menus. <BR/>Interview on 5/17/24 at 7:50 AM with ADM stated the regional staff and she had gone in kitchen at random times and had trained the dietary manager on how to manage the kitchen. <BR/>Record review of the Facility Menu, dated December 2008, reflected Menu shall a) meet the nutritional needs of residents; b) be prepared in advance; and c) be followed. 2. Menu and available snacks shall be adjusted to meet individual caloric and nutrient intake needs of the resident. 3. Menus for regular and therapeutic diets are written and Atlas 2 weeks in advance and are dated and posted in the kitchen as least 1 week in advance. 13. copies of menus will be posted in at least 2 resident areas. in positions and in print large enough for resident to read them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure Food prepared in a form designed to meet individual needs for 1 of 8 (#2) residents, in that:<BR/>Resident #2 was served a puree meat, instead of mechanical soft. <BR/>This could affect all resident with diet orders that were prescribed by a physician and could result in residents not served the correct diet texture. <BR/>The Findings were:<BR/>Record review of Resident #2's face sheet dated 5/16/2024 reflected she was admitted on [DATE], age was 71. Her diagnoses included polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body) in disease, muscle weakness, dysphagia (difficulty or discomfort in swallowing, as a symptom of disease.), feeding difficulties, cognitive communications deficit. <BR/>Record review of Resident #2's consolidated physician orders for May 2024 reflected her diet, regular mechanical soft, ground meat and pureed fruits and vegetables, diagnoses Dysphagia. <BR/>Record review of Resident #2's quarterly MDS dated [DATE] reflected she was moderately cognitively impaired, she required a manual wheelchair to mobilize, and she required partial/moderate assistance with eating. <BR/>Record review of Resident #2's care plan dated 3/31/2024 reflected to serve diet and fluids as ordered. <BR/>Record review of Resident #2's Speech Therapy note dated 1/19/2024 reflected she was on a precautions/contraindications: Fall aspiration and reflux, puree fruits and vegetables/ground meat regular liquids.<BR/>Record review of her meal ticket read mechanical soft texture, ground beef, pureed vegetables and fruit. <BR/>Observation on 5/14/24 at 11:51 AM of Resident #2, at lunch time revealed she was served pureed meatloaf when her diet was ordered mechanical soft ground meat, and pureed vegetables and fruit. She had pureed potatoes, peas and peaches. She had pureed meatloaf instead of mechanical soft. <BR/>Interview on 5/14/2024 at 11:52 AM LVN D stated, they must have ground it too much. <BR/>Interview on 5/14/2024 at 3:55 PM the DM stated cook J was working on 5/14/2024 for lunch and he was aware that Resident #2 was served puree meat, instead of mechanical soft meat. The DM stated cook J ran out of mechanical soft meat, so she served puree meat to Resident #2; no other response. <BR/>Interview on 5/16/24 at 10:20 AM cook J stated she did not have enough mechanical soft meat for Resident #2, so she served her puree meat; no other response. [NAME] J stated she measured the food types for residents. [NAME] J had no response. <BR/>Interview on 5/16/24 at 10:48 AM the Dietary Consultant stated the DM was a new DM in the kitchen. The Dietary Consultant stated the ADM/DM did talk to him about Resident #2's served pureed meat, instead of mechanical soft meat. The Dietary Consultant stated the resident was not at risk choking due to a decrease in the texture of the meal. Dietary Consultant stated no weight loss for Resident #2 and had a good appetite. <BR/>Interview on 5/16/2024 at 11:00 AM the ADM stated no concerns with supplies, she orders extra, if they are out of any supplies they can always to local store. The ADM stated she was not made aware staff provided the wrong diet texture to residents. She stated dietary manager required to be certified. The ADM stated the dietary manger was promoted on 2/1/2024. <BR/>Interview on 05/17/24 at 7:50 AM the ADM stated the regional staff and she had gone in the kitchen at random times and has trained the dietary manager. <BR/>Record review of the Facility policy Resident Nutrition Services dated November 2010 reflected, Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance. 2. Nursing personnel will ensure that residents are served the correct food tray. 3. Prior to service the food tray, the nurse aide/feeding assistant must check the tray card to ensure that the correct food tray is being served to the resident. <BR/>Record review of the Facility Therapeutic Diets policy, dated December 2008, reflected Therapeutic dies shall be prescribed by eh Attending Physician. The facility will strive for the fewest possible dietary restrictions. 1. Mechanically altered diets, as well as dies modified for medial or nutritional needs, will be considered Therapeutic diets. 5. The food Service Manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered.

Based on observation, interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal spa: the failure to ensure residents were made aware of how to obtain a snack when desired for 4 of 9 residents (confidential residents in group) reviewed for frequency of meals.<BR/>The facility failed to ensure residents were offered snacks at bedtimes as required due to mealtimes being more than 14 hours apart.<BR/>This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. <BR/>Findings included: <BR/>Record review of the resident snack list, no date was provided by the DM. There were 27 residents that received morning and afternoon snacks. There was no resident list with HS snacks provided.<BR/>Record review of the resident rooster dated on 5/14/2024 reflected a census of 31 residents. <BR/>Observation on 5/14/2024 at 9:50 AM, of the posted Meal Service Times in the dining room revealed the following:<BR/>Breakfast - 7:30 -7:45 AM <BR/>Lunch - 11:30-11:45 AM <BR/>Evening meal - 5:30 -5:45 PM- There is no posting to advise any resident a snack or availability of type of snack after specified times. <BR/>During interview on 5/14/2024 at 1:35 PM with residents in group of 6 residents, it was brought to the attention of the state surveyors that they have not been made aware of options of a snack which are available to residents. Residents said they were not offered any HS snacks . <BR/>Interview on 5/16/2024 at 10:48 AM with dietary consultant stated he was not aware of residents not offered snacks after dinner. The Dietary consultant stated the effects of residents not offered snacks by staff would he a potential for weight loss, the resident might be diabetic, resident blood sugar levels and resident morale.<BR/>Interview on 5/14/2024 at 4:00 PM the DM stated the resident that received snacks had orders and or have some weight loss. The DM provided a list of 27 out of 31 residents that received snacks . <BR/>Interview on 5/14/2024 at 4:15 PM the ADM stated they give snacks to the residents and snacks are available when resident ask the nurse. The ADM stated the residents that were diabetic or have an order get snacks from kitchen. The ADM stated that residents were provided snacks by the nurse if they ask for snacks.<BR/>Interview on 5/15/2024 at 5:15 PM LVN G stated resident get snacks at the nurse's station. LVN G stated when residents ask for snacks, they provide residents with snacks. <BR/>Interview on 5/15/2024 at 5:24 PM with CNA I who worked the 6 AM to 6 PM shift during the week. CNA I stated not all resident get snacks when they come out from the kitchen. CNA I stated the resident that are offered snacks are residents with physician orders and diabetic residents . CAN I stated the snack that had labels were brought out by kitchen and the nurses' stations always had snacks for residents, at resident request. CNA I stated the residents had refrigerators that had snacks they bought our was brought in by the family. <BR/>Record Review of Facility Policies and Procedures Snacks dated September 2017, reflected The purpose of this procedure is to provide the resident with adequate nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the maintenance of mechanical, electrical, and patient care equipment in safe operating condition for 3 (Residents #11, #15 and #18) of 20 residents reviewed for safe environment, in that:.<BR/>1. Resident #11's wheelchair on 05/14/2024 at 10:00 a.m. had the left armrest vinyl torn and sharp and appeared worn and damaged.<BR/>2. Resident #15's wheelchair on 05/14/2024 at 10:12 a.m., had both armrests vinyl torn and worn on the edges.<BR/>3. Resident #18's wheelchair on 05/14/2024 at 10:15 a.m. had both armrests vinyl torn and worn. The left side armrest was missing vinyl and foam and the baseboard was exposed. <BR/>These deficient practices could affect residents who rely on facility equipment for mobilization and could result in skin tears or injuries.<BR/>The findings included:<BR/>1. Record review of Resident #11's electronic face sheet dated (05/14/2024) reflected he was admitted to the facility on [DATE]. His diagnoses included: abnormalities of gait and mobility (any deviations from normal walking or gait), thyrotoxicosis (a condition that happens when there is too much thyroid hormone in the body and can cause rapid weight loss and a rapid heartbeat), paroxysmal atrial fibrillation (type of irregular heartbeat) and adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability)<BR/>Record review of Resident #11's quarterly MDS assessment with an ARD of 04/02/2024 reflected he scored a 10/15 on his BIMS which signified he was moderately cognitively impaired. He could understand and be understood. He required a manual wheelchair and could roll 150 feet once seated in the chair.<BR/>Record review of Resident #11's comprehensive person-centered plan of care 09/29/2023 reflected Problem, ADL's Functional Status/Rehabilitation Potential, Approach, promote dignity, assist with ADL's as needed.<BR/>Observation on 05/14/2024 at 10:00 a.m., Resident #11 was sitting in his wheelchair and the left armrest vinyl was torn with sharp ragged edges and appeared worn and damaged.<BR/>During an interview on 05/17/2024 at 1:30 p.m. with Resident #11, he stated the torn vinyl on his left wheelchair armrest was sharp. He stated he had cut his arm on the vinyl. He stated he had the wheelchair for as long as he could remember. When asked why he did not ask the staff to repair it, he stated what good would it do? He stated he did not want to bother anyone. He stated the worn and torn armrest made him feel depressed.<BR/>2. Record review of Resident #15's electronic face sheet dated 05/14/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: hypothyroidism (the thyroid gland cannot make enough thyroid hormone to keep the body running normally), dementia (a loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and muscle weakness (when full effort does not produce a normal muscle contraction or movement).<BR/>Record review of Resident #15's quarterly MDS review with an ARD of 03/25/2024 reflected he scored a 09/15 on his BIMS which signified he was moderately cognitively impaired. He could usually understand and could usually be understood. He required a manual wheelchair and could move independently.<BR/>Record review of Resident #15's comprehensive person-centered care plan dated 03/24/2024 reflected Problem, ADLs Functional Status/Rehabilitation Potential, Approach, promote dignity, assist with ADL's as needed.<BR/>Observation on 05/14/2024 at 10:12 a.m. Resident #15 was sitting in his wheelchair and both the armrests vinyl was torn and worn which caused him to feel a loss of dignity.<BR/>During an interview on 05/17/2024 at 2:00 p.m. with Resident #15, who was sitting in his wheelchair in 300 hallways, he had new armrests which on his wheelchair which were replaced on 05/16/2024 after the surveyor spoke with the RNC. He stated the new armrests were nice, and he could wear short sleeve shirts now, because the old armrests scratched his arms. He stated the old armrests made him feel bad. When asked why he did not mention the worn and torn armrests to the staff, he stated he did not want to bother anyone. He stated he had the wheelchair since he was admitted to the facility.<BR/>3. Record review of Resident #18's electronic face sheet dated 05/14/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and mood issues), weakness (lacking strength), unspecified abnormalities of gait (any deviations from normal walking or gait) and mobility and spinal stenosis (space inside the backbone is too small and can cause pain, tingling and weakness).<BR/>Record review of Resident #18's quarterly MDS assessment with an ARD of 03/21/2024 reflected he scored a 10/15 on his BIMS which signified he was moderately cognitively impaired. He could understand and be understood. He required a manual wheelchair and could move independently.<BR/>Record review of Resident #18's comprehensive person-centered care plan dated 08/14/2023 reflected Problem, ADLs Functional Status/Rehabilitation Potential, Approach, promote dignity, assist with ADL's as needed.<BR/>Observation on 05/14/2024 at 10:15 a.m. of Resident #18, he was sitting in his wheelchair, and both the armrests had torn and worn vinyl and the left armrest was missing foam which exposed the baseboard.<BR/>During an interview on 05/14/2024 at 10:17 a.m. with Resident #18, he stated he had the wheelchair since his admission and the vinyl was worn and torn. He stated he did not want to bother the staff and did not complain.<BR/>During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated worn and torn armrest on resident's wheelchairs were a safety and dignity issue. She stated she had only been at the facility for less than a year and the company just hired a DON who had not started work. She stated she was not aware and had not noticed the resident wheelchairs needed armrests replaced or repaired. She stated if staff saw something that required repair they needed to write it down in the Maintenance book at the nurse's station, and she presumed no one had noticed since the residents did not complain. She stated she would get them replaced right away. She stated she was not aware of any injuries from the torn vinyl on the armrests, but the potential was there. <BR/>. <BR/>Observation on 05/17/2024 of Resident #18 at 3:00 p.m. sitting in his wheelchair in the 300 halls, he had new armrests. The new armrests were the result of the surveyor intervention, who spoke with the RNC on 05/16/2024 about the torn and worn armrests.<BR/>During an interview on 05/17/2024 at 3:02 p.m. with Resident #18, he stated the new armrests on his wheelchair were soft and comfortable, and he felt much better.<BR/>The Maintenance Director was not available for interview.<BR/>Record review of the facility incident and accident reports from 03/1/2024 to 05/01/2024 reflected residents had skin tears, but not related to any equipment issues.<BR/>Upon Request on 05/16/2024 of the RNC, the facility did not provide a policy or procedure to address safe equipment or maintenance of wheelchairs.<BR/>Record review of the facility policy and procedure titled Equipment-General Use for All Residents dated revised August 2006 reflected Our facility shall provide routine equipment for the general use of the resident population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the Resident's assessment accurately reflected the resident's status, for 1 of 24 residents (Resident #2) reviewed for lack of assessment for dentures, in that:<BR/>1. <BR/>Resident #2 was admitted and assessed without documenting her need for dentures after a hospitalization where Resident #2 was treated for having swallowed her dentures.<BR/>This failure could have placed residents at risk for harm by unidentified dentures and lack of care and support for the dentures.<BR/>The findings included:<BR/>A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 11/22/2022 and 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care.<BR/>A record review of Resident #2's hospital discharge records, dated 02/26/2023, revealed history of present illness; chief complaint; altered mental status, low oxygen level, and foreign body (dentures) in esophagus . this is a [AGE] year-old white female brought by emergency medical services 2[name of hospital] emergency room on the evening of 02/21/2023 for recurrent episodes of aspiration associated with shortness of breath for two days prior to presentation. the patient is unable to provide any history due to cognitive impairment at baseline . the patient was sent 2 . emergency room by care staff at the skilled nursing facility where the patient resides for two episodes of food aspiration for two days prior to presentation. the patient had one episode of food aspiration on 02/20/2023 and a second episode of food aspiration on 02/21/2023. her second episode was more severe and associated with significant coughing and choking. care staff reports gradual onset of worsening shortness of breath for approximately 2 days prior to presentation . the patient was noted to meet criteria for sepsis with elevated heart rate, elevated temperature, and elevated white blood cell count. the patient was found to have a bacterial source in the form of bilateral aspiration pneumonia . X-ray of the soft tissues of the neck performed at the emergency room showed a U-shaped foreign body noted within the cervical esophagus [back of the throat] consistent with dentures. upon further inspection of the patient, the patient's upper dentures were accounted for, but the patient's lower dentures were not. because of these findings, the patient . has been transferred to a higher-level of care for further medical management and evaluation, including an ear nose and throat specialist consultation findings of foreign body and cervical esophagus . foreign body dentures removed by medical doctor and ear nose and throat specialist this morning after locating object in hypopharynx [back of the throat] and extending into the cervical esophagus .<BR/>A record review of Resident #2's re-entry and quarterly MDS's, dated 02/27/2023 revealed the Regional MDS LVN documented in section A0310 type of assessment 99 which indicated none of the above. Further review of section A0310 revealed the choices were 01. Admission, 02. Quarterly, 03. Annual, 04. Significant Change in Status, 05. Significant Correction to prior comprehensive assessment, 06. Significant correction to prior quarterly assessment, and 99. None of the above. Further review revealed the MDS assessment was not signed by a RN.<BR/>A record review of Resident #2's quarterly MDS's, dated 03/01/2022, revealed the Regional DON assessed Resident #2 as returned from an acute care hospital on [DATE]. The MDS assessment revealed Resident #2 was severely impaired for cognition and was assessed as needing limited assistance and supervision during meals. Resident #2 was diagnosed with pneumonia, loss of liquids/solids from mouth when eating or drinking and required a change in textures of food and liquids. Review of the MDS Section L revealed no documentation for the assessment broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose). <BR/>A record review of Resident #2's physical paper chart revealed a Care Plan worksheet, dated 01/11/2023, which reflected the attendees as the AD and the DOR. The document revealed there was a concern made by Resident #2's representative for Resident #2's bottom dentures. Further review revealed no documents to reveal any subsequent care plan meetings. <BR/>A record review of Resident #2's Care Plan, dated, 01/13/2023, revealed no focuses, interventions, and/or care instructions for Resident #2's needs for dentures. Further review of Resident #2's medical records evidenced no further care plans other than the 01/13/2023 care plan. <BR/>During an interview on 03/23/2023 at 01:55 PM, the Regional MDS LVN stated she was the MDS coordinator for the facility intermittingly. The Regional MDS LVN stated she had been helping periodically per the facility's needs with resident assessments and would be alerted by the facility of the need for an MDS assessment. The Regional MDS LVN stated she had completed the MDS assessment for Resident #2 on 02/27/2023 and documented the assessment section as 99 and did not document the assessment as a change of status . The Regional MDS LVN stated she was not aware of Resident #2's change of status and her hospitalization for swallowing her dentures with a diagnosis of sepsis pneumonia. The Regional MDS LVN stated she was not assigned to follow the MDS with care plans and the duty was assigned to someone at the facility by the Administrator possibly ADON S [ADON S from another facility] who helped at the facility or the Regional DON. <BR/>During an interview on 03/24/2023 at 04:50 PM, the Regional DON stated a care plan was prepared by the IDT per the MDS assessment within 14 days of the completed MDS assessment. The Regional DON stated she had completed the quarterly MDS for Resident #2 on 03/01/2023 and did not document an assessment for Resident #2's oral/dental status under Section L, broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose) mouth or facial pain, discomfort or difficulty with chewing. The Regional DON stated she did not know if Resident #2's dentures were or were not loose fitting and after her discharge from the hospital there were no reports of Resident #2 having swallowing issues. The Regional DON stated she was responsible for 5 other facility's and was on call for all 5. The Regional DON stated she was not in the facility for 40 hrs. a week. The Regional DON stated she had not coordinated a care plan for Resident #2's change of status for her needs with dentures and assistance supervision during meals within 14 days of the 02/27/2023 re-admission from the hospital or within 14 days of the 03/01/2023 quarterly MDS assessment . The Regional DON stated there should have been care instructions in Resident #2's care plan to reflect Resident #2's needs for support with her dentures and assistance with meals to include diet textures and swallow studies as assessed by the SLP who was an IDT member.<BR/>During an interview on 03/24/2023 at 04:32 PM the Administrator stated the ex-DON resigned in October 2022 and since then the corporate regional nursing support staff, to include the Regional DON, the Regional DON I, the Regional Director of Quality, and the Regional MDS nurse, were all involved with the facility's nursing services while the search for a replacement DON ensued. The administrator stated he relied on the corporate regional nursing support staff for the daily continuation of nursing services. The administrator stated the facility policy is to provide an accurate and comprehensive MDS assessments to include care plan development and implementation upon admission, change in conditions, and at a minimum, quarterly. The Administrator stated this was not done as evidenced by Resident #2's MDS assessments and care plan which do not support Resident #2 with her denture needs. The Administrator stated if he had been given a report from nursing staff, that MDS assessments were incomplete, care plans were not performed as required, he would have ensured gaps in nursing services were addressed. <BR/>A record review of the facility's policy admission Assessment and Follow Up: Role of the Nurse, dated December 2012, revealed, The purpose of this procedure is to gather information about the residents physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the Resident, initiating the care plan, and completing required assessment instruments, including the MDS . steps in the procedure . conduct a physical assessment, including the following systems: eyes, ears, nose, throat; teeth and gums . contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtained admission orders that are based on these findings . notify the supervisor and the attending physician of immediate needs that the resident may have . report other information in accordance with facility policy and professional standards of practice.

**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 for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 4 of 8 residents (Resident #2, #32, #28, and #7) reviewed for care plans in that:<BR/>Residents #32 and #7 did not have a comprehensive person-centered care plan in their resident file.<BR/>Residents #2 and #28 did not have a comprehensive care plan that met a resident's medical needs. <BR/>These failures could place residents at risk of receiving inadequate interventions not individualized to their care needs. <BR/>The findings were:<BR/>- <BR/>Record review of Resident #32's face sheet dated 3/23/23, revealed an [AGE] year-old female admitted on [DATE] with diagnosis that include malignant neoplasm of brain (a fast-growing tumor in the brain), gastro-esophageal reflux disease (a condition where acidic gastric fluid flows backward into the esophagus), and depression. <BR/>- <BR/>Record review of Resident #32's most recent MDS dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills. <BR/>- <BR/>Record review of Resident #32's EHR reflected no evidence of a comprehensive person-centered care plan. <BR/>- <BR/>Record review of Reside #7's face sheet dated 3/23/23, revealed a [AGE] year-old female admitted on [DATE] with diagnosis that include Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves), Stage 3 pressure ulcer (an injury to skin resulting from prolonged pressure), and Dysphasia (impairment in speech due to brain disease or damage). <BR/>- <BR/>Record review of Resident #7's most recent MDS dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills. <BR/>- <BR/>Record review of Resident #7's EHR reflected no evidence of a comprehensive person-centered care plan. <BR/>- <BR/>Record review of Resident #28's face sheet dated 3/23/23, revealed an [AGE] year-old male admitted on [DATE] with diagnosis that include Gout (a form of arthritis), Oropharyngeal dysphagia (swallowing problems occurring in the mouth/throat), Aphasia (language disorder that affects the ability to communicate) and open wounds to forearm and left ankle.<BR/>- <BR/>Record review of Resident #28's most recent MDS dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills. <BR/>- <BR/>Record review of Resident #28's care notes from the dietician dated 9/19/22 indicate that the resident had lost 8.1% of their total body weight in 1 month. Stated there were current orders for protein shakes.<BR/>- <BR/>Record review or Resident #28's care notes from the dietician dated 315/23 indicate that the resident had lost 7.8% of their total body weight in 1 month. The care note also states that the resident should be on a fortified meal plan. <BR/>- <BR/>Record review of Resident #28's comprehensive person-centered care plan revealed there were no interventions present for the resident's weight loss as recommended by the dietician. <BR/>- <BR/>Record review of facility policy on care planning revealed that comprehensive care plans for each resident must be developed within seven days of completion of the MDS. <BR/>- <BR/>Record review of facility policy on care planning revealed that a change in condition that will not resolve itself without intervention is required to be reviewed by an interdisciplinary team and revised on the care plan. <BR/>- <BR/>In an interview on 3/24/23 at 10:55 AM, ADON stated she is teaching herself the facilities EHR system and has recently taught herself how to do Care Plans in the system. The ADON stated that she was not aware Resident #32 and Resident #7 did not have record of a care plan in the EHR. The ADON also stated that she was not aware that Resident #28's care plan did not accurately reflect his medical needs. <BR/>- <BR/>In an interview on 3/24/23 at 1:06 PM, Administrator stated he was not aware care plans were not being completed adequately. Administrator stated there were care plan meetings but that there were not RNs at these meetings. The administrator stated he does not know why Residents #32, #7, and #28 do not have accurate care plans.<BR/>Resident #2<BR/>A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care.<BR/>A record review of Resident #2's hospital discharge records, dated 02/26/2023, revealed history of present illness; chief complaint; altered mental status, low oxygen level, and foreign body(dentures) in esophagus . this is a [AGE] year-old white female brought by emergency medical services 2[name of hospital] emergency room on the evening of 02/21/2023 for recurrent episodes of aspiration associated with shortness of breath for two days prior to presentation. the patient is unable to provide any history due to cognitive impairment at baseline . the patient was sent 2 . emergency room by care staff at the skilled nursing facility where the patient resides for two episodes of food aspiration for two days prior to presentation. the patient had one episode of food aspiration on 02/20/2023 and a second episode of food aspiration on 02/21/2023. her second episode was more severe and associated with significant coughing and choking. care staff reports gradual onset of worsening shortness of breath for approximately 2 days prior to presentation . the patient was noted to meet criteria for sepsis with elevated heart rate, elevated temperature, and elevated white blood cell count. the patient was found to have a bacterial source in the form of bilateral aspiration pneumonia . X-ray of the soft tissues of the neck performed at the emergency room showed a U-shaped foreign body noted within the cervical esophagus consistent with dentures. upon further inspection of the patient, the patient's upper dentures were accounted for but the patient's lower dentures were not. because of these findings, the patient . has been transferred to a higher-level of care for further medical management and evaluation, including an ear nose and throat specialist consultation findings of foreign body and cervical esophagus . foreign body dentures removed by medical doctor and ear nose and throat specialist this morning after locating object in hypopharynx and extending into the cervical esophagus <BR/>A record review of Resident #2's re-entry and quarterly MDS's, dated 02/27/2023 revealed the Regional MDS LVN documented in section A0310 type of assessment 99 which indicated none of the above. Further review of section A0310 revealed the choices were 01. Admission, 02. Quarterly, 03. Annual, 04. Significant Change in Status, 05. Significant Correction to prior comprehensive assessment, 06. Significant correction to prior quarterly assessment, and 99. None of the above. Further review revealed the MDS assessment was not signed by a RN. <BR/>A record review of Resident #2's quarterly MDS's, dated 03/01/2022, revealed the Regional DON assessed Resident #2 as returned from an acute care hospital on [DATE]. The MDS assessment revealed Resident #2 was severely impaired for cognition and was assessed as needing limited assistance and supervision during meals. Resident #2 was diagnosed with pneumonia, loss of liquids/solids from mouth when eating or drinking and required a change in textures of food and liquids. Review of the MDS Section L revealed no documentation for the assessment broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose). <BR/>A record review of Resident #2's physical paper chart revealed a Care Plan worksheet, dated 01/11/2023, which documented the attendees as the Activities Director [AD] and the Director of Rehabilitation [DOR]. The document revealed there was a concern made by Resident #2's representative for Resident #2's bottom dentures. Further review revealed no documents to reveal any subsequent care plan meetings. <BR/>A record review of Resident #2's Care Plan, dated, 01/13/2023, revealed no focuses, interventions, and/or care instructions for Resident #2's needs for dentures. Review of Resident #2's care plan revealed 1 care instruction, Resident [#2] is at risk for falls due to amputation and weakness . Resident [#2] will be free of falls through next review . encourage call light usage . increased staff supervision with intensity based on Resident [#2] need. Further review of Resident #2's medical records evidenced no further care plans other than the 01/13/2023 care plan. <BR/>During an interview on 03/22/2023 at 02:15 PM CNA D and CNA E, who were the CNAs for Resident #2 revealed the CNAs stated they were not aware Resident #2 had top and bottom dentures and believed she only had top dentures. The CNAs stated they had no care instructions for Resident #2 in their version of the care plan, the [NAME] . The CNA's stated they had no training or care instructions for Resident #2's denture care.<BR/>During an interview on 03/23/2023 at 01:55 PM, the Regional MDS LVN stated she was the MDS coordinator for the facility intermittingly. The Regional MDS LVN stated she had been helping periodically per the facility's needs with Resident assessments and would be alerted by the facility for the need for an MDS assessment. The Regional MDS LVN stated she had completed the MDS assessment for Resident #2 on 02/27/2023 and documented the assessment section as 99 and did not document the assessment as a change of status. The Regional MDS LVN stated she was not aware of Resident #2's change of status and her hospitalization for swallowing her dentures with a diagnosis of sepsis pneumonia. The Regional MDS LVN stated she was not assigned to follow the MDS with care plans and the duty was assigned to someone at the facility by the Administrator possibly ADON S [ADON S from another facility] who helped at the facility or the Regional DON. <BR/>During an interview on 03/24/2023 at 04:50 PM, the Regional DON stated a care plan is prepared by the Interdisciplinary Team [IDT] per the MDS assessment within 7 days of the completed MDS assessment. The Regional DON stated she had completed the quarterly MDS for Resident #2 on 03/01/2023 and did not document an assessment for Resident #2's oral / dental status under section L, broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose) mouth or facial pain, discomfort or difficulty with chewing. The Regional DON stated she did not know if Resident #2's dentures were or were not loose fitting and after her discharge from the hospital there were no reports of Resident #2 having swallowing issues. The Regional DON stated she was responsible for 5 other facility's and was on call for all 5. The Regional DON stated she was not in the facility for 40 hrs. a week. The Regional DON stated she had not coordinated a care plan for Resident #2's change of status for her needs with dentures and assistance supervision during meals within 7 days of the 02/27/2023 re-admission from the hospital or within 7 days of the 03/01/2023 quarterly MDS assessment . The Regional DON stated there should have been care instructions in Resident #2's care plan to reflect Resident #2's needs for support with her dentures and assistance with meals to include diet textures and swallow studies as assessed by the Speech Language pathologist [SLP] who was an IDT member. <BR/>During an interview on 03/24/2023 at 04:32 PM the Administrator stated the ex-DON resigned in October 2022 and since then the corporate regional nursing support staff, to include the Regional DON, the Regional DON I, the Regional Director of Quality, and the Regional MDS nurse, were all involved with the facility's nursing services while the search for a replacement DON ensued. The administrator stated he relied on the corporate regional nursing support staff for the daily continuation of nursing services. The administrator stated the facility policy is to provide an accurate and comprehensive MDS assessments to include care plan development and implementation upon admission, change in conditions, and at a minimum, quarterly. The Administrator stated this was not done as evidenced by Resident #2's MDS assessments and care plan which do not support Resident #2 with her denture needs. The Administrator stated if he had been given a report from nursing staff, that MDS assessments were incomplete, care plans were not performed as required, he would have ensured gaps in nursing services were addressed. <BR/>A record review of the facility's policy Care Planning - Interdisciplinary Team, dated February 2014, revealed, policy statement: our facilities care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each Resident. a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment MDS. the care plan is based on the residence comprehensive assessment and is developed by a care planning interdisciplinary team which includes but is not necessarily limited to the following personnel: the residents attending physician; the registered nurse who has responsibility for the Resident; the activities director coordinator; therapist speech; occupational; recreational; etcetera as applicable; consultants; the director of nursing; the charge nurse responsible for the Resident; nursing assistants responsible for residents care; others as appropriate. the Resident, the residents family and or the residents legal representative guardian are encouraged to participate in the development of and revisions to the residents care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 9 residents (Resident #2) reviewed for reviewed for neglect for denture care and supervision at meals, in that:<BR/>The facility failed to identify care or support for Resident #2's dentures. During 3 meals, on 02/20/2023 and 02/21/2023, Resident #2 choked on food and aspirated food. Resident #2 swallowed her lower dentures which became lodged in the back of her throat during the 2nd meal and was served the third meal in this condition. [Choking occurs when the airway is blocked by food, drink, or foreign objects. Aspiration occurs when food, drink, or foreign objects are breathed into the lungs (going down the wrong tube).]<BR/>An IJ was identified on 03/24/2023. The IJ template was provided to the facility on [DATE] at 05:15 PM. While the IJ was removed on 03/25/2023, the facility remained out of compliance at a scope of IJ and a severity level of J because of the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure placed Residents at risk for death by a blocked airway and secondary pulmonary infection by aspirated food/vomit. <BR/>The findings included:<BR/>A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 11/22/2022 and 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care.<BR/>A record review of Resident #2's admission notes, 11/22/2022 to 02/20/2023, failed to reveal any assessments for dentures or oral dentition. <BR/>A record review of Resident #2's admission MDS, dated [DATE], revealed the Regional MDS LVN prepared the assessment and failed to assess Resident #2 was admitted with and used dentures. Further review revealed Regional DON I signed the MDS. <BR/>A record review of Resident #2's Care Plan, dated, 03/22/2023, revealed no focuses, interventions, and/or care instructions for Resident #2's needs for dentures. <BR/>A record review of Resident #2's nursing progress notes revealed LVN H documented on 02/20/2023 at 06:30 PM, Approximately 1730 [05:30 PM] resident was eating dinner in the dining room when she aspirated [inhaled food and/or vomit into lungs] while eating her meal. Writer and staff acted quickly and was able to assist Resident to clear what was caught in her throat. Writer contacted the physician and was told to monitor resident for fever and shortness of breath. Resident [family member] was contacted and let known of the situation. Resident vitals are stable and Resident has been placed back in her bed in high fowlers position to prevent any further aspiration. will continue to monitor.<BR/>A record review of Resident #2's nursing progress notes revealed LVN A documented on 02/21/2023 at 01:53 PM, To dining room for meals for supervision. Pureed diet served today due to sore and hoarse throat. Resident began coughing on first bite of food. Resident able to clear and then slowly ate pureed food. X-ray ordered with two views.<BR/>A record review of Resident #2's final X-ray Report, dated 02/21/2023 , revealed, examination: chest . findings: . a metallic foreign body projects over the neck <BR/>A record review of Resident #2's nursing progress notes revealed the ADON documented on 02/21/2023 at 06:11 PM, Patient presenting increased SOB using ABDM muscles, cold, clammy to touch, pale, diaphoretic [excessive sweating], speech therapist here tried to feed patient at this time patient did not tolerate but one bite of mashed potatoes. Drooling and discharge from nose called. [Resident #2's representative] and doctor [name] on call for [Resident #2's doctor] send to ED for evaluation and treatment .<BR/>A record review of Resident #2's hospital medical records revealed a History of Present Illness, dated 02/22/2023, authored by Dr. T, chief complaint: altered mental status, low oxygen level, and foreign body (dentures) in esophagus [throat] . is a [AGE] year old white female brought by EMS to [local hospital] hospital emergency room on the evening of 02/21/2023 for recurrent episodes of aspiration associated with shortness of breath for two days prior to presentation. The patient is unable to provide any history due to cognitive impairment at baseline. As a result, history is obtained exclusively from review of hard copy medical records provided by the transferring facility. The patient was sent to the outside emergency room by care staff at the skilled nursing facility where the patient resides for two episodes of food aspiration for two days prior to presentation. The patient had one episode of food aspiration on 02/20/2023 and a second episode of food aspiration on 02/21/2023. Her second episode was more severe and associated with significant coughing and choking. Care staff reports gradual onset of worsening shortness of breath for approximately 2 days prior to presentation. Her shortness of breath was worse if she laid flat and improves if she sat up. At the outside emergency room, the patient's initial vital signs were remarkable for blood pressure 131/72, heart rate 106, respiratory rate 18, temperature 101.4, and 90% oxygen saturation on room air. Labs were remarkable for white blood cell count 25.4, hemoglobin 13.1, hematocrit 40.2, platelet count 270, sodium 138, potassium 4.3, creatinine 0.73, glucose 170, lactic acid 1.35, negative troponin, BNP 37, lipase 22, phosphorus 3.5, magnesium 1.7, TSH 1.06, PT 12.4, INR 1.1, PTT 30.4, and negative urinalysis. The patient was noted to meet criteria for sepsis with elevated heart rate, elevated temperature, an elevated white blood cell count. the patient was found to have a bacterial source in the form of bilateral aspiration pneumonia. CTA of chest was negative for PPE but did show acute findings consistent with bilateral aspiration pneumonia. CT of abdomen and pelvis with IV contrast performed at the outside emergency room showed fecal impaction with wall thickening and adjacent stranding. X-ray of the soft tissues of the neck performed at the outside of emergency room showed a U-shaped foreign body noted within the cervical esophagus consistent with dentures. upon further inspection of the patient, the patient's upper dentures were accounted for, but the patient's lower dentures were not. As a result of these findings, the patient has been transferred to [out of town specialty hospital] to a higher-level care for further medical management and evaluation, including ear nose and throat specialist consultation.<BR/>A record review of Resident #2's hospital records revealed a patient assessment document Bedside Swallowing Evaluation, dated 02/22/2023, authored by Dr. U, medical history diagnosis, date of onset: patient is a [AGE] year-old female admitted with hypoxemia, concern for aspiration pneumonia, findings of foreign body and cervical esophagus. her are in, history of renal cancer. chest X-ray 02/22: segmental atelectasis vs RRL pneumonia. foreign body dentures removed by medical doctor and ear nose and throat specialist this morning after locating object in hypopharynx and extending into the cervical esophagus. per emergency medical record documented dysphasia at nursing facility.<BR/>During an interview on 03/22/2023 at 10:23 AM, the ADON stated on her 2nd day of employment at the facility, Resident #2 aspirated during the evening dinner on 2/20/2023. The ADON stated LVN H was assigned to supervise the residents at the evening meal and was absent from his duty. The ADON stated she heard the commotion and calls from the dining room when she ran to the dining room and assessed Resident #2, pale, cyanotic [blue skin], cold, tearing eyes and anxiously attempting to breath. The ADON stated she performed the Heimlich maneuver [performed by wrapping your arms around a person, making a fist with one hand and clasping it with the other. You place your fists between the person's ribcage and belly button and thrust your hands into their abdomen until the object is freed], swept Resident #2's oral cavity and expelled food from Resident #2's oral cavity. The ADON stated she was not familiar with Resident #2 and did not know Resident #2 had dentures. The ADON stated she did not feel or visualize Resident #2's dentures in her mouth. The ADON stated she could not access Resident #2's care plan due to her lack of training on the facility's electronic record. The ADON stated she now understood, even if she had access to Resident #2's care plan there were no interventions to alert anyone to Resident #2's dentures. The ADON stated Resident #2 was assessed with vital signs within normal limits, her physician was given a report and was assisted to bed for the evening. The ADON stated the physician was not given any report regarding her dentures. <BR/>During an interview on 03/22/2023 at 02:15 PM CNA D and CNA E, who were the CNAs for Resident #2 to include the dinner meal on 02/20/2023 and 02/21/2023, the CNAs stated they were not aware Resident #2 had top and bottom dentures and believed she only had top dentures. The CNAs stated they had no training or care instructions for Resident #2's denture care.<BR/>During an interview on 03/23/2023 at 02:00 PM, LVN H stated he was the nurse on duty on 02/20/2022 and that Resident #2 had aspirated and had recovered. LVN H stated he called the on-call physician, gave report of the incident, and received new orders for monitoring Resident #2 for signs and symptoms of aspiration complications . LVN H stated he did not document the SBAR or the new orders received. LVN H stated he was not aware Resident #2 had dentures. LVN H stated Resident #2 was assisted to bed for the evening and was not in distress. LVN H stated he had no knowledge if Resident #2 had her lower dentures lodged in her airway that evening. LVN H stated there was a miscommunication as to his duty to supervise the dining room meal that evening. <BR/>During an interview on 03/23/2023 at 02:05 PM the ADON stated Resident #2 refused the breakfast meal on 02/21/2023. The ADON stated Resident #2 was receiving mechanical soft diet and the diet was discontinued on 02/21/2023 and a pureed diet was ordered . The ADON stated Resident #2 was assisted with the lunch meal by LVN A and Resident #2 began to aspirate on pureed foods. The ADON received the report of the 2nd aspiration episode and SBAR'ed the physician and received a new order for a chest x-ray. The ADON stated the image was captured shortly afterward, and the facility awaited the results of the image. The ADON stated Resident #2 was assisted by the SLP with the evening meal on 02/21/2023 when Resident #2 began to aspirate a 3rd time and was sent to the hospital for treatment and evaluation. The ADON stated the facility received the image result of the x-ray at 10:00 PM. The ADON stated the x-ray revealed a foreign object in the airway. <BR/>During an interview on 03/23/2023 at 02:00 PM the NP stated he was a NP who worked for the PCP responsible for Resident #2. The NP stated he had reviewed Resident #2's medical records to include her admitting nursing assessments and was not aware of Resident #2 using dentures. The NP stated if the nursing staff had assessed and documented Resident #2's dentures he could have had an opportunity to review her assessments, he may have possibly ordered a referral for Resident #2 to see a dentist to assess for Resident #2's dentures for proper fit. The NP stated often, as people age, the lower jaw changed shape and dentures became loose fitting. The NP stated Resident #2 could have died when she was not provided support while eating with dentures, such as proper care for dentures, instructions for wearing dentures, proper supervision for proper fitting dentures prior to meals. The NP stated the danger for aspiration was still in place due to the floor staff not having access to a complete and accurate care plan developed to support Resident #2's nutritional needs, and assistance with meals and dentures.<BR/>During an interview on 03/24/2023 at 04:32 PM the Administrator stated the ex-DON resigned in October 2022 and since then the corporate regional nursing support staff, to include the Regional DON, Regional DON I, the Regional Director of Quality, and the Regional MDS nurse, were all involved with the facility's nursing services while the search for a replacement DON ensued. The Administrator stated he relied on the corporate regional nursing support staff for the daily continuation of nursing services. The Administrator stated the facility policy was to provide an accurate and comprehensive MDS assessments to include care plan development and implementation upon admission, change in conditions, and at a minimum, quarterly. The Administrator stated this was not done as evidenced by Resident #2's MDS assessments and care plan which did not support Resident #2 with her denture needs. The Administrator stated if he had been given a report from nursing staff, that MDS assessments were incomplete, care plans were not performed as required, he would have ensured gaps in nursing services were addressed . <BR/>A record review of the facility's policy admission Assessment and Follow Up: Role of the Nurse, dated December 2012, revealed, The purpose of this procedure is to gather information about the residents physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the Resident, initiating the care plan, and completing required assessment instruments, including the MDS . steps in the procedure . conduct a physical assessment, including the following systems: eyes, ears, nose, throat; teeth and gums . contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtained admission orders that are based on these findings . notify the supervisor and the attending physician of immediate needs that the resident may have . report other information in accordance with facility policy and professional standards of practice.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/24/20223 at 05:17 PM. The Administrator was notified. The Administrator was provided with the IJ template on 03/24/2023. The following Plan of Removal was accepted on 03/25/2023 at 3:00 PM.<BR/>Plan of Removal Verification 03/26/2023<BR/>Resident # 2 assessed by the RN for any s/s of discomfort/pain or changes in condition, physician was notified of the alleged deficiency on 3/24/23. There were no new orders obtained. The affected resident's responsible party was notified by the Administrator of alleged deficiencies and plan of correction. Resident was evaluated by SLP, clarification on diet received, new orders for speech treatment and swallow study ordered by physician.<BR/>A record review of Resident #2's medical record revealed a progress note authored by the Regional DON, dated 03/24/2023, revealed, resident in the dining room without dentures, oral cavity without signs and symptoms of pain or discomfort. no redness or irritation noted.<BR/>A record review of the facility's ad-hoc QAPI attendee sign in log, dated 03/24/2023, revealed attendees to include the Regional DON, Medical Director, Administrator, ADON, and RDO<BR/>A record review of Resident #2's order summary revealed new orders on 03/25/2023, for: the mechanical soft diet to be discontinued and for a pureed diet with thin liquids to begin, denture care to include monitoring daily for comfort and fit, an order for a modified barium swallow test, and an order for speech language to evaluate and treat.<BR/>A record review of Resident #2's speech therapy notes, dated 03/25/2023, revealed Resident #2 was evaluated by the SLP, clarification on diet received, new orders for speech treatment and a swallow study was ordered by the physician.<BR/>A record review of Resident #2's progress notes revealed a note authored by the ADON on 03/25/2023, [family member] called and informed there was an active and investigation from state surveyors on the incident with his [Resident #2's] dentures . <BR/>Residents with dentures were assessed by the RN (Regional DON) on 3/24/2023, the plan of care was updated and POC was updated to reflect patients' dentures utilization.<BR/>A record review of the facility's daily census report revealed 9 residents (Residents #2, #5, #6, #10, #16, #20, #21, #28, and #88) were assessed for their needs for dentures. <BR/>A record review of Resident #2's care plan, dated 03/26/2023, revealed a focus on denture care with interventions for denture supports, Problem: Resident has dental concerns AEB: (x ) resident without dentures currently, pt refuses to wear.<BR/>A record review of Resident #5's care plan, dated 03/26/2023, revealed a focus on denture care with interventions for denture supports, Problem: Resident has dental concerns AEB: (x ) resident without dentures currently, pt refuses to wear.<BR/>Residents will be identified on admission, by the charge nurse, if dentures are in place. The ADON will enter the information in the Matrix EMR and Point of Care mechanism. The ADON will also initiate dental care plan.<BR/>During an interview on 03/26/2023 at 10:33 AM the ADON stated she had reviewed all residents for needs for dentures and has assessed 9 residents with dentures to include Residents #2, #5, #6, #10, #16, #20, #28, and #88. The ADON stated she reviewed their care plans for accurate assessment and nursing interventions for the residents related to their needs for dentures. <BR/>Staff have been educated on abuse and neglect, changes in condition by the Administrator and ADON starting on 3/24/2023. IDT has been in-serviced starting on 3/24/2023 by the RNC on Care Planning, MDS completion, and communication with staff on interventions/Point of care EHR documentation. Nursing staff has been educated on denture care, refusals, instructions for wearing dentures and notification of any issues with dentures/missing dentures starting on 3/24/2023 by ADON. Staff will not be allowed to work until they receive training.<BR/>A record review of the facility's in-service titled Change of Condition, dated 03/24/2023, revealed 43 employees were educated for, facility policy title change in the residence condition or status policy statement our facility shall promptly notify the Resident, his or her attending physician, and representative of changes in the Resident's mechanical, mental condition and or status . policy interpretation and implementation; the nurse surveyor charge nurse will notify the resident's attending physician or alcohol physician when there has been . discovery of injuries of unknown source, . a significant change in the residence physical, emotional mental condition .<BR/>A record review of the facility's in-service titled Abuse and Neglect, dated 03/24/2023, revealed 43 employees were educated for, abuse and neglect clinical protocol the nurse will assess the individual and document related findings, assessment data will include injury assessment, all current medications, vital signs . the nurse who report findings to the physician as needed the physicians well let's ask the resident to verify or clarify such finding . reporting abuse to the facility management, policy statement, it is the responsibility of our employees, facility consultants, attending physicians, family members, visitors etcetera, to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to the facility management.<BR/>A record review of the facility's in-service titled Care Planning IDT, dated 03/24/2023, revealed 43 employees were educated for, policy statement her facilities care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each Resident . policy interpretation and implementation . a comprehensive care plan for each resident is developed within seven days have a completion of the resident assessment MDS. the care plan is based on the resident's comprehensive assessment and is developed by care planning introducing [NAME] team which includes, but it's not necessarily limited to the following personnel: the resident attending physician: the registered nurse who has responsibility for the Resident: the dietary manager dietitian: the social services worker responsible for the Resident: the activity director coordinator: therapist speech, occupational, recreational, etcetera, as applicable: the charge nurse responsible for resident care: nursing assistants responsible for the residents care: and others as appropriate or necessary to meet the needs of the Resident. comprehensive care plan . policy statement; an individualized comprehensive care plan that includes measurable objective objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each Resident. policy interpretation and implementation; are facilities care planning in the disciplinary team in coordination with the Resident, is her family or representative, develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning and resident may be expected to attain . the comprehensive care plan is based on a thorough assessment that includes, but it's not limited to the MDS. <BR/>A record review of the facility's in-service titled denture Cleaning and Storing, dated 03/24/2023, revealed 43 employees were educated for, the purpose of this procedure are two cleans and freshen the residents mount, to clean the residence dentures, to prevent infections of the mouth, to protect the residents dentures from breakage when dentures are out of the residents mouth, and to store dentures at bedtime . review the residents care plan to assess for any special needs of the Resident. assemble the equipment and supplies needed loose or poor fitting dentures can cause gum sores and prevent the resident from chewing his or her food properly. if a resident is not chewing his or her food thoroughly report it to your supervisor. encourage the resident to keep dentures in his or her mouth as much as possible. when dentures are left out of the mouth for several days, the bone structure to the mouth changes and the gums will shrink causing the dentures to fit improperly . <BR/>During an interview on 03/26/2023 at 11:10 AM the Human Resources Manager stated she reviewed the employee roster and compared the roster to the in-service roster and stated it was accurate for all of the facility's employees, to include employees who worked during the IJ up to midnight on 03/25/2023. <BR/>Nursing staff received in-service training on documenting physician team contact in the progress notes for each resident as appropriate. Notification to physician of any changes of condition will be noted on the 24-hour report and the facility activity report and will be reviewed by the IDT team at the morning meetings Monday-Friday, and by the Manager on Duty on weekends.<BR/>During an interview on 03/26/2023 at 10:33 AM the ADON stated she received in-service education from the facility's Regional DON to include reporting to the physician and documenting in residents' medical records, the 24- hour report, the facility activity report, any notification to physicians of any changes of conditions, and would be noted on the 24-hour report and the facility activity report, and would be reviewed by the IDT team at the morning meetings Monday-Friday, and by the Manager on Duty on weekends. The ADON stated she and the Regional DON provided in-service training education for all of the facility's, 43 staff, to include reporting to the physician and documenting in residents' medical records, the 24- hour report, the facility activity report, any notification to physicians of any changes of conditions, and will be noted on the 24-hour report and the facility activity report, and will be reviewed by the IDT team at the morning meetings Monday-Friday, and by the Manager on Duty on weekends. The ADON stated the weekend RN and the ADON would in-service staff as needed, new staff, since all staff had been in-serviced by 03/25/2023. <BR/>Upon reporting to work the appropriate in-service will be given to staff before they can begin work. All staff will complete Abuse/Neglect in-service by the Administrator and verified by the RDO. Nursing staff will also complete denture care, requirement for a nurse to be in dining room during meals, physician notification of change of condition, access to care plan in matrix, and update to Point of Care mechanism for CNA/nurse documentation of denture care from the ADON and verified by the Administrator.<BR/>During an interview on 03/26/2023 at 10:11 AM, RN K stated she was the facility's weekend RN supervisor and worked from 06:00 AM to 10:00 PM. RN K stated she had received in-service education to include abuse and neglect, residents' changes in condition, care planning, MDS completion, and communication with staff on interventions/Point of care EHR documentation. RN K stated she and nursing staff had been educated on denture care, refusals, instructions for wearing dentures and notification of any issues with dentures/missing dentures starting on 3/24/2023 by ADON. RN K stated staff would not be allowed to work until they received training. RN K stated she and the ADON would in service staff as needed, new staff, since all staff had been in- serviced by 03/25/2023. <BR/>During an interview on 03/26/2023 at 10:58 AM, the BOM/HR, and MOD as assigned, stated the in-service roster was accurate for employees who worked from the date of the IJ to midnight on 03/25/2023 to include all of the facility's 43 employees. <BR/>During an interview on 03/26/2023 at 11:18 AM, CNA L stated she assisted residents with dressing, eating, toileting and activities of daily life. CNA L stated she received education/in-services for dentures, clean make sure they have them in, don't fit right, refuse, change of condition, refusal to eat drink, s/s of aspiration, and to report everything. <BR/>During an interview on 03/26/2023 at 12:30 PM CNA M stated she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA M stated the facility's electronic record for resident care now included an area where CNAs could now document denture care for residents. <BR/>During an interview on 03/26/2023 at 3:20 PM LVN N stated she worked the 02:00 PM to 10:00 PM shift and occasionally the 10:00 PM to 06:00 AM shift. LVN N stated she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the ADON and/or DON any complications and or concerns with residents and their dentures. LVN N stated the facility's electronic record for resident care now included an area where CNA's could now document denture care for residents and LVN N would inspect the documentation for accuracy and assess residents with dentures prior to and after meals. <BR/>During an interview on 03/26/2023 at 04:53 PM CNA O stated she worked the 10:00 PM to 06:00 PM shift, received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA O stated the facility's electronic record for resident care now included n area where CNA's could now document denture care for residents. CNA O stated she was trained to assess all residents at the beginning of her shift, and throughout the shift for resident's skin conditions, and overall wellbeing, and to focus on residents needs for dentures and denture care to include well-fitting dentures and to report to the nurse any resident's refusal to wear dentures. <BR/>During an interview on 03/26/2023 at 04:54 PM CNA P stated worked she worked 02:00 to 10 :00 PM and she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA P stated the facility's electronic record for resident care now included an area where CNA's could now document denture care for residents. CNA P stated she was trained to assess all residents at the beginning of her shift, and throughout the shift for residents' skin conditions, and overall wellbeing, and to focus on residents needs for dentures and denture care to include well-fitting dentures and to report to the nurse any resident's refusal to wear dentures. <BR/>During an interview on 03/26/2023 at 05:01 PM CNA Q stated she worked 06:00 PM to 06:00 AM and she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA Q stated the facility's electronic record for resident care now included an area where CNAs could now document denture care for residents. CNA Q stated she was trained to assess all residents at the beginning of her shift, and throughout the shift for residents' skin conditions, and overall wellbeing, and to focus on residents needs for dentures and denture care to include well-fitting dentures and to report to the nurse any resident's refusal to wear dentures. <BR/>During an interview on 03/26/2023 at 06:00 PM LVN R stated she has been in serviced for main issue to assess residents for dentures, and to assess residents for refusals to eat and assess for ill-fitting dentures, and to inspect delegation of care to CNAs for resident denture care. LVN R stated she would assess CNAs for assistance with resident care to include eating and oral care. LVN R stated she had worked double shifts from 06:00 AM to 10:00 PM, but usually worked the 06:00 AM to 2:00 PM shift. <BR/>During an interview on 03/26/2023 at 06:10 PM LVN B stated she had been in service for main issue to assess residents for dentures, and to assess residents for refusals to eat and assess for ill-fitting dentures, and to inspect delegation of care to CNAs for Resident denture care. LVN B stated she would assess CNAs for assistance with Resident care to include eating, and oral care. LVN R stated she has worked double shifts from 06:00 AM to 10:00 PM, but usually works the 06:00 to 2:00 PM shift. also, in serviced on documenting SBARS and reviewing residents care plans for accuracy, also to report all allegations of suspected ANE and/or mistreatment. <BR/>During an interview on 03/26/2023 at 06:16 PM CNA E stated she had been in-serviced for has received education in services any changes of conditions and report to the charge nurse, the ADON, and if ANE, mistreatment, and or injuries of unknown origin to the nurse, ADON, and to include the Administrator. CNA E stated the CNA documentation screen for residents now included a care plan for residents who had dentures. CNA E stated she usually worked the 02:00 PM to 10:00 PM shift and had worked the 10:00 PM to 06:00 AM shift. <BR/>All in-service and training will be completed by 3/25.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized, for 1 of 24 residents (Resident #30) reviewed for accurate medical records, in that:<BR/>LVN A failed to document an order for a urinalysis laboratory test ordered for Resident #30.<BR/>This failure could place residents at risk for harm by inaccurate records.<BR/>The findings included:<BR/>A record review of Resident #30's Face Sheet, dated 03/22/2023, revealed an admission date of 01/06/2022, with diagnosis which included obstructive and reflux uropathy [a condition when the passage of urine from the kidneys to the exterior is blocked by an obstruction anywhere along the urinary tract].<BR/>A record review of Resident #30's quarterly MDS, dated [DATE], revealed Resident #30 was an [AGE] year-old female assessed with severe mental cognition impairment, as evidenced by a Brief Interview for Mental status score of 05 out of 15. Resident #15 was assessed with the need for total assistance with activities of daily life to include toileting. Further review revealed Resident #30 was assessed as always incontinent of bowel and bladder. <BR/>A record review of Resident #30's care plan, dated 03/22/2023, revealed, problem activities of daily life self-care deficit: requires assistance; total staff performs / provides total assistance; will be clean, dry and free form odors with dignity maintained throughout next quarter; approach document activities of daily life performance staff assistance as per policy, notify charge nurse of change in ability . <BR/>During an observation on 03/21/2023 at 12:16 PM, revealed an empty 4 oz. specimen cup with Lids & ID Label, on the sink counter of Resident #30's bedroom. Further observation revealed the specimen cup label read, UA [urinalysis] 03/20/2023, [Resident #30], [Dr. T ].<BR/>A record review of Resident #30's physician's order summary, dated 03/22/2023, revealed no order for a urinalysis laboratory for Resident #30.<BR/>During an interview on 03/22/2023 at 01:10 PM, LVN A stated she called Dr. T, on 03/20/2023, and gave a SBAR for Resident #30's change of condition with a fever and altered mental status. LVN A stated Dr. T gave her an order to obtain a urinalysis for Resident #30. LVN A stated she failed to document the order in Resident #30's medical record . LVN A stated the failure placed Resident #30 at risk for inaccurate records. LVN A stated inaccurate records denied interdisciplinary team members information needed for quality care for residents. <BR/>During an interview on 03/24/2023 at 04:40 PM the ADON stated physician's orders should always be documented in the resident's medical record as soon as the order had been received. The ADON stated the documentation of the order was critical to quality care for residents. The AND stated the nurses needed orders documented to ensure nursing practice within their scope of duty. The ADON stated inaccurate records denied interdisciplinary team members information needed for quality care for residents.<BR/>A record review of the facility's policy regarding recording/documenting physicians' orders was requested, from the Administrator, on 03/22/2023 at 02:16 PM. As of 03/26/2023 at 04:30 PM a policy was not provided and the Regional DON stated the facility followed the CMS and state regulations/guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles, for 1 of 1 Activities Director Care Plan Coordinator, reviewed for training as the care plan coordinator, in that:<BR/>The facility failed to train the Activities Director in the assigned job as the care plan coordinator.<BR/>This failure could place residents at risk for harm by not having a complete and accurate care plan to support the residents needs and preferences. <BR/>The finding included:<BR/>A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care.<BR/>A record review of Resident #2's hospital discharge records, dated 02/26/2023, revealed history of present illness; chief complaint; altered mental status, low oxygen level, and foreign body(dentures) in esophagus . this is a [AGE] year-old white female brought by emergency medical services 2[name of hospital] emergency room on the evening of 02/21/2023 for recurrent episodes of aspiration associated with shortness of breath for two days prior to presentation. the patient is unable to provide any history due to cognitive impairment at baseline . the patient was sent 2 . emergency room by care staff at the skilled nursing facility where the patient resides for two episodes of food aspiration for two days prior to presentation. the patient had one episode of food aspiration on 02/20/2023 and a second episode of food aspiration on 02/21/2023. her second episode was more severe and associated with significant coughing and choking. care staff reports gradual onset of worsening shortness of breath for approximately 2 days prior to presentation . the patient was noted to meet criteria for sepsis with elevated heart rate, elevated temperature, and elevated white blood cell count. the patient was found to have a bacterial source in the form of bilateral aspiration pneumonia . X-ray of the soft tissues of the neck performed at the emergency room showed a U-shaped foreign body noted within the cervical esophagus consistent with dentures. upon further inspection of the patient, the patient's upper dentures were accounted for but the patient's lower dentures were not. because of these findings, the patient . has been transferred to a higher-level of care for further medical management and evaluation, including an ear nose and throat specialist consultation findings of foreign body and cervical esophagus . foreign body dentures removed by medical doctor and ear nose and throat specialist this morning after locating object in hypopharynx and extending into the cervical esophagus .<BR/>A record review of Resident #2's re-entry and quarterly MDS's, dated 02/27/2023 revealed the Regional MDS LVN documented in section A0310 type of assessment 99 which indicated none of the above. Further review of section A0310 revealed the choices were 01. Admission, 02. Quarterly, 03. Annual, 04. Significant Change in Status, 05. Significant Correction to prior comprehensive assessment, 06. Significant correction to prior quarterly assessment, and 99. None of the above. Further review revealed the MDS assessment was not signed by a RN. <BR/>A record review of Resident #2's quarterly MDS's, dated 03/01/2022, revealed the Regional DON assessed Resident #2 as returned from an acute care hospital on [DATE]. The MDS assessment revealed Resident #2 was severely impaired for cognition, and was assessed as needing limited assistance and supervision during meals. Resident #2 was diagnosed with pneumonia, loss of liquids / solids from mouth when eating or drinking, and required a change in textures of food and liquids. Review of the MDS section L revealed no documentation for the assessment broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose). <BR/>A record review of Resident #2's physical paper chart revealed a Care Plan worksheet, dated 01/11/2023, which documented the attendees as the Activities Director [AD] and the Director of Rehabilitation [DOR]. The document revealed there was a concern made by Resident #2's representative for Resident #2's bottom dentures. Further review revealed no documents to reveal any subsequent care plan meetings. <BR/>A record review of Resident #2's Care Plan, dated, 01/13/2023, revealed no focuses, interventions, and/or care instructions for Resident #2's needs for dentures. Review of Resident #2's care plan revealed 1 care instruction, Resident [#2] is at risk for falls due to amputation and weakness . Resident [#2] will be free of falls through next review . encourage call light usage . increased staff supervision with intensity based on Resident [#2] need. Further review of Resident #2's medical records evidenced no further care plans other than the 01/13/2023 care plan. <BR/>During an interview on 03/24/2023 at 10:40 AM the AD stated she was assigned by the ex-DON to help as a CNA and as a Care Plan Coordinator. The AD stated she had not been trained for the duty as the care plan coordinator and did not understand the care plan coordinator was responsible to invite the IDT to participate in the development of the care plan. The AD stated there were many times she and the DOR] were the only persons involved with preparation of the residents' care plans. The AD stated she was not aware a nurse was responsible to help coordinate the care plan with assessments and care recommendations from different IDT members. The AD stated she was not aware an RN needed to sign off on the care plan. The AD stated she did not know how to update the care plan in residents' records. The AD stated Resident #2's care plan meeting, on 01/11/2023, was attended by Resident #2, her representative, and the DOR only. The AD stated the care plan meeting addressed Resident #2's representative's concern for loose fitting dentures to which she [the AD] reported to the Administrator in the next leadership morning meeting. The AD stated she had no documentation to support her report to the leadership at the morning meeting. The AD stated she was not aware Resident #2 had no care supports in her care plan for dentures. <BR/>During an interview on 03/23/2023 at 01:55 PM, the Regional MDS LVN stated she was the MDS coordinator for the facility intermittingly. The Regional MDS LVN stated she had been helping periodically per the facility's needs with Resident assessments and would be alerted by the facility for the need for an MDS assessment. The Regional MDS LVN stated she had completed the MDS assessment for Resident #2 on 02/27/2023 and documented the assessment section as 99 and did not document the assessment as a change of status. The Regional MDS LVN stated she was not aware of Resident #2's change of status and her hospitalization for swallowing her dentures with a diagnosis of sepsis pneumonia. The Regional MDS LVN stated she was not assigned to follow the MDS with care plans and the duty was assigned to someone at the facility by the Administrator possibly ADON S [ADON S from another facility] who helped at the facility or the Regional DON. <BR/>During an interview on 03/24/2023 at 04:50 PM, the Regional DON stated a care plan is prepared by the Interdisciplinary Team [IDT] per the MDS assessment within 7 days of the completed MDS assessment. The Regional DON stated she had completed the quarterly MDS for Resident #2 on 03/01/2023 and did not document an assessment for Resident #2's oral / dental status under section L, broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose) mouth or facial pain, discomfort or difficulty with chewing. The Regional DON stated she did not know if Resident #2's dentures were or were not loose fitting and after her discharge from the hospital there were no reports of Resident #2 having swallowing issues. The Regional DON stated she was responsible for 5 other facility's and was on call for all 5. The Regional DON stated she was not in the facility for 40 hrs. a week. The Regional DON stated she had not coordinated a care plan for Resident #2's change of status for her needs with dentures and assistance supervision during meals within 7 days of the 02/27/2023 re-admission from the hospital or within 7 days of the 03/01/2023 quarterly MDS assessment. The Regional DON stated there should have been care instructions in Resident #2's care plan to reflect Resident #2's needs for support with her dentures and assistance with meals to include diet textures and swallow studies as assessed by the Speech Language pathologist [SLP] who was an IDT member.<BR/>During an interview on 03/24/2023 at 04:32 PM the Administrator stated the ex-DON resigned in October 2022 and since then the corporate regional nursing support staff, to include the Regional DON, the Regional DON I, the Regional Director of Quality, and the Regional MDS nurse, were all involved with the facility's nursing services while the search for a replacement DON ensued. The administrator stated he relied on the corporate regional nursing support staff for the daily continuation of nursing services. The administrator stated the facility policy is to provide an accurate and comprehensive MDS assessments to include care plan development and implementation upon admission, change in conditions, and at a minimum, quarterly. The Administrator stated this was not done as evidenced by Resident #2's MDS assessments and care plan which do not support Resident #2 with her denture needs. The Administrator stated if he had been given a report from nursing staff, that MDS assessments were incomplete, care plans were not performed as required, he would have ensured gaps in nursing services were addressed. <BR/>A record review of the facility's policy admission Assessment and Follow Up: Role of the Nurse, dated December 2012, revealed, The purpose of this procedure is to gather information about the residents physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the Resident, initiating the care plan, and completing required assessment instruments, including the MDS . steps in the procedure . conduct a physical assessment, including the following systems: eyes, ears, nose, throat; teeth and gums . contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtained admission orders that are based on these findings . notify the supervisor and the attending physician of immediate needs that the resident may have . report other information in accordance with facility policy and professional standards of practice.

Based on interview and record review, the facility failed to designate a registered nurse (RN) to serve as DON on a full-time basis in that:<BR/>- <BR/>The facility had no full time Director of Nurses (DON) from October of 2022 through present [3/22/23]. <BR/>This failure could place all residents at risk for not receiving necessary care and services.<BR/>The findings included:<BR/>Record review of facility policy on Director of Nursing Services revealed that the Director is employed full-time at 40-hours per week.<BR/>In an interview on 3/21/23 at 11:28 AM, the ADON stated there was no DON at the facility, and she believed the regional DON was the acting DON. <BR/>In an interview on 3/21/23 at 3:20 PM, the Administrator stated the facility had no full time DON and the corporate regional RN's assisted with nursing services.<BR/>In an interview on 3/24/23 at 1:10 PM the Regional DON stated the facility had no full-time designated DON. The regional DON stated she was not in the facility for 40 hours a week and occasionally was in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 24 Residents (Resident #13) reviewed for injuries of unknown origin, in that:<BR/>The facility failed to report an injury of unknown origin to the state agency when Resident #13 was discovered with a large bruise over her chest and around her back . Resident #13 could not state how she developed the bruise, and no one witnessed the development of the bruise. <BR/>This failure could place residents at risk for harm by not reporting, not investigating and providing for oversight of the investigation to reveal the possible source of the injury.<BR/>The findings included :<BR/>A record review of Resident #13's Face Sheet, dated 03/22/2023, revealed an admission date of 09/25/2015, with diagnoses which included Alzheimer's disease [a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks]. <BR/>A record review of Resident #13's quarterly MDS, dated [DATE], revealed Resident #13 was [AGE] year-old female who was cognitively severely impaired and rarely understood others and rarely could make herself understood. Further review revealed Resident #13 had a need for extensive assistance with transfers and activities of daily life, to include the use of a wheelchair and a Hoyer lift device [a mobility tool used to help seniors with mobility challenges get out of bed or the bath]. <BR/>A record review of the Resident #13's care plan, dated 03/22/2023, revealed the resident was at risk for skin injuries due to fragile skin and had a goal in place to have a minimized risk for bruising . <BR/>A record review of Resident #13's medical record Incident Accident Report, dated 03/20/2023, authored by the ADON, revealed, Reported per CNA to this nurse [ADON] large purple hematoma to the right back torso area traveling to the front of torso discoloration noted no swelling or open areas patient has contractures and is hard to turn noted patient is on aspirin daily patient in no distress resting comfortably vitals within normal limits injury report initiated in service staff as to how to turn patient and use Hoyer lift on patient if needing to get her out of bed floor nurse aware administrator also made aware no other injury noted will continue to monitor patient closely and staff as to how to handle brittle patient.<BR/>A record review of the TULIP website accessed 03/22/2023, revealed no report for Resident #13's injury of unknown origin. <BR/>During an interview on 03/22/2023 at 01:22 PM LVN A stated she was alerted by CNA E to a bruise on Resident #13. LVN A stated she assessed Resident #13 with a large bruise from Resident #13's chest to around her back. LVN A stated she immediately reported the injury to the ADON. LVN A stated she reported to the ADON that Resident #13 could not state how she developed the bruise and no one had reported witnessing an event to produce the injury. <BR/>During an interview on 03/22/2022 at 02:15 PM CNA E stated she discovered a large bruise on Resident #13 on Monday 03/20/2023 when she was providing incontinent care for Resident #13. CNA E stated Resident #13 was not able to state how she came to have the bruise. CNA E stated she reported the bruise to the charge nurse LVN A. <BR/>During an interview on 03/24/2023 at 02:14 PM the ADON stated she was alerted to a bruise on Resident #13 by LVN A and CNA E. The ADON stated she initiated an accident incident report and reported the injury to the Administrator. The ADON sated the injury was unwitnessed and the source was unknown, but the ADON believed she could speculate how the injury came to be. The ADON stated she believed the injury came from a caregiver not properly utilizing the Hoyer lift and thus bruised Resident #13. The ADON stated she did not report the injury to the state and/or the Administrator as an injury of unknown origin. <BR/>During an interview on 03/24/2023 at 04:45 PM the Administrator stated he received a report of Resident #13's bruise on 03/20/2023 and the source of the bruise was due to a caregiver, possibly a can, not properly utilizing the Hoyer lift. The Administrator stated he believed the ADON had direct knowledge of the source of the bruise and not speculation. The Administrator stated it was the facility's policy to report all injuries of unknown origin. The Administrator stated he had not reported the injury of unknown origin for Resident #13 to the state agency . <BR/>A record review of the facility's policy Reporting Abuse to Facility Management, dated February 2014, revealed, it is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etcetera, to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source . policy interpretation and implementation . to help with recognition of incidents of abuse, the following definitions of abuse are provided: injury of unknown source is defined as an injury that meets both of the following conditions: the source of the injury was not observed by any person or the source of the injury could not be explained by the Resident: and the injury is suspicious because of the extent of the injury; or the location of the injury, for example the injury is located in an area not generally vulnerable to trauma; or the number of injuries observed at one particular point in time; or the incidence of injuries overtime.

Based on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment requirement, for 1 of 1 kitchen staff (Food Service Manager) reviewed for qualifications, in that: <BR/>- <BR/>The Dietary Manager did not have the appropriate license, certification, or qualifications to function as the food service supervisor. <BR/>This failure could place all residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition. <BR/>The findings included:<BR/>Record review of the certifications obtained by facility kitchen staff revealed that the FSM did not have the certification required for her current position.<BR/>In an interview on 3/25/23 at 10:20 AM, the FSM revealed she does not have the certification required for her current position. She explained she did not have the time to take the test as she is not able to take time off from the facility due to a staffing shortage. <BR/>In an interview on 3/25/23 at 11:28 AM, the ADON stated she was not aware the FSM did not have the certifications required for her position.<BR/>In an interview on 3/25/232 at 11:37 AM, the Administrator stated that he was aware that the FSM did not have the certifications required for her position. The administrator stated that the facility had attempted to hire FSM's but have not had success.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a minimum of 80 square feet per resident for residents in 9 of 9 multiple occupancy resident rooms (Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317).<BR/>Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317 did not have the required 80 square feet per resident.<BR/>These failures could affect the residents placed in these multiple occupancy rooms and place them at-risk by reducing their living space and posing problems in their activities of daily living.<BR/>The findings were:<BR/>Record review of Form 3740 Bed Classifications, completed by the Administrator on 2/26/2020, revealed rooms 109, 111, 112, 201, 204, 209, 211, 315 and 317 were classified to have 3 resident beds in each room.<BR/>Observation on 02/26/2020 from 11:00 AM to 11:17 AM with the Maintenance Director revealed the measurements of the rooms 109, 111, 112, 201, 204, 209, 211, 315 and 317 were as follows:<BR/>1. room [ROOM NUMBER] (3 person room - 2 residents in room) 14.9 ft x 14.83 ft = 221.7 sq ft / 3 residents = 73.9 sq. ft/resident<BR/>2. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.9 ft x 14.75 ft = 220.9 sq ft / 3 residents = 73.6 sq. ft/resident<BR/>3. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.75 ft x 15 ft = 221.3 sq ft / 3 residents = 73.8 sq. ft/resident<BR/>4. room [ROOM NUMBER] (3-person room - 1 resident in room) 14.83 ft x 15 ft = 222.4 sq ft / 3 residents = 74.2 sq. ft/resident<BR/>5. room [ROOM NUMBER] (3-person room - 2 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident<BR/>6. room [ROOM NUMBER] (3-person room - 2 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident<BR/>7. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.9 ft x 14.75 ft = 219.8 sq ft / 3 residents = 73.3 sq. ft/resident<BR/>8. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.9 ft x 14.9 ft = 222.0 sq ft / 3 residents = 74 sq. ft/resident<BR/>9. room [ROOM NUMBER] (3-person room - 0 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident<BR/>In an interview on 03/21/23 at 2:27 PM the Administrator stated the facility continues with the room waiver for the rooms less than regulation size. The administrator stated they did not have any plans to increase the number of occupants in each room to 3 at this time.<BR/>Interview on 3/22/23 at 11:08 AM the maintenance director stated that the facility continues to utilize the room size waiver. The maintenance director stated there have been no changes since last year [2022].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #1) whose records were reviewed for infections.<BR/>The facility failed to follow protocols when Resident #1 was diagnosed with Salmonella:<BR/>a. There was not a physician's order or a sign on Resident #1's room to inform nursing staff and others he was on contact precautions for an infection.<BR/>b. The ADM and DON did not contact the local state authority or HHSC to report Resident #1 was diagnosed with Salmonella.<BR/>These deficient practices could affect any resident and contribute to the spread of infections.<BR/>The findings were:<BR/>Review of Resident #1's face sheet, dated 3/7/24, revealed he was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation (an irregular and often very rapid heart rhythm.) and Hyperlipidemia (elevated lipid levels within the human body). Further review revealed Resident #1 was discharged from the facility on 3/1/24.<BR/>Review of Resident #1's admission MDS, dated [DATE], revealed Resident #1's BIMS was 11 reflecting moderate cognitive impairment. Further review did not reveal he had an existing infection.<BR/>Review of Resident #1's Care Plan, dated, 1/28/24, revealed Resident #1 had diarrhea related to Salmonella (most commonly cause diarrhea illness). and was on contact precautions.<BR/>Review of Resident #1's consolidated physician orders for February 2024 did not reveal an order for isolation or contact precautions related to diagnosis of Salmonella. <BR/>Review of hospital lab report dated, 12/24/23 revealed Resident #1 was detected with Salmonella sp (most commonly cause diarrhea illness. Other types of Salmonella - Salmonella Typhi and Salmonella Paratyphi - cause typhoid fever and paratyphoid fever).<BR/>Review of hospital lab report dated, 2/24/23 revealed Resident #1 was detected with Salmonella sp.<BR/>Review of an Infection Event Summary Report [DATE] to [DATE] revealed Resident #1 was diagnosed with Gastroenteritis infection on 12/27/23 and resolved on 12/28/23; then again on 2/26/24. Further review revealed there were no other residents with same the same diagnosis during this time period.<BR/>Review of progress notes from December 2023 to February 2024 revealed the following: <BR/>*12/24/23 at 12:07 PM written by LVN E, indicated Resident #1 had lose stools and sent out to the hospital. <BR/>*12/27/23 at 1440 (2:40 PM) written by LVN F, revealed a new order for Cefpodoxime related to salmonella infection. <BR/>*1/9/24 at 2050 (8:50 PM) written by LVN G indicated Resident #1 received ABT. The MD indicated he did not re-test because Resident #1 did not have any more lose stools and he completed the ABT. Further review revealed Resident #1's family member mentioned Resident #1 was not getting better on the medication. <BR/>*2/18/24 at 2128 (9:28 PM), revealed Resident #1 had signs and symptoms of nausea and diarrhea again. <BR/>*2/20/24 at 13:43 (1:43 PM) written by LVN F, revealed Resident #1 did not have any lose stools. <BR/>*2/21/24 at 1342 (1:42 PM) written by LVN F, revealed NP A assessed Resident #1, and Resident #1's family member requested IV therapy for dehydration and NP A agreed and provided an order. There was also new orders for Zofran (used alone or with other medications to prevent nausea and vomiting) and Loperamide (treat sudden diarrhea) to be administered until 2/29/24. <BR/>Interview on 3/5/24 at 3:30 PM with the DON revealed NP A ordered a stool sample per protocol after Resident #1 had a few episodes of diarrhea upon admission. She stated the diarrhea subsided and then about 1 week later it started again. It was more persistent and lasted for about 4 to 5 days. The DON stated NP A ordered Resident #1 with a full treatment of antibiotics. She further stated the signs/symptoms cleared and then last week or the week before Resident #1 had diarrhea again. The DON stated Resident #1 was diagnosed with salmonella. She stated she learned most recently she was supposed to report it to the local state authority after she received a call from a representative from the local state authority. She was provided with a document with a list of reportable infections and Salmonella was on the list. The DON stated she had been the facility DON as of June 2023 and it was her first DON position. The DON provided the document and further stated it also reflected they should also report the incident to HHSC. She stated it would be the ADM who would report the incident. <BR/>Interview on 3/5/24 at 4:35 PM with the ADM revealed she was responsible for reporting all reportable incidents to HHSC but did not know she had to report a positive infection for salmonella. She stated in the 20 years as an ADM she had never had experienced residents with Salmonella. <BR/>Interview on 3/5/24 at 4:38 PM with CNA B revealed she had worked at the facility for 25 years and remembered Resident #1. She stated Resident #1 had a few episodes of diarrhea upon admission and learned he was diagnosed with an infection: food poisoning. She stated she did not remember Resident #1 being on isolation. <BR/>Interview on 3/5/24 at 5 PM with the DON revealed she was the Infection Preventionist. She stated the purpose for reporting contagious infections to their local health authority would be for accountability, tracking infections in the city that could spread and the local state health department would be able to provide guidance. She stated Resident #1 was placed on contact precautions; placed a sign on the door and a cart with PPE outside of his room. <BR/>Interview on 3/5/24 at 5:27 PM with LVN C revealed she worked 2 to 10 PM for about 1 year. LVN C stated Resident #1 was diagnosed with Salmonella during February 2024. She stated Resident #1 was not placed on contact isolation but stated he was on contact precautions; standard precautions. However, there were no signs on Resident #1's door he was on contact precautions.<BR/>Interview on 3/7/24 at 11:38 AM with the DON revealed she provided nursing staff a verbal order that Resident #1 was on contact precautions but she did not enter it into Resident #1's consolidated orders which would let nursing staff he was on contact precautions. The DON stated she should have entered the orders to ensure nursing staff that were not present at the time were aware and would take the necessary precautions. <BR/>Interview on 3/5/24 at 12:41 PM with LVN D revealed she had worked in the facility for 33 years. She stated Resident #1 was tested after he started having diarrhea and was diagnosed with food poisoning, Salmonella. He was put on antibiotic. LVN D stated Resident #1 was on standard precautions but there was not a sign on the door reflecting he was on standard precautions related to an infection. She stated nursing staff protocol was to always use standard precautions. However, it was protocol required a sign to let nursing staff Resident #1 had an active infection. This also served the purpose to letting nursing staff to monitor and document on the resident's condition.<BR/>Review of facility policy, Infection Prevention and Control Program, revised on 1/1/24 read: This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precaution, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. Surveillance: b. The infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings to the facility's Quality Assessment and Assurance Committee. c. The RNs and LPs participate in surveillance through assessment of residents and reporting changes in condition to the resident's physician and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. <BR/>Review of Texas Notifiable Conditions-2024 provided by the Texas Department of State Health Services revised 11/28/23 read Report all Confirmed and Suspected cases, Salmonellosis, including typhoid fever within 1 week.<BR/>

Based on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment requirement, for 1 of 1 kitchen staff (Food Service Manager) reviewed for qualifications, in that: <BR/>- <BR/>The Dietary Manager did not have the appropriate license, certification, or qualifications to function as the food service supervisor. <BR/>This failure could place all residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition. <BR/>The findings included:<BR/>Record review of the certifications obtained by facility kitchen staff revealed that the FSM did not have the certification required for her current position.<BR/>In an interview on 3/25/23 at 10:20 AM, the FSM revealed she does not have the certification required for her current position. She explained she did not have the time to take the test as she is not able to take time off from the facility due to a staffing shortage. <BR/>In an interview on 3/25/23 at 11:28 AM, the ADON stated she was not aware the FSM did not have the certifications required for her position.<BR/>In an interview on 3/25/232 at 11:37 AM, the Administrator stated that he was aware that the FSM did not have the certifications required for her position. The administrator stated that the facility had attempted to hire FSM's but have not had success.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: <BR/>The facility failed to ensure proper food storage of dry goods and fresh produce.<BR/>This failure could place all residents who consume food prepared from the kitchen at increased risk of food borne illness. <BR/>The findings included:<BR/>Observation on 3/21/23 at 11:09 AM revealed a 10-pound box labeled imitation bacon bits open, undated, in a dry storage area in the kitchen. Upon further investigation, box appeared open with bag full of red flakes approximately 3 cm in diameter, and the bag is open.<BR/>Observation on 3/22/23 at 9:11 AM revealed a box labeled Idaho potatoes unlabeled and on the floor of a dry storage area in the kitchen. Fresh produce resembling potatoes observed through holes in box. <BR/>In an interview on 3/25/23 at 10:20 AM, the FSM stated that boxes should be dated with either markers or stickers. She stated that the items in the box labeled imitation bacon bits should have been in a sealed plastic container. She then stated that there should not have been anything on the floor in the kitchen or storage rooms. <BR/>Record review of Food Storage Policy, undated, stated Food in designated dry storage areas shall be kept off the floor,. The food policy stated on dry foods stated Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 3 resident (Resident #6) reviewed for incontinent care. <BR/>CNA G failed to spread and clean within Resident #6's labial folds after an incontinent episode. <BR/>This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. <BR/>The findings were:<BR/>Record review of Resident # 6's electronic face sheet dated 05/17/2024 reflected she was admitted to the facility on [DATE]. The resident's diagnoses included: cerebral infarction (damage to tissues on the brain due to a loss of oxygen to the area), dementia (loss of memory, language, problem-solving, and other thinking abilities that were severe), hypothyroidism (thyroid gland does not make enough thyroid hormone), neuropathy (weakness, numbness, and pain form nerve damage), and glaucomatous flecks (disease that damages eye). <BR/>Record review of Resident #6's quarterly MDS, dated [DATE], indicated she did not have a BIMS score which she had impaired cognition. The MDS also indicated Resident #6 was always incontinent for bladder and bowel. <BR/>Observation on 05/15/2024 at 4:55 p.m. revealed while providing incontinent care for Resident #6, CNA G cleaned the perineal area and did not separate and clean between the labial folds. <BR/>In an interview on 05/15/2024 at 5:14 p.m. CNA G revealed she was supposed to open and clean the labia (labia minor-inner fold) and confirmed she did not. CNA G stated she was supposed to clean between the folds to remove germs and prevent infections. <BR/>In an interview with the RNC on 05/15/2024 at 5:20 p.m., the RNC said that during incontinent care the labial folds need to be cleaned to make sure they are properly cleaned and to remove any bacteria in the area. <BR/>Record Review of annual skills check for CNA G revealed CNA G passed competency for Perineal care/incontinent care on 03/27/2024.<BR/>Record review of the facility policy, titled Perineal care, revised 10/2010, revealed Steps in the Procedure . 9. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back (1) Separate labia and wash area downward from front to back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that when the facility anticipated discharge, a resident must have a discharge summary that included, but was not limited to, the following: A recapitulation of the resident's stay that included, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for 1 of 3 (#31) closed records.<BR/>Resident #31's discharge summary was not signed by a physician. <BR/>This could affect all discharge residents and could result in record errors. <BR/>The Findings were:<BR/>Record review of Resident #31's face sheet dated 5/17/2024 revealed she was admitted on [DATE] and discharged on 2/27/2024.<BR/>Record review of Resident #31's discharge MDS dated [DATE] reflected this was a planned discharge, to home/community and she was cognitively intact. <BR/>Record review of Resident #31's Discharge summary dated [DATE] revealed Resident #31 went home with home health and no physician signature or date. <BR/>Record review of Resident #31's progress note date 2/27/2024 reflected she was discharged home on home health. <BR/>In an interview on 5/17/24 at 4:36 PM with the RN corporate MDS nurse stated she was not sure why the discharge summary for Resident #31 did not have a physician signature. She stated she would investigate it, but no response before exit. <BR/>In an interview on 5/17/2024 at 5 PM with ADM stated she did not have a policy for resident discharge summary.

Based on observation, interview, and the facility failed to ensure garbage was disposed of properly for 1 of 1 facility, in that: <BR/>The area near the facility's two dumpsters was on dirt and not concrete slab . <BR/>This deficient practice could lead to an unsanitary environment and encourage the presence of pests. <BR/>The findings were: <BR/>Observation on 5/13/2024 at 10:02 AM., of the area near the facility's 2 dumpsters reflected there were on dirt and not concrete slab. Observation of a concrete slab big enough for 1 dumpster near the 2 dumpsters. <BR/>Interview on 5/14/2024 at 10:03 AM with the DM stated the 2 dumpsters had been moved to a dirt ground due to only had room for 1 dumpster on a concrete slab. DM was not sure how long the 2 dumpsters were moved to the dirt. <BR/>Interview on 5/16/2024 at 5:33 PM with ADM stated she was not aware of the 2 dumpsters in dirt, instead of a concrete slab. ADM stated no policy on dumpsters that required to be on concrete slab.<BR/>Record review of FDZ Food code, 5-5 Refuse, Recyles, and Returnables section- 5-501.11 Outdoor Storage Surface. An outdoor storage surface for REFUSE, recyclables, and returnables shall be <BR/>constructed of nonabsorbent material such as concrete or asphalt and shall be SMOOTH, durable, and sloped to drain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to ensure each resident receives and the facility provides-Food that accommodates resident preferences for 5 of 16 (#13, #17, #18, #24 and #29) reviewed for preferences, in that: <BR/>Residents #13, #17, #18, #24 and #29 were not served their preferences. No documentation of dietary assessment with preferences. <BR/>This could affect all residents with food preferences and could result in a decrease in resident choices and diminished interest in meals. <BR/>The Findings were:<BR/>Interview on 5/14/2024 at 1:35 PM in a group meeting, Resident #13, #17, #24 and #29 stated they preferred fried eggs and Resident #18 preferred hard-boiled eggs for his chef salad. <BR/>1. Record review of Resident #13's face sheet dated 5/16/2024 reflected she was admitted on [DATE], re-admitted on [DATE] she was [AGE] years old. <BR/>Resident #13 Quarterly MDS dated [DATE] reflected she had a BIMS score of 9/15 (moderate cognitive impairment). <BR/>Record review of Resident #13's food preference assessment was dated 9/29/2021, reflected no preference at this time. <BR/>Record review of Resident #13's care plan dated 2/27/2024 reflected no food preferences.<BR/> Record review of Resident # #13's diet card reflected under notes section no eggs. <BR/>2. Record review of Resident #17's face sheet dated 5/16/2024 reflected she was admitted on [DATE], re-admitted on [DATE], she was [AGE] years old.<BR/> Resident #17's Quarterly MDS dated [DATE] reflected she has a BIMS score of 12/15 (moderate cognitive impairment). <BR/>Record review of Resident #17's care plan dated 2/27/2024 reflected no food preferences. <BR/>Record review of #17's chart revealed no food preference assessment. Record review of Resident # #17's diet card reflected under notes section: fried eggs . <BR/>3. Record review of Resident #18's face sheet dated 5/14/2024 reflected he was admitted to the facility on [DATE]. <BR/> Record review of Resident #18's Quarterly MDS assessment was dated 3/21/2024 reflected his BIMs scored was 10/15 (moderate cognitive impairment).<BR/>Record review of Resident #18's care plan dated 5/16/2024 reflected no food preferences for eggs. <BR/>Resident #18's chart revealed no food preference assessment.<BR/> Record review of Resident # #18's diet card reflected under notes section extra eggs. <BR/>4.Record review of Resident #24's face sheet dated 5/16/204 reflected she was admitted on [DATE], re-admitted on [DATE], she was [AGE] years old.<BR/>Resident #24's quarterly MDS dated [DATE] reflected she had a BIMS score of 9/15 (moderate cognitive impairment). <BR/>Record review of Resident #24's care plan dated 2/27/2024 chart revealed no food preference assessment. <BR/>Record review of Resident # #24's diet card reflected under notes section, no preferences. <BR/>5. Record review of Resident #29 face sheet dated 5/16/2024 reflected he was admitted on [DATE], he was [AGE] years old. <BR/>Resident #29's admission MDS dated [DATE] reflected he had a BIMS score was 9/15 (moderate cognitive impairment).<BR/> review of Resident #29's care plan reflected no food preferences for eggs. Resident #29's chart revealed no food preference assessment. <BR/>Record review of Resident # #29's diet card reflected under notes section scrambled eggs.<BR/>Interview on 5/14/2024 at 9:51 AM with the DM stated there were 2 (#29, #17) residents that he could think of that prefer fried eggs for breakfast. The DM stated he did not do any Resident Food Preference assessments, since he started working on 2/1/2024. <BR/>Interview on 5/16/2024 at 11 AM ADM stated the dietary manager required to be certified. The ADM stated dietary manger was promoted on 2/1/2024. The ADM stated the regional staff and she had gone in kitchen random times and has trained the dietary manager. ADM did respond to who and why the resident preferences were not completed. The ADM did not provide dietary assessment/preferences policy.

Based on interviews and record review, the facility failed to employ or contract with a qualified social worker for a facility of 120 beds or less for 1 of 1 facility in that:<BR/>The facility failed to ensure an employed or contracted social worker visited the facility as needed.<BR/>This failure could place all residents at risk for not receiving necessary social services. <BR/>The findings included:<BR/>In an interview on 3/21/23 at 11:28 AM, the ADON stated that the facility did not have a social worker employed, and she was not aware of a contracted social worker.<BR/>In an interview on 3/21/23 at 3:20 PM, the Administrator stated the facility did not have a social worker employed or contracted to come to the facility. The administrator stated they do not have a specific policy on social workers or social services, and the facility follows federal and state regulations as policy.<BR/>In an interview on 3/24/23 at 1:10 PM, the regional DON stated that the facility did not employ or contract a social worker on a full-time or part-time basis. The regional DON stated the facility follows the federal and state regulations as policy. <BR/>Record review of employee roster, undated, revealed there was not a social worker on staff at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 3 resident (Resident #6) reviewed for incontinent care. <BR/>CNA G failed to spread and clean within Resident #6's labial folds after an incontinent episode. <BR/>This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. <BR/>The findings were:<BR/>Record review of Resident # 6's electronic face sheet dated 05/17/2024 reflected she was admitted to the facility on [DATE]. The resident's diagnoses included: cerebral infarction (damage to tissues on the brain due to a loss of oxygen to the area), dementia (loss of memory, language, problem-solving, and other thinking abilities that were severe), hypothyroidism (thyroid gland does not make enough thyroid hormone), neuropathy (weakness, numbness, and pain form nerve damage), and glaucomatous flecks (disease that damages eye). <BR/>Record review of Resident #6's quarterly MDS, dated [DATE], indicated she did not have a BIMS score which she had impaired cognition. The MDS also indicated Resident #6 was always incontinent for bladder and bowel. <BR/>Observation on 05/15/2024 at 4:55 p.m. revealed while providing incontinent care for Resident #6, CNA G cleaned the perineal area and did not separate and clean between the labial folds. <BR/>In an interview on 05/15/2024 at 5:14 p.m. CNA G revealed she was supposed to open and clean the labia (labia minor-inner fold) and confirmed she did not. CNA G stated she was supposed to clean between the folds to remove germs and prevent infections. <BR/>In an interview with the RNC on 05/15/2024 at 5:20 p.m., the RNC said that during incontinent care the labial folds need to be cleaned to make sure they are properly cleaned and to remove any bacteria in the area. <BR/>Record Review of annual skills check for CNA G revealed CNA G passed competency for Perineal care/incontinent care on 03/27/2024.<BR/>Record review of the facility policy, titled Perineal care, revised 10/2010, revealed Steps in the Procedure . 9. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back (1) Separate labia and wash area downward from front to back.

Based on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment requirement, for 1 of 1 kitchen staff (Food Service Manager) reviewed for qualifications, in that: <BR/>- <BR/>The Dietary Manager did not have the appropriate license, certification, or qualifications to function as the food service supervisor. <BR/>This failure could place all residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition. <BR/>The findings included:<BR/>Record review of the certifications obtained by facility kitchen staff revealed that the FSM did not have the certification required for her current position.<BR/>In an interview on 3/25/23 at 10:20 AM, the FSM revealed she does not have the certification required for her current position. She explained she did not have the time to take the test as she is not able to take time off from the facility due to a staffing shortage. <BR/>In an interview on 3/25/23 at 11:28 AM, the ADON stated she was not aware the FSM did not have the certifications required for her position.<BR/>In an interview on 3/25/232 at 11:37 AM, the Administrator stated that he was aware that the FSM did not have the certifications required for her position. The administrator stated that the facility had attempted to hire FSM's but have not had success.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a minimum of 80 square feet per resident for residents in 9 of 9 multiple occupancy resident rooms (Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317).<BR/>Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317 did not have the required 80 square feet per resident.<BR/>These failures could affect the residents placed in these multiple occupancy rooms and place them at-risk by reducing their living space and posing problems in their activities of daily living.<BR/>The findings were:<BR/>Record review of Form 3740 Bed Classifications, completed by the Administrator on 2/26/2020, revealed rooms 109, 111, 112, 201, 204, 209, 211, 315 and 317 were classified to have 3 resident beds in each room.<BR/>Observation on 02/26/2020 from 11:00 AM to 11:17 AM with the Maintenance Director revealed the measurements of the rooms 109, 111, 112, 201, 204, 209, 211, 315 and 317 were as follows:<BR/>1. room [ROOM NUMBER] (3 person room - 2 residents in room) 14.9 ft x 14.83 ft = 221.7 sq ft / 3 residents = 73.9 sq. ft/resident<BR/>2. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.9 ft x 14.75 ft = 220.9 sq ft / 3 residents = 73.6 sq. ft/resident<BR/>3. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.75 ft x 15 ft = 221.3 sq ft / 3 residents = 73.8 sq. ft/resident<BR/>4. room [ROOM NUMBER] (3-person room - 1 resident in room) 14.83 ft x 15 ft = 222.4 sq ft / 3 residents = 74.2 sq. ft/resident<BR/>5. room [ROOM NUMBER] (3-person room - 2 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident<BR/>6. room [ROOM NUMBER] (3-person room - 2 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident<BR/>7. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.9 ft x 14.75 ft = 219.8 sq ft / 3 residents = 73.3 sq. ft/resident<BR/>8. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.9 ft x 14.9 ft = 222.0 sq ft / 3 residents = 74 sq. ft/resident<BR/>9. room [ROOM NUMBER] (3-person room - 0 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident<BR/>In an interview on 03/21/23 at 2:27 PM the Administrator stated the facility continues with the room waiver for the rooms less than regulation size. The administrator stated they did not have any plans to increase the number of occupants in each room to 3 at this time.<BR/>Interview on 3/22/23 at 11:08 AM the maintenance director stated that the facility continues to utilize the room size waiver. The maintenance director stated there have been no changes since last year [2022].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a minimum of 80 square feet per resident for residents in 9 of 9 multiple occupancy resident rooms (Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317).<BR/>Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317 did not have the required 80 square feet per resident.<BR/>These failures could affect the residents placed in these multiple occupancy rooms and place them at-risk by reducing their living space and posing problems in their activities of daily living.<BR/>The findings were:<BR/>Record review of Form 3740 Bed Classifications, completed by the Administrator on 2/26/2020, revealed rooms 109, 111, 112, 201, 204, 209, 211, 315 and 317 were classified to have 3 resident beds in each room.<BR/>Observation on 02/26/2020 from 11:00 AM to 11:17 AM with the Maintenance Director revealed the measurements of the rooms 109, 111, 112, 201, 204, 209, 211, 315 and 317 were as follows:<BR/>1. room [ROOM NUMBER] (3 person room - 2 residents in room) 14.9 ft x 14.83 ft = 221.7 sq ft / 3 residents = 73.9 sq. ft/resident<BR/>2. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.9 ft x 14.75 ft = 220.9 sq ft / 3 residents = 73.6 sq. ft/resident<BR/>3. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.75 ft x 15 ft = 221.3 sq ft / 3 residents = 73.8 sq. ft/resident<BR/>4. room [ROOM NUMBER] (3-person room - 1 resident in room) 14.83 ft x 15 ft = 222.4 sq ft / 3 residents = 74.2 sq. ft/resident<BR/>5. room [ROOM NUMBER] (3-person room - 2 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident<BR/>6. room [ROOM NUMBER] (3-person room - 2 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident<BR/>7. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.9 ft x 14.75 ft = 219.8 sq ft / 3 residents = 73.3 sq. ft/resident<BR/>8. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.9 ft x 14.9 ft = 222.0 sq ft / 3 residents = 74 sq. ft/resident<BR/>9. room [ROOM NUMBER] (3-person room - 0 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident<BR/>In an interview on 03/21/23 at 2:27 PM the Administrator stated the facility continues with the room waiver for the rooms less than regulation size. The administrator stated they did not have any plans to increase the number of occupants in each room to 3 at this time.<BR/>Interview on 3/22/23 at 11:08 AM the maintenance director stated that the facility continues to utilize the room size waiver. The maintenance director stated there have been no changes since last year [2022].

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: <BR/>The facility failed to ensure proper food storage of dry goods and fresh produce.<BR/>This failure could place all residents who consume food prepared from the kitchen at increased risk of food borne illness. <BR/>The findings included:<BR/>Observation on 3/21/23 at 11:09 AM revealed a 10-pound box labeled imitation bacon bits open, undated, in a dry storage area in the kitchen. Upon further investigation, box appeared open with bag full of red flakes approximately 3 cm in diameter, and the bag is open.<BR/>Observation on 3/22/23 at 9:11 AM revealed a box labeled Idaho potatoes unlabeled and on the floor of a dry storage area in the kitchen. Fresh produce resembling potatoes observed through holes in box. <BR/>In an interview on 3/25/23 at 10:20 AM, the FSM stated that boxes should be dated with either markers or stickers. She stated that the items in the box labeled imitation bacon bits should have been in a sealed plastic container. She then stated that there should not have been anything on the floor in the kitchen or storage rooms. <BR/>Record review of Food Storage Policy, undated, stated Food in designated dry storage areas shall be kept off the floor,. The food policy stated on dry foods stated Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date).