GREENVILLE HEALTH & REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care.<BR/>The facility failed to ensure LVN A assessed Resident #1 buttocks after CNA B reported that Resident #1 had skin issues.<BR/>This failure could place residents of risk for not receiving appropriate care and treatment, a decreased quality of life, and pressure ulcers. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 05/22/24, indicated a [AGE] year-old female who initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident #1's diagnoses included peripheral vascular disease (narrowing of arteries that supply blood to your legs and feet), Type 2 diabetes mellitus (chronic condition that affects how your body uses sugar for energy), congestive heart failure (impairment in the heart's ability to fill with and pump blood), and protein calorie malnutrition (not consuming enough protein and calories).<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #1 had a BIMS score of 15, indicating her cognition was intact. The MDS assessment indicated Resident #1 was frequently incontinent of urine and always incontinent of bowel. The MDS assessment indicated Resident #1 required partial/moderate assistance with lower body dressing, taking off footwear and sitting to lying/lying to sitting. Resident #1 was independent with eating, oral hygiene, and personal hygiene. The MDS indicated Resident #1 was at risk for developing pressure ulcers/injuries and did not have any skin problems. <BR/>Record review of Resident #1's comprehensive care plan dated 05/01/23 and revised on 08/28/23, indicated Resident #1 was incontinent of bowel/bladder with interventions for weekly skin checks to monitor for redness, circulatory problems, breakdown, or other skin concerns. The care plan indicated to report any new skin conditions to the physician.<BR/>Record review of Resident #1's order summary report dated 05/22/24, with active orders as of 04/01/24, indicated Resident #1 had an order to perform head to toe skin assessment, document any changes in skin integrity in the medical record on Wednesday for wound prevention/early identification with a start date of 08/16/23. The order indicated to notify the physician with any changes in skin integrity. <BR/>Record review of Resident #1's progress notes dated 04/22/24-05/22/24 did not indicate any documented skin issues.<BR/>Record review of Resident #1's Treatment Administration Record for the month of May 2024, did not indicate she was receiving any treatment to her buttocks. <BR/>Record review of Resident #1' shower sheets dated 05/15/24 and 05/17/24 indicated no change in skin color or condition. <BR/>During an interview on 05/22/24 at 09:29 AM, Resident #1's family member said Resident #1's butt was raw when she arrived at the hospital on Monday, 05/20/22. Resident #1's family member said their concern was that someone should have noticed the bed sore to Resident #1's buttocks since it was large, and they should have been treating it.<BR/>During an interview on 05/22/24 at 12:15 PM, RN D said the nurses checked off the skin assessments on the TAR as completed, if the residents had a change to their skin assessment. The nurses documented it in the progress notes. RN D said she was not the nurse for Resident #1. <BR/>During an observation and interview on 05/22/24 at 1:15 PM, Resident #1 was currently at the local hospital. The hospital nurse said Resident #1 admitted to the hospital with redness and irritation to her buttocks. The hospital nurse turned Resident #1 over and Resident #1 was noted to have redness and irritation to bilateral buttocks and under both buttocks. <BR/>During an interview on 05/22/24 at 2:59 PM, RN E said she was usually Resident #1's nurse, and no one reported to her that Resident #1 had any skin issues. RN E said there was no documentation on the 24-hour report that Resident #1 had any skin issues. <BR/>During an interview on 05/22/24 at 3:24 PM, CNA B said the day she came back to work, she believed it was Sunday 05/19/24, Resident #1 was broke out. She said Resident #1's bottom was raw, and she had asked her what happened since she had no skin issues on Thursday when she last worked. CNA B said she reported it to the charge nurse (unsure of who it was), and the charge nurse instructed her to keep applying cream on her bottom. CNA B said she reported it to ADON C as well on Sunday.<BR/>During an interview on 05/22/24 at 3:44 PM, ADON C said CNA B reported to her Resident #1 had skin breakdown, and she was applying A&D ointment (ointment used as a protective barrier to help protect skin) per the resident's request. ADON C said CNA B told her she had already reported it to the charge nurse. ADON C said she then told CNA B to let her know if they needed to have wound care look at it. ADON C said Resident #1's breakdown should have been documented on Sunday (05/19/24) when it was reported by the CNA to the charge nurse. ADON C said failure to document Resident #1's skin issues could cause them to get a fine or get in trouble. ADON C she had expected the charge nurse to have documented Resident #1's skin issues when it was reported to her so they could monitor for worsening or improvement. ADON C said Resident #1's skin breakdown not being documented could be considered neglect because the nurses would not be able to properly monitor Resident #1's skin breakdown. <BR/>During an interview on 05/22/24 at 4:07 PM, RN A said she was Resident #1's nurse the past weekend. RN A said one of the CNAs reported to her that Resident #1 had excoriation to her buttocks, but the CNA reported to her that the excoriation was like it has been and she was continuing to apply barrier cream. RN A said the way the CNA reported it to her made it seem like it was not a new skin issue. RN A said if it had been a new area to Resident #1's buttock, then she would have assessed the area, completed a skin assessment, contacted the physician, obtained new orders, notified the family, and documented it.<BR/>During an interview on 05/22/24 at 3:36 PM, the Administrator said any skin issues should be referred to the nurse and she expected them to follow their protocol. The Administrator said the DON was responsible for overseeing the skin issues at the facility.<BR/>During an interview on 05/22/24 at 4:11 PM, the Interim DON said when a resident had excoriation there were not necessarily wound care orders given. The Interim DON said she did not believe barrier cream or zinc required a physician's order. The Interim DON said excoriation did not necessarily require documentation. The Interim DON said if the CNA reported that it was raw and peeling then she would have expected the nurse to assess, document and obtain orders if necessary. <BR/>Record review of the facility's Skin Management Policy, indicated . The purpose of the policy is to describe the process steps for identification of patients at risk for the development of pressure ulcers, identify prevention techniques and interventions to assist with the management of pressure ulcers and skin alterations .6. if a change in patient condition occurs such as deterioration in or development of new risk factors or skin alterations, the license nurse notifies the physician, wound team, family or responsible party and documents follow up in the clinical record. The patients plan of care is then updated to reflect the patient's current status and care needs. Communication with the physician, patient and family are documented in the clinical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 3 of 20 residents reviewed for ADLs (Residents #24, Resident #25, and Resident #182).<BR/>The facility failed to ensure Resident #24, and Resident #182 received showers or bed baths as scheduled. <BR/>The facility failed to provide assistance with facial hair removal for Resident #25.<BR/>These failures could place residents at risk of not receiving services and care, and a decreased quality of life.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #24's face sheet dated 02/08/23 revealed an [AGE] year old male initially admitted on [DATE] with diagnoses of pneumonia, unspecified organism (an infection of the lungs), chronic combined systolic (congestive) and diastolic (congestive) heart failure (heart does not pump blood well enough to meet the body's demand for blood and oxygen), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with no behaviors). <BR/>Record review of Resident #24's quarterly MDS assessment with an ARD of 12/30/22 revealed Resident #24 was understood and understood others. The MDS assessment indicated Resident #24 had a BIMS score of 8, indicating cognition was moderately impaired. The MDS assessment indicated Resident #24 required extensive assist for bed mobility, transfer, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence of one person assist for bathing. <BR/>Record review of the care plan last revised on 08/24/22 revealed Resident #24 had a focus of Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner with a goal of resident will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date and resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date and interventions included personal hygiene: extensive assistance, bathing: extensive assistance and provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Resident #24's care plan did not indicate Resident #24 refused ADL care or baths/showers. <BR/>During an observation on 02/06/23 at 12:08 PM, Resident #24 was lying in bed sleeping wearing a hospital gown, hair was messy and disheveled.<BR/>During an observation and interview on 02/07/23 at 9:32 AM, Resident #24 was lying in bed in a hospital gown, hair appeared messy and disheveled. Resident #24 said he had not received a shower or a bed bath since last week. <BR/>During an observation and interview on 02/08/23 at 9:29 AM, Resident #24 was lying in bed wearing a hospital gown, hair appeared messy and disheveled, and he said he still had not received a shower or a bed bath. <BR/>Record review of Resident #24's shower sheets revealed he received showers or bed baths on Tuesday, Thursday, and Saturday. Record review of Resident #24's shower sheets revealed:<BR/>Thursday 01/26/23- shower sheet not signed<BR/>Saturday 01/28/23- no shower sheet was provided by the DON<BR/>Tuesday 01/31/23- no shower sheet was provided by the DON<BR/>Thursday 02/02/23- shower sheet signed refused<BR/>Saturday 02/04/23- no shower sheet was provided by the DON<BR/>Tuesday 02/07/23- shower sheet signed bed bath <BR/>2. <BR/>Record review of a face sheet dated 02/08/23 revealed Resident #182 was a [AGE] year-old male admitted on [DATE] with diagnoses of quadriplegia (paralysis of all four extremities), paroxysmal atrial fibrillation (rapid, erratic heart rate), and neurogenic bladder (bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves).<BR/>Record review of the electronic health record on 02/08/23 revealed Resident #182's MDS assessment was not yet completed. <BR/>Record review of Resident #182's care plan revealed a focus with date initiated of 02/08/23, resident has an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner, goal of resident will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date and resident will participate to the best of their ability and maintain current level of functioning with<BR/>activities of daily living (ADLs) through the next review date, and interventions including dressing: extensive assistance, personal hygiene: extensive assistance, bathing: dependent on staff, and provide shower, shave, oral care, hair care, and nail care per schedule and when needed. <BR/>During an observation and interview on 02/06/23 9:59 AM, Resident #182 said he had not had a shower or a bed bath since he admitted on Friday 02/03/23. Resident #182 was wearing a navy-blue long sleeve shirt. <BR/>During an observation on 02/07/23 at 8:21 AM, Resident #182 was in bed wearing a navy-blue long sleeve shirt. <BR/>During an observation on 02/08/23 at 8:19 AM, Resident #182 was in bed wearing a navy-blue long sleeve shirt crumbs and white particles were all over the shirt. Resident #182 said he still had not received a bed bath or shower. <BR/>Record review of Resident #182's shower sheets revealed only one shower sheet for 02/07/23 and the shower sheet indicated he had a bed bath.<BR/>During an interview on 02/08/23 at 9:45 AM, ADON H said the CNAs do the showers and bed baths. ADON H said there was a shower aide, but if the shower aide was not able to give a shower/bed bath she should let the CNAs on the floor know for them to do it. ADON H said she was responsible for overseeing Resident #24's showers/bed baths. ADON H said she was not aware Resident #24 had not received bed baths/showers. ADON H said she randomly checked with residents and asked them if they were getting their showers/bed baths. ADON H said it was important for the residents to receive showers/bed baths to keep them clean, free of infection, looking good and for overall good health. <BR/>During an interview on 02/08/23 at 10:13 AM, ADON K said the nurses were responsible for making sure the residents received a bed bath/shower. ADON K said she was not aware Resident #182 had not received a shower/bed bath. ADON K said she trusted the CNAs to do the showers/bed baths, and that CNA O had told her she had given Resident #182 a bed bath on Tuesday (02/07/23). ADON K said it was important for the residents to have their clothes changed daily and to receive their showers/bed baths for hygiene, and not receiving showers/bed baths could cause skin breakdown and infections from not being clean. <BR/>During an interview on 02/08/23 at 11:08 AM, CNA O said she had not given Resident #182 a bed bath on Tuesday (02/07/23). CNA O said she was not able to go back and change her charting on the shower sheet to reflect she did not give Resident #182 a bed bath. CNA O said the residents' clothes should be changed every day and the residents should get there baths as scheduled. <BR/>During an interview on 02/08/23 at 12:01 PM CNA N said she had not offered Resident #182 a shower or bed bath and she had not changed his clothes on Monday (02/06/23) because she ran out of time and did not get to it. CNA N said it was necessary to change the residents clothes every day and give them showers/bed baths to prevent odor, bacteria and to prevent neglect. <BR/>During an interview on 02/08/23 at 5:31 PM, CNA L said she was the shower aide and gave the showers Monday-Friday and if she was not at the facility the CNAs on the floor were responsible for giving the showers/bed baths. CNA L said she was not responsible for giving Resident #24 and Resident #182 their showers/bed baths because they were not assigned to her. CNA L said the CNAs on the floor should have done them. CNA L said it was important for the residents to receive a shower/bed bath for them to be clean and to make them feel better, and if they did not get a shower/bed bath this could cause residents to get an infection, sores, or yeast. <BR/>During an interview on 02/08/23 at 5:40 PM, LVN D said the residents' clothes should be changed every day, and the aides and the nurses should make sure the residents' clothes were changed every day and showers/bed baths were given as scheduled. LVN D said it was important for the residents' clothes to be changed and for them to receive their bed baths/showers for clean hygiene and for their health and skin. <BR/>During an interview on 02/08/23 at 5:55 PM, RN B said sometimes Resident #24 refused his showers/bed baths and care. RN B said if Resident #24 refused his showers/bed baths staff was supposed to document the refusals, and it should be in his care plan. RN B said it was important for the residents to have showers/bed baths to prevent illness and odor. <BR/>During an interview on 02/08/23 at 6:29 PM, the DON said the nurse aides were responsible for providing showers/bed baths and the nurses should oversee this. The DON said not providing showers/bed baths was a dignity problem. The DON said he was not aware Resident #24 and Resident #182 had not received a shower/bed bath. The DON said he was not aware Resident #24 refused showers/bed baths, and if Resident #24 did refuse, it should be in his care plan. <BR/>During an interview on 02/08/23 at 7:54 PM, the administrator said the nurses were responsible for ensuring ADL care was provided. The administrator said he expected the CNAs to change the residents clothes every day and provide showers/bed baths as scheduled. The administrator said not changing the residents' clothes every day and not providing showers/bed baths as scheduled would affect the residents' dignity.<BR/>3. Record review of consolidated physician orders dated 2/08/23 indicated Resident #25 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, heart failure, lack of coordination, dementia, and hypertension (elevated blood pressure).<BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #25 understood others and was understood by others. The MDS indicated Resident #25 had a BIMS score of 04 indicating she was severely cognitively impaired. The MDS indicated Resident #25 was not resistive to evaluation or care. The MDS indicated Resident #25 required extensive assistance with dressing and personal hygiene. <BR/>Record review of the most recent comprehensive care plan updated 2/06/23 indicated Resident #25 had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner. The care plan indicated interventions for Resident #25 included provide shower, shave, oral care, hair care, and nail care per schedule and when needed.<BR/>Record review of Resident #25's shower schedule indicated she was to be provided showers on Mondays, Wednesdays, and Fridays.<BR/>Record review of Resident #25's showers sheets dated 1/30/22 through 2/06/23 indicated she had received all her schedule showers. <BR/>During an observation on 2/06/23 at 11:54 a.m. Resident #25 was observed with thick silver colored chin hair approximately 0.5cm in length.<BR/>During an observation and interview on 2/07/23 at 9:58 a.m. Resident #25 was observed with thick silver colored chin hair approximately 0.5cm in length. Resident #25 was confused and unable to be interviewed.<BR/>During an observation on 2/08/23 at 8:33 a.m. Resident #25 was observed with thick silver colored chin hair approximately 0.5cm in length.<BR/>During an interview on 2/08/23 at 1:54 p.m. CNA L said she had given Resident #25 her shower on 2/06/23. CNA L said she did not assist Resident #25 with facial hair removal during her shower. CNA L said she did not notice the Resident #25 having facial hair during her shower. CNA L said another CNA later that day told her about Resident #25's facial hair needing removed. CNA L said she did not go back and assist Resident #25 with her facial hair removal after the other CNA informed of the facial hair. CNA L said Resident #25 was not resistive to care. CNA L said the importance of assisting residents with facial hair removal was for their dignity.<BR/>During an interview on 2/08/23 at 2:20 p.m. LVN D said residents were assisted with facial hair removal during showers. LVN D said Resident #25 was not resistive to care including showers and facial hair removal. LVN D said the importance of assisting residents with facial hair removal was the resident's dignity. <BR/>During an interview on 2/08/23 at 6:08 p.m. the DON said he expected facial hair removal to be performed with resident showers. The DON said Resident #25 sometimes refused care but was easily redirected. The DON said assisting resident with facial hair removal was for dignity.<BR/>During an interview on 2/08/23 at 7:10 p.m. the Administrator he expected staff to assist with residents with facial hair removal during showers and as needed. The Administrator said it was the CNAs responsibility to perform grooming including facial hair removal and showering. The Administrator said all staff responsible for reporting issues including facial hair needing groomed to the appropriate staff. The Administrator said facial hair not being removed was a dignity issue.<BR/>Record review the facility's Activities of Daily Living Care Guidelines policy last reviewed, 2/11/21 indicated, Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene Residents participate in and receive the following person-centered care: Bathing includes grooming activities such as shaving, and brushing teeth and hair, Dressing: wearing garments appropriate to season dress and undress .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 2 of 23 residents reviewed for misappropriation of resident property. (Resident # 9 and Resident #63)<BR/>The facility failed to protect Resident #9 from misappropriation of his personal funds when CNA D and CNA E attempted an ATM transaction for $200.00 on 2/21/2025 with unauthorized use of Resident #9's debit card.<BR/>The facility failed to protect Resident #9 from misappropriation when Resident #63 used Resident #9's debit card and gave it to CNA E and CNA D to withdraw money that was not authorized by Resident #9 to allow CNA E and CNA D to use his debit card.<BR/>The facility failed to prevent unauthorized transactions on Resident #9's debit card account on 1/27/25, 2/6/25, 2/7/25, and 2/10/25. <BR/>An IJ was identified on 05/09/25. The IJ template was provided to the facility on [DATE] at 06:29 PM. While the IJ was removed on 05/10/25, the facility remained out of compliance at a scope isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. <BR/>These failures could place residents at risk for decreased quality of life, misappropriation of property, and financial distress. <BR/>Findings included: <BR/>Record review of Resident #9's face sheet dated 05/09/25 indicated he was an [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses dementia and anxiety. <BR/>Record review of Resident #9's quarterly MDS dated [DATE] indicated he made himself understood and understood others. The MDS also indicated he had a BIMS score of 8 which meant he had moderate cognitive impairment. <BR/>Record review of Resident #9's care plan revised on 04/07/25 indicated he had impaired cognition and was at risk for further decline with a goal of his needs being met timely, dignity maintained, and current level of functioning maintained. The care plan interventions included keep routine consistent and try to keep caregivers consistent, and monitor/document/report to physician any changes in cognitive function. <BR/>Record review of the facility associate discplinary memorandum dated 02/24/25 indicated CNA D was suspended pending investigation. <BR/>Record review of Resident #9's checking account statement dated 01/16/25-02/14/25 indicated there were transactions at the ATM:<BR/>1)01/27/25 in the amount of $103.00, $2.00 and $103.00, $2.00 and $203.00, $2.00 and $203.00<BR/>2)2/06/2025 in the amount of $103.00, $2.00, $203.00, $2.00<BR/>3)2/7/25 in the amount of $103.00; $2.00; $203.00; $2.00<BR/>4)2/10/2025 in the amount of $103.00; $2.00, $203.00, $2.00<BR/>5) 2/10/2025 Temu charge in the amount of $20.25 and $277.89<BR/>During an interview on 05/5/25 at 02:22 PM CNA D stated a lot of staff would go to the store for Resident #63 and purchased things knowing the card did not belong to Resident #63. CNA D stated she never returned back to the facility to work because it's a lot of messy stuff going on and people taking advantage of that man card. <BR/>During an interview on 05/08/25 at 4:40 p.m., CNA E stated her, and CNA D were leaving for break when Resident #63 asked her if she could go and withdraw $200 from the ATM. CNA E stated Resident #63 handed her a card and gave her the pin number to the card. CNA E stated she did not know at the time the card belonged to Resident #9 until she tried to withdraw the money and suspicious fraud popped up on the screen. CNA E stated she called to the facility and spoke with CNA N and had her to put Resident #63 on the phone. CNA E stated when Resident #63 got on the phone she stated she told him that was not his card and Resident #63 stated yes, I know, go ahead, and bring it back. We have to call his family member to fix the card because the same thing happened yesterday. CNA E stated she brought the card back and gave it to Resident #63 and told him to give it back to Resident #9. CNA E stated she did not report the incident to the Administrator until Monday (02/24/25) when an incident happened between CNA N and another resident. CNA E stated she was suspended that 02/24/25. CNA E stated there had been several occasions she witnessed Resident #63 going to get money from Resident #9 and handing it to Laundry V, CNA N, and Housekeeping C. CNA E stated CNA N's family member charge Resident #9 $1,000 to go to Walmart and CNA N' family member charged him $600 to take him to (city) Texas. CNA E stated Resident #29 family member has charged him $1,000 to go to the bank. CNA E stated Resident #29 and Resident #37 also takes money from Resident #9. CNA E stated she did not report any of these incidents to the ADM because was already aware. CNA E stated she also heard the ADM was taking money from Resident #9. <BR/>During an interview on 05/06/25 at 1:41 p.m., MA UU stated she has heard about Resident #63 taking money from Resident #9. MA UU stated she had also heard Resident #29's family member coming to take Resident #9 to the bank. MA UU stated she reported what she had heard to the ADM. MA UU stated she could not recall the exact date. <BR/>During an interview on 05/08/25 05:13 PM The Administrator said she was not aware of any staff members taking Resident #9's money. She said she asked Resident #9 about his money, and he told her he was giving out money to residents if they needed it. The Administrator said she called Resident #9's family member and told them about him giving away his money to residents in the facility. She said the VA came to the facility to assess Resident #9 and what he was doing with his money and the VA said he had the right to give his money away because his BIMS was high. The Administrator said Resident #9 gave Resident #63 his card to use. She said she knew CNA D and CNA E went to the gas station to get some chicken for a red soda. The Administrator said she said she was not aware of the $200 the CNAs attempted to get. She said CNA D and CNA E both were suspended on 02/24/25. She said it was not acceptable for staff to get Resident #9's card. She said she never got any money from that Resident #9. The Administrator said misappropriation was the state guideline but Resident #9 gave Resident #63 his card to use so that made it not misappropriation. She said CNA D and CNA E did not get money. The Administrator said the police said it was not misappropriation if Resident #9 gave it to Resident #63. <BR/>During an interview on 05/09/25 at 1:41 p.m., Laundry aide V said she did not take any money from Resident #9, and he did not offer her any money. She said she was aware of Resident #63 getting money from Resident #9. She said the Administrator was aware that Resident #63 had taken Resident #9's money, but nothing was done about it. She said she took the Administrator and Resident #9 to the bank several times and once to the funeral home. She said she stayed on the bus, so she was unaware of what occurred while at the bank or the funeral home.<BR/>During an observation and interview on 05/09/25 at 2:21 PM, Resident #9 said he gave Resident #63 his debit card to use 1 time. He told Resident #63 he could have between 20-30 dollars. He said Resident #63 did pay him back for the money. The surveyor asked if he knew Resident #63 was giving others his debit card, including staff, and Resident #9 said he was unaware and he did not authorize Resident #63 to give his debit card to anyone else. Resident #9 and the surveyor reviewed some of his bank statements. After reviewing the bank statements, he and the surveyor saw some charges on 02/07/25, showing Resident #9 made an ATM withdrawal 3 times for 203 dollars, and 103 dollars, totaling 918 dollars in a day. Resident #9 put his head down and said he did not know about those charges in a shaky voice. Resident #9 became saddened and teary-eyed after discussing the charges on his bank account. The surveyor went to get ADON AA, and she witnessed Resident #9 say he had not given staff permission to use his card, and he authorized Resident #63 to use his card, but not for those amounts. <BR/>During a telephone interview on 05/09/25 at 2:58 p.m., CNA D stated her, and CNA E was going to lunch and CNA E told her to stop at the store so she could withdraw some money for Resident #63. CNA D stated, I had no dealing with card, I was just the driver. <BR/>During an interview on 05/09/25 at 4:41 p.m., the ADM stated she had taken Resident #9 to the bank to get his statements so she could see if any money was withdrawn from the account when Resident #63 gave Resident #9 bank card to CNA E and CNA N. The ADM stated the bank was not going to give him another card because of the fraudulent activity. The ADM stated, I agreed with the lady at the bank. The ADM stated on Monday (02/24/25) there was a risk call made that included she, DON, Regional Consultant Nurse and the Regional Operations to discuss the incident about CNA E, CNA D, Residents #63 and #9 and another incident with CNA D. The ADM stated she stated during the call during the investigation her and the DON found out by CNA D that CNA E was given Resident #9 card by Resident #63 and was told to withdraw $200. The ADM stated during the call she told the regional people CNA E attempted to withdraw the money but was unsuccessful. The ADM stated she told them she suspended CNA E and was told by the Regional Operations Manager she should have never suspended her just written her up because there was no money taken. The ADM stated she was told by Resident #9 family member to take Resident #9 to a funeral home to take out a pre-burial policy because Resident #9 would not let his family member take him. The ADM stated she took out $13,034.41 And $500 to start him a trust fund at the facility. The ADM stated her, and Laundry V took him to the funeral home to take out the policy. <BR/>During an interview on 05/09/25 at 5:45 p.m., the BOM stated the ADM told her when she took Resident #9 to the bank after the incident with CNA E, CNA D and Resident #63 the card was put on hold. The BOM stated the ADM did not elaborate if the bank put the card on hold or if she initiated it. The BOM stated she was told by the ADM she did get bank statements that day. The BOM stated Resident #9 family member had brought statements in before the incident between CNA E, CNA D, and Resident #63 because she wanted to know what all the withdrawals was for. The BOM stated she told her she would look into and that was when the BOM spoke with the ADM about the withdrawals of the bank account. The BOM stated the ADM told her She would look into it. The BOM stated the issue was brought up several times in morning meetings and the ADM stated she was looking into it. The BOM stated it got to a point the ADM stated, were done talking about that. <BR/>Record review of the facility policy Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/22 indicated:<BR/>Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property<BR/>This was determined to be an Immediate Jeopardy (IJ) on 05/09/2025 at 06:24 PM. Administrator was provided with the IJ template on 05/09/2025. The following Plan of Removals was accepted on 05/12/2025 at 02:57 PM. <BR/>The plan of removal was accepted on 5/12/2025 at 2:57 p.m., and included:<BR/>Immediate Action Taken:<BR/>V. <BR/>On 5/9/2025 DON completed an assessment on Resident # 9 to determine if resident was having any emotional distress related to this incident. The resident stated he was fine and was attending church services. The assessment was conducted privately prior to church services.<BR/>W. <BR/>On 5/9/2025 the DON completed a Comprehensive Trauma screen on the resident, and resident will be referred to Psychology services for further evaluation. On 5/9/2025 The V.A. Social Worker was contacted by the facility regarding the need of the resident needing a Psychology evaluation related to this incident.<BR/>X. <BR/>On 5/9/2025 the Regional Director of Operations provided 1:1 in-service with the Regional Nurse Consultant on the facility's abuse, Neglect, and Misappropriations policy.<BR/>Y. <BR/>On 5/9/2025 The Regional Nurse Consultant provided 1:1 education to the facility DON on the Abuse, Neglect, and Misappropriations policy. This was completed on 5/9/25.<BR/>Z. <BR/> On 5/9/2025 DON started in-service education with all staff on the facility's Abuse, Neglect, Misappropriations policy, including post-test. This was completed at 8:00pm on 5/9/2025, and no staff will be allowed to work until they have completed their education.<BR/>AA. <BR/>On 5/8/2025 the Administrator was suspended by the Regional Director of Operations pending investigation.<BR/>BB. <BR/>On 5/12/2025 the resident will be taken to his bank by the Maintenance Director and Social Services to obtain a new debit card. Residents' family will be encouraged to go as well. Resident does have an active Trust fund in the facility and has access to immediate funds if he chooses. Residents have made 10 trust fund withdrawals in April 2025, and 4 in May 2025.<BR/>CC. <BR/>On 5/8/2025 the Misappropriation incident was reported to HHSC by DON.<BR/>DD. <BR/>On 5/8/2025 the Misappropriation incident was also reported to the local law enforcement agency.<BR/>EE. <BR/>On 5/9/2025 this incident was reported to HHSC by DON regarding resident # 63 not being authorized to use resident #9 debit card. <BR/>FF. <BR/>Resident # 63 was discharged from the facility on 5/7/2025 and does not have access to resident # 9 debit card.<BR/>GG. <BR/>On 5/8/2025 the facility started an investigation into the incident, the investigation was completed on 5/10/2025 at 12:00 pm.<BR/>HH. <BR/>On 5/9/2025 C.N.A. E was suspended by the DON related to this incident.<BR/>II. <BR/>C.N.A. D was suspended on 2/24/2025 and never returned to work.<BR/>2. Identification of Residents Affected or Likely to be Affected:<BR/>A. Starting 5/7/25 the Social Worker/designee will complete alert resident interviews 3 x week for 3 weeks, then weekly x 6 weeks to validate that all residents are allowed to make choices about aspects of his/her life in the facility, including financial choices. This will be reviewed after each interview is completed by the DON and Social Services so any issues, if applicable, can be addressed immediately.<BR/>B. The Regional Nurse Consultant will oversee this process weekly x 6 weeks.<BR/>7. <BR/> On 5/9/25the facility's DON notified the Medical Director regarding the Immediate Jeopardy the facility received related to failure to implement the abuse policy <BR/>8. <BR/>On 5/9/25 the facility conducted an Ad Hoc QAPI meeting to discuss Misappropriation, and implementation of the abuse policy and sustaining compliance.<BR/>The surveyor confirmed the following actions had been implemented sufficiently to remove the immediacy by:<BR/>Record review of Resident #9's emotional assessment was completed by the DON on 5/09/2025.<BR/>Record review of Resident #9's Comprehensive Trauma assessment was completed by the DON on 5/09/2025.<BR/>Record review of a referral dated 5/09/2025 to the VA Social Worker for psychological services.<BR/>Record review of the Administrator's suspension form dated 5/08/2025 indicated she was suspended pending investigation.<BR/>Record review of the DON's in-service on the facilities Resident Rights policy dated 5/09/2025. <BR/>Record review of the Regional Nurse Consultant's 1:1 in-service with the DON on the Abuse, Neglect, and Misappropriation policy.<BR/>Record review of the Regional Director of Operation's 1:1 in-service with the Regional Nurse Consultant on the Abuse, Neglect, and Misappropriation policy.<BR/>Record review of the in-service on the facility's Abuse, Neglect, Misappropriation policy dated 5/09/2025 conducted by the DON. The in-service also included a post test.<BR/>During an observation on 5/12/2025 Resident #9 was driven to his financial institution where he was able to obtain a new debit card to his personal account. <BR/>During an interview on 5/12/2025 at 11:54 AM Resident #9 said he had obtained a working debit card to his personal account.<BR/>Record review of the reportable incident on 5/08/2025 to HHSC with intake #1008525 regarding Resident #9's misappropriation.<BR/>Record review of the policy report # dated 5/08/2025 indicated the local authority was notified of the unauthorized use of Resident #9's debit card.<BR/>Record review of the reportable incident on 5/09/2025 to HHSC with intake #1008767 indicated the reporting of Resident #63's unauthorized use of Resident #9's debit card.<BR/>Record review of Resident #63's electronic record indicated he had discharged from the facility on 5/07/2025.<BR/>Record review of the facility's investigation regarding the incident #--- with the completion date of 5/10/2025.<BR/>Record review of CNA E's personnel record indicated she had been suspended pending investigation.<BR/>Record review of CNA D's personnel record indicated she was suspended on 2/24/2025 and never returned to work.<BR/>During an interview on 5/10/2025 the Medical Director indicated he was made aware by the DON of the facility's immediate jeopardy regarding failure to implement the abuse policy regarding misappropriation.<BR/>During interviews conducted on 5/10/2025 - 5/12/2025 the Administrator, DON, ADON AA, ADON XX, MDS Nurse, CNA F, CNA G, CNA L, CNA N, CNA O, MA T, MA T,CNA B, CNA D, CNA E, RN H, MA K, LVN M, CNA P, CNA Q, CNA R, CNA S, CNA U, Van Driver V, MA W, CNA X, MA Y, CNA Z, MA BB, LVN CC, LVN DD, CNA EE, LVN FF, MA GG, RN HH, Dishwasher KK, Dietary Aide LL, [NAME] MM, LVN OO, LVN PP, CNA QQ, CNA RR, CNA SS, LVN TT, MA UU, CNA VV, and RNC WW indicated they had been in-serviced on the facilities abuse and neglect policy. The staff indicated a resident had the right to be free from abuse including misappropriation of property, and allegations should be reported immediately to the abuse coordinator.<BR/>The Administrator was informed the Immediate Jeopardy was removed on 05/12/2025 at 11:54 AM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, 4 of 13 (Residents #3, #4, #5, and #6) reviewed for abuse.<BR/>1. The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 10/17/24 between Resident #3 and Resident #4<BR/>2. The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 08/28/24 between Resident #3 and Resident #4. <BR/>These deficient practices could place residents at risk for abuse, neglect, and not having their needs met.<BR/>Findings included:<BR/>Record review of the facility policy for Policy and Procedures: Abuse, Neglect and Exploitation revised 09/06/24, reflected . 2. The facility's abuse prevention coordinator is responsible for reporting allegations or suspected abuse, neglect . to the state survey agency and other official in accordance with state law .III. Prevention of Abuse, Neglect and Exploitation . A. (2.) Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: 2(a). Immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involves abuse (with or without bodily injury) .<BR/>1. Resident #3<BR/>Record review of Resident #3's face sheet, dated 02/27/25, reflected Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included supraventricular tachycardia (abnormal fast heartbeat). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 02/04/25, reflected Resident #3 usually made himself understood and understood others. Resident #3's BIMS score was 9, which indicated his cognition was moderately impaired. The MDS reflected Resident #3 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #3's comprehensive care plan revised 06/20/24 reflected Resident #3 had a behavior problem as evidenced by: verbal/physical behaviors, and rejection of care. The care plan interventions included: administer medications as ordered, monitor behavior episodes, and attempt to determine underlying cause and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet, dated 02/27/25, reflected Resident #4 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #4's annual MDS assessment, dated 01/02/25, reflected Resident #4 made himself understood and usually understood others. Resident #4's BIMS score was 5, which indicated his cognition was severely impaired. The MDS reflected Resident #4 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #4's comprehensive care plan revised 04/05/24 reflected Resident #4 had a behavior problem as evidence by resident with physical aggression toward another resident when verbally antagonized. The care plan interventions included: administer medication as ordered and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Record review of the PIR dated 10/22/24 reflected an allegation of resident-to-resident incident on Resident #3 and #4 that occurred on 10/17/24 at 10:50 a.m. The PIR reflected both residents were sitting in the sitting area and Resident #4 asked Resident #3 if he would move his chair into his spot. Resident #4 then pushed Resident #3's wheelchair forward from behind. Resident #3 became upset because Resident #4 moved his chair. Resident #3 then went back into Resident #4 with his wheelchair because he moved him. Resident #4 hit Resident #3 on the back of the head due to him hitting his wheelchair. The PIR reflected staff witnessed the incident. The incident was reported to the state agency on 10/17/24 at 1:20 p.m. <BR/>2. Resident #5<BR/>Record review of Resident #5's face sheet, dated 02/27/25, reflected Resident #5 was a [AGE] year-old female, originally admitted to the facility 12/14/23 with a diagnosis which included heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). <BR/>Record review of Resident #5's annual MDS assessment, dated 01/10/25, reflected Resident #5 made herself understood and understood others. Resident #5's BIMS score was 5, which indicated her cognition was severely impaired. The MDS reflected Resident #5 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #5's comprehensive care plan revised on 09/06/24 reflected Resident #5 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to paranoid personality disorder, and depression adult failure to thrive. The care plan interventions included: monitor/document/report to physician any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes and reduce any distractions. <BR/>Resident #6<BR/>Record review of Resident #6's face sheet, dated 02/27/25, reflected Resident #6 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #6's quarterly MDS assessment, dated 02/01/25, reflected Resident #6 made herself understood and understood others. Resident #6's BIMS score was 15, which indicated her cognition was intact. The MDS reflected Resident #6 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #6's comprehensive care plan revised on 08/21/23 reflected Resident #6 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to dementia. The care plan interventions included: identify yourself at each interaction, reduce any distractions and provide instructions to resident using clear voice and simple sentences. <BR/>Record review of the undated PIR reflected an allegation of resident-to-resident incident on Resident #5 and Resident #6 that occurred 8/28/24 around 7:30 a.m. per the witnessed statement written by LVN B. The PIR reflected Resident #5 hit Resident #6 with her silverware packet at the breakfast table. The PIR reflected the incident was witnessed. The incident was reported to the state agency on 8/28/24 at 10:00 a.m. The PIR stated the facility substantiate the allegation of abuse. <BR/>During a telephone interview on 02/26/25 at 2:25 p.m., LVN B stated on the morning of 8/28/24 at approximately 7:30 a.m., she was in the dining room with another resident when she heard a noise and then heard Resident #6 state, she hit me referring to Resident #5. Resident #5 was sitting in the chair where Resident #6 normally sits. Resident #6 stated she asked Resident #5 to move, and Resident #5 picked up her silverware packet and hit her on her left arm. Resident #5 was questioned as to why she hit Resident #6 and she stated, she tried to take my silverware. LVN B stated she notified the DON, and the resident was assigned someone to stay with her while investigation was ongoing. LVN B stated the abuse coordinator was the Administrator and she knew the Administrator was on her way to the facility that morning, so she was going to tell her when she got there. <BR/>During an interview on 02/27/25 at 3:10 p.m., the Administrator stated she was the abuse coordinator for the facility. The Administrator stated the incident between Resident #3 and Resident #4 was witnessed by several staff members including herself. The Administrator stated the incident took longer to diffuse that required multiple staff member including herself to calm both residents down. The Administrator stated Resident #3 did not respond well to other staff members, but she was one that he did respond well too. The Administrator stated she was aware of the incident on 8/28/24 due to Resident #6 been at her office door upon her arrival. The Administrator stated after Resident #6 made the allegation, she went down to talk to LVN B and she informed her of the allegation, but she expected LVN B to contact her immediately regarding the incident. The Administrator stated she did agree that the allegations should always be reported within 2 hours unless there are extenuating circumstances. The Administrator stated she was responsible for overseeing by frequent rounding of the halls and dining room and trying to deescalate any agitation by residents as it arises. The Administrator stated she was the only one in the facility who could report abuse allegations to HHSC. The Administrator stated it was important to report an allegation of abuse and neglect for safety and protection of the residents and try to circumvent other incidents of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 4 of 13 (Residents #3, #4, #5, and #6) residents reviewed for reporting.<BR/>1. The facility did not report the resident-to-resident altercation between Resident #3 and Resident #4 to the State Survey Agency within 2 hours of been notified. <BR/>2. The facility did not report the resident-to-resident altercation between Resident #5 and Resident #6 to the State Survey Agency within 2 hours of been notified. <BR/>These failures to report could place the residents at risk for abuse. <BR/>Findings included:<BR/>1. Resident #3<BR/>Record review of Resident #3's face sheet, dated 02/27/25, reflected Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included supraventricular tachycardia (abnormal fast heartbeat). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 02/04/25, reflected Resident #3 usually made himself understood and understood others. Resident #3's BIMS score was 9, which indicated his cognition was moderately impaired. The MDS reflected Resident #3 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #3's comprehensive care plan revised 06/20/24 reflected Resident #3 had a behavior problem as evidenced by: verbal/physical behaviors, and rejection of care. The care plan interventions included: administer medications as ordered, monitor behavior episodes, and attempt to determine underlying cause and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet, dated 02/27/25, reflected Resident #4 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #4's annual MDS assessment, dated 01/02/25, reflected Resident #4 made himself understood and usually understood others. Resident #4's BIMS score was 5, which indicated his cognition was severely impaired. The MDS reflected Resident #4 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #4's comprehensive care plan revised 04/05/24 reflected Resident #4 had a behavior problem as evidence by resident with physical aggression toward another resident when verbally antagonized. The care plan interventions included: administer medication as ordered and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Record review of the PIR dated 10/22/24 reflected an allegation of resident-to-resident incident on Resident #3 and #4 that occurred on 10/17/24 at 10:50 a.m. The PIR reflected both residents were sitting in the sitting area and Resident #4 asked Resident #3 if he would move his chair into his spot. Resident #4 then pushed Resident #3's wheelchair forward from behind. Resident #3 became upset because Resident #4 moved his chair. Resident #3 then went back into Resident #4 with his wheelchair because he moved him. Resident #4 hit Resident #3 on the back of the head due to him hitting his wheelchair. The PIR reflected staff witnessed the incident. The incident was reported to the state agency on 10/17/24 at 1:20 p.m. <BR/>2. Resident #5<BR/>Record review of Resident #5's face sheet, dated 02/27/25, reflected Resident #5 was a [AGE] year-old female, originally admitted to the facility 12/14/23 with a diagnosis which included heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). <BR/>Record review of Resident #5's annual MDS assessment, dated 01/10/25, reflected Resident #5 made herself understood and understood others. Resident #5's BIMS score was 5, which indicated her cognition was severely impaired. The MDS reflected Resident #5 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #5's comprehensive care plan revised on 09/06/24 reflected Resident #5 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to paranoid personality disorder, and depression adult failure to thrive. The care plan interventions included: monitor/document/report to physician any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes and reduce any distractions<BR/>. <BR/>Resident #6<BR/>Record review of Resident #6's face sheet, dated 02/27/25, reflected Resident #6 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #6's quarterly MDS assessment, dated 02/01/25, reflected Resident #6 made herself understood and understood others. Resident #6's BIMS score was 15, which indicated her cognition was intact. The MDS reflected Resident #6 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #6's comprehensive care plan revised on 08/21/23 reflected Resident #6 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to dementia. The care plan interventions included: identify yourself at each interaction, reduce any distractions and provide instructions to resident using clear voice and simple sentences. <BR/>Record review of the undated PIR reflected an allegation of resident-to-resident incident on Resident #5 and Resident #6 that occurred 8/28/24 around 7:30 a.m. per the witnessed statement written by LVN B. The PIR reflected Resident #5 hit Resident #6 with her silverware packet at the breakfast table. The PIR reflected the incident was witnessed. The incident was reported to the state agency on 8/28/24 at 10:00 a.m. The PIR stated the facility substantiate the allegation of abuse. <BR/>During a telephone interview on 02/26/25 at 2:25 p.m., LVN B stated on the morning of 8/28/24 at approximately 7:30 a.m., she was in the dining room with another resident when she heard a noise and then heard Resident #6 state, she hit me referring to Resident #5. Resident #5 was sitting in the chair where Resident #6 normally sits. Resident #6 stated she asked Resident #5 to move, and Resident #5 picked up her silverware packet and hit her on her left arm. Resident #5 was questioned as to why she hit Resident #6 and she stated, she tried to take my silverware. LVN B stated she notified the DON, and the resident was assigned someone to stay with her while investigation was ongoing. LVN B stated the abuse coordinator was the Administrator and she knew the Administrator was on her way to the facility that morning, so she was going to tell her when she got there. <BR/>During an interview on 02/27/25 at 3:10 p.m., the Administrator stated she was the abuse coordinator for the facility. The Administrator stated the incident between Resident #3 and Resident #4 was witnessed by several staff members including herself. The Administrator stated the incident took longer to diffuse that required multiple staff member including herself to calm both residents down. The Administrator stated Resident #3 did not respond well to other staff members, but she was one that he did respond well too. The Administrator stated she was aware of the incident on 8/28/24 due to Resident #6 been at her office door upon her arrival. The Administrator stated after Resident #6 made the allegation, she went down to talk to LVN B and she informed her of the allegation, but she expected LVN B to contact her immediately regarding the incident. The Administrator stated she did agree that the allegations should always be reported within 2 hours unless there are extenuating circumstances. The Administrator stated she was responsible for overseeing by frequent rounding of the halls and dining room and trying to deescalate any agitation by residents as it arises. The Administrator stated she was the only one in the facility who could report abuse allegations to HHSC. The Administrator stated it was important to report an allegation of abuse and neglect for safety and protection of the residents and try to circumvent other incidents of abuse.<BR/>Record review of the facility policy for Policy and Procedures: Abuse, Neglect and Exploitation revised 09/06/24, reflected . it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect . 1. The facility provides resident protection that included: (a) prevention/prohibit resident abuse, neglect . 2. The facility's abuse prevention coordinator is responsible for reporting allegations or suspected abuse, neglect . to the state survey agency and other official in accordance with state law .III. Prevention of Abuse, Neglect and Exploitation . A. (2.) Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: 2(a). Immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involves abuse (with or without bodily injury) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including misappropriation of resident property were thoroughly investigated for 1 of 23 residents (Resident #9) reviewed for abuse.<BR/>1.The facility failed to thoroughly investigate and failed to protect Resident #9 from misappropriation of his personal funds when CNA D and CNA E attempted an ATM transaction on 02/21/25 using Resident #9's debit card associated with his personal bank account.<BR/>2.The facility failed to thoroughly investigate and failed to protect Resident #9 from misappropriation of his personal funds when staff reported allegations of misappropriation. <BR/>These failures could place residents at risk for abuse, neglect, exploitation, mistreatment, and further injuries of unknown source. <BR/>Findings included:<BR/>Record review of Resident #9's face sheet dated 05/09/25 indicated he was an [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses dementia, anxiety, hear failure, high blood pressure, and lack of coordination. <BR/>Record review of Resident #9's quarterly MDS dated [DATE] indicated he made himself understood and understood others. The MDS also indicated he had a BIMS score of 8 which meant he had moderate cognitive impairment. <BR/>Record review of Resident #9's care plan revised on 04/07/25 indicated he had impaired cognition and was at risk for further decline with a goal of his needs being met timely, dignity maintained, and current level of functioning maintained. <BR/>During an interview on 05/08/25 at 4:40 p.m., CNA E stated she and CNA D were leaving for break on 02/23/25 when Resident #63 asked her if she could go and withdraw $200 from the ATM. CNA E stated Resident #63 handed her a card and gave her the pin number to the card. CNA E stated she did not know at the time the card belonged to Resident #9 until she tried to withdraw the money and suspicious fraud popped up on the screen. CNA E stated she called the facility and spoke with CNA N and had her to put Resident #63 on the phone. CNA E stated when Resident #63 got on the phone she stated she told him that was not his card and Resident #63 stated Yes, I know, go ahead, and bring it back. We have to call Resident #9's family member to fix the card because the same thing happened yesterday. CNA E stated she brought the card back and gave it to Resident #63 and told him to give it back to Resident #9. She said she gave it back to Resident #63 instead of Resident #9 because that was who she got the card from. CNA E stated she did not report the incident to the Administrator until Monday 02/24/25 when an incident happened between CNA N and another resident. CNA E stated she was suspended that 02/24/25. CNA E stated there had been several occasions she witnessed Resident #63 going to get money from Resident #9 and handing it to Laundry V, CNA N, and Housekeeping C. CNA E stated CNA N's aunt charged Resident #9 $1,000 to take him to Walmart and CNA N's cousin charged Resident #9 $600 to take him to another city. CNA E stated Resident #29's family member has charged Resident #9 $1,000 to go to the bank. CNA E stated Resident #29 and Resident #37 also took money from Resident #9. CNA E stated she did not report any of those incidents to the ADM because the ADM was already aware. CNA E stated she also heard the ADM was taking money from Resident #9. <BR/>During an interview on 05/06/25 at 1:41 p.m., MA UU stated she heard about Resident #63 taking money from Resident #9. MA UU stated she had also heard Resident #29's family member taking Resident #9 to the bank. MA UU stated she reported what she had heard to the ADM. MA UU stated she could not recall the exact date. <BR/>During an interview on 05/08/25 05:13 PM the Administrator said she was not aware of any staff members taking Resident #9's money. She said she asked Resident #9 about his money on several occasions, and he told her he was giving out money to residents if they needed it. The Administrator said she called Resident #9's family member and told them about him giving away his money to residents in the facility. She said the VA came to the facility to assess Resident #9 and what he was doing with his money and the VA said he had the right to give his money away because his BIMS was high. The Administrator said Resident #9 gave Resident #63 his card to use. She said she knew CNA D and CNA E went to the gas station to get some chicken and for a red soda. The Administrator said she was not aware of the $200 the CNAs attempted to get. She said CNA D and CNA E both were suspended on 02/24/25. She said it was not acceptable for staff to get Resident #9's card. She said she never got any money from Resident #9. The Administrator said misappropriation was the state guideline but Resident #9 gave Resident #63 his card to use so that made it not misappropriation. She said CNA D and CNA E did not get money. The Administrator said the police said it was not misappropriation if Resident #9 gave it to Resident #63. <BR/>During an observation and interview on 05/09/25 at 2:21 PM, Resident #9 said he gave Resident #63 his debit card to use 1 time on an unrecalled date. He told Resident #63 he could have between $20-$30. He said Resident #63 did pay him back for the money. The surveyor asked if he knew Resident #63 was giving others his debit card, including staff, and Resident #9 said he was unaware and he did not authorize Resident #63 to give his debit card to anyone else. Resident #9 and the surveyor reviewed some of his bank statements. After reviewing the bank statements dated 1/16/25-2/14/25, he and the surveyor saw some charges on 02/07/25 that reflected Resident #9 made an ATM withdrawal 3 times for $203, and $103, totaling $918in a day. Resident #9 put his head down and said he did not know about those charges in a shaky voice. Resident #9 became saddened and teary-eyed after discussing the charges on his bank account. The surveyor went to get ADON AA, and she witnessed Resident #9 say he had not given staff permission to use his card, and he authorized Resident #63 to use his card, but not for those amounts and he had not been to an ATM. <BR/>During a telephone interview on 05/09/25 at 2:58 p.m., CNA D stated she, and CNA E were going to lunch on 02/23/25 and CNA E told her to stop at the store so she could withdraw some money for Resident #63. CNA D stated, I had no dealing with card, I was just the driver. <BR/>During an interview on 05/09/25 at 4:41 p.m., the ADM stated she had taken Resident #9 to the bank to get his statements so she could see if any money was withdrawn from the account when Resident #63 gave Resident #9 bank card to CNA E and CNA N. The ADM stated the bank was not going to give him another card because of the fraudulent activity. The ADM stated, I agreed with the lady at the bank. The ADM stated on Monday (02/24/25) there was a risk call made that included herself, the DON, the Regional Consultant Nurse and the Regional Operations to discuss the incident about CNA E, CNA D, Residents #63 and #9 and another incident with CNA D. The ADM stated she stated during the call during the investigation her and the DON found out by CNA D that CNA E was given Resident #9 card by Resident #63 and was told to withdraw $200. The ADM stated during the call she told the regional people CNA E attempted to withdraw the money but was unsuccessful. The ADM stated she told them she suspended CNA E and was told by the Regional Operations Manger she should have never suspended her just written her up because there was no money taken. The ADM stated she was told by Resident #9 sister to take Resident #9 to a funeral home to take out a pre-burial policy because Resident #9 would not let the sister take him. The ADM stated she took out #13,034.41 and $500 to start him a trust fund at the facility. The ADM stated she and Laundry V took him to the funeral home to take out the policy. <BR/>During an interview on 05/09/25 at 5:45 p.m., the BOM stated the ADM told her when she took Resident #9 to the bank after the incident with CNA E, CNA N and Resident #63 the card was put on hold. The BOM stated the ADM did not elaborate if the bank put the card on hold or if she initiated it. The BOM stated she was told by the ADM she did get bank statements that day (02/24/25). The BOM stated Resident #9's family member had brought statements in (on an unknown date) before the incident between CNA E, CNA N, and Resident #63 because she wanted to know what all the withdrawals were for. The BOM stated she told her she would look into it and that was when the BOM spoke with the ADM about the withdrawals of the bank acct. The BOM stated the ADM told her she would look into it. The BOM stated the issue was brought up several times in morning meetings and the ADM stated she was looking into it. The BOM stated it got to a point the ADM stated, We're done talking about that. <BR/>Record review of the facility policy titled Abuse, Neglect, Exploitation, revised 10/24/22, indicated, policy: it is the policy of this facility to provide protection for the health, wealth, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury. Policy Explanation and Compliance Guidelines: The facility provides resident pro1ec1ion that include:<BR/>a) <BR/>Prevention/prohibit resident abuse, neglect, and exploitation and misappropriation of resident property;<BR/>b) <BR/>Investigation of all allegations listed above and<BR/>c) <BR/>Training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedure, and dementia management and resident abuse prevention; A. New employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned In-services and as needed. C. <BR/>Training topics will include: 1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. 2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. 3. Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychoactive indicators. 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources IV. <BR/>Identification of Abuse, Neglect, and Exploitation A. <BR/>The facility assists staff to understand the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff-to-resident abuse and certain resident-to-resident altercations Reporting: A. The facility reports abuse and abuse allegations that include: I. Reporting allegations involving staff-to-resident abuse, resident-to-resident altercations, injuries of unknown source, misappropriation of resident property/exploitation, and mistreatment. 2. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timelines: A. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or B. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received therapeutic diets that were prescribed by the attending physician for 2 of 21 residents (Resident #10 and Resident #29) reviewed for therapeutic diets.<BR/>1. The facility failed to ensure Resident #10 received her fortified food, Ensure Clear, or water on 05/05/25 as indicated on her tray card.<BR/>2. The facility failed to ensure Resident #29 received fortified foods with his lunch meal on 05/05/25.<BR/>The facility did not ensure Resident #29 was given his fortified food on 05/05/25 as indicated on his tray card.<BR/>These failures could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity.<BR/>Findings Included:<BR/>Record review of Resident #10's face sheet dated 05/10/25 indicated a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses which included Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), heart failure, dysphagia (difficulty swallowing), and high blood pressure.<BR/>Record review of Resident #10's quarterly MDS assessment dated [DATE] indicated Resident #10 understood and was understood by others. The MDS assessment indicated Resident #10 had a BIMS score of 06, indicating she was severely cognitively impaired. The MDS indicated she required assistance with ADLs and supervision with meals. The MDS assessment indicated Resident #10 had a therapeutic diet and weight loss.<BR/>Record review of Resident #10's comprehensive care plan revised on 04/25/25, indicated Resident #10 had a mechanical soft diet and was at risk for nutritional & hydration. Resident #10 could not have dairy products. The care plan interventions were for staff to provide and serve diet as ordered and for the registered dietitian to evaluate and make diet/supplement change recommendations as needed.<BR/>Record review of Resident #10's lunch meal ticket for 05/05/25 indicated . ***Fortified food (foods that have nutrients added to them, typically vitamins and minerals) all meals. The meal ticket included Mexican lasagna, Buttered dinner roll, buttered diced carrots, yellow cake with vanilla icing, 8 oz water, 8 oz iced tea, and add Ensure Clear to the tray.<BR/>During an interview on 05/05/25 at 12:18 p.m., [NAME] MM said she added extra sour cream and cheese to the regular Mexican Lasagna, but did not add any fortified ingredients to the mechanically soft Mexican Lasagna. She said she did not serve any fortified food for the lunch meal today (05/05/25).<BR/>During an observation and interview on 05/05/25 at 12:23 p.m., Resident #10 was sitting in the assisted dining room for the lunch meal. She received the mechanical soft Mexican lasagna, roll, diced carrots, tea, and cake. CNA S was sitting at the table assisting Resident #10 with her lunch meal. CNA S said she did not know what was fortified on Resident #10's tray.<BR/>During an interview on 05/08/25 at 2:26 p.m., the DM said if the tray card read fortified food, then the resident should have been served fortified foods. He said he did not know what the fortified meal was on Monday (05/05/25), but they usually had mashed potatoes for residents who required fortified food. He said the cook was responsible for serving fortified food to each resident who required fortified food. He said the cook was supposed to read the meal ticket to ensure the resident received the correct diet or supplements. He said failure to serve the fortified food could lead to potential weight loss. <BR/>During an interview on 05/09/25 at 4:47 p.m., the DON said the trays were supposed to be checked by the nurses in the dining room and then by the aides when they passed the trays. She said it was important for the staff to read the tickets and ensure the residents were receiving the correct diets. She said if Resident #10's tray card read fortified foods, then she should have received fortified foods on her lunch tray. She said failure to give the fortified foods could lead to weight loss.<BR/>During an interview on 05/09/25 at 6:04 p.m., the Administrator said that when staff were serving the trays, they were responsible for ensuring the resident had the correct diet and all supplements that were ordered. She said it was important for residents to receive the correct diet/supplement to prevent weight loss. <BR/>2.Record review of Resident #29's face sheet dated 05/08/25, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #29 had diagnoses of diabetes mellitus (disease that results in too much sugar in the blood), anorexia (eating disorder causing abnormally low body weight), anemia (condition in which the blood does not have enough healthy red blood cells to carry oxygen throughout the body), and cerebral infarction (stroke). <BR/>Record review of Resident #29's quarterly MDS assessment dated [DATE], indicated he was understood and understood others. Resident #29 had a BIMS score of 15, which indicated his cognition was intact. Resident #29 was independent with all ADLs. Resident #29 had not had a weight loss/gain of 5% or more in the last month or 10% or more in the last 6 months. The MDS assessment did not indicate Resident #29 received a therapeutic diet. <BR/>Record review of Resident #29's comprehensive care plan revised on 05/01/25, indicated he was on a Regular/CCHO/NAS and at nutritional and hydration risk related to anemia and anorexia. The care plan interventions included to provide and serve diet as ordered. <BR/>Record review of Resident #29's order summary report dated 05/14/25, indicated he had an order for CCHO NAS diet regular texture with an order start date of 01/24/24.<BR/>Record review of Resident #29's lunch meal ticket for 05/05/25 indicated . ***Fortified food all meals, fried eggs for Breakfast the meal ticket included Mexican lasagna, Buttered dinner roll, 1 cup of tossed salad with dressing, yellow cake with vanilla icing, 8 oz water, 8 oz iced tea, and 4 oz fortified mashed potatoes. <BR/>During an observation on 05/05/25 at 12:19 PM, Resident #29 was sitting in the dining room for the lunch meal. He received the Mexican lasagna, roll, salad, tea, and cake. Resident #29 did not receive the 4 oz of fortified mash potatoes as indicated on his meal ticket. <BR/>During an interview on 05/05/25 at 12:31 PM, [NAME] MM said she did not make any fortified mash potatoes. She said she did not realize Resident #29 required fortified foods. [NAME] MM said Resident #29 should have gotten a pudding. [NAME] MM said she was responsible for ensuring residents received the correct meal. [NAME] MM said failure to provide Resident #29 fortified meals could cause him to lose weight. <BR/>During an interview on 05/05/25 at 1:51 PM, the Dietary Manager said the cook was responsible for ensuring the resident received what was ordered on the meal ticket. He said Resident #29 should have received the fortified mash potatoes. The Dietary Manager said failure to provide Resident #29 with the fortified foods placed him at risk for weight loss. <BR/>During an interview on 05/09/25 at 2:00 PM, the DON said Resident #29's meal ticket had a typo. She said Resident #29 was supposed to receive fortified foods but not specifically mashed potatoes. She said the dietary staff was responsible for ensuring residents received fortified foods as ordered. She said failure to provide residents with fortified foods could cause them to have a weight loss. <BR/>During an interview on 05/09/25 at 5:24 PM, the Administrator said she expected residents to receive fortified foods as ordered. She said the dietary staff was responsible for ensuring residents received fortified foods as ordered. She said failure to provide residents with fortified foods could cause them to have a weight loss.<BR/>Record review of the facility's policy Therapeutic Diet Orders Process dated 08/25/22 indicated . The facility provides all residents will foods in the appropriate form and/or the appropriate nutritive content as prescribed by the physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences . 3. All diet orders are to be communicated to the dietary department in accordance with facility procedures. 4. The Dietary Manager or designee should check the resident orders to validate all diet, diet textures and changes in diet order and texture .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 staff (RN M, CNA N, and Treatment Nurse) viewed for infection control.<BR/>1. The facility failed to ensure RN M performed hand hygiene after removing his gloves and before putting on clean gloves during tracheostomy care for Resident #62<BR/>2. The facility failed to ensure RN M changed gloves and performed hand hygiene after picking up a nebulizer machine off the ground and before performing oral care and washing Resident #62's face.<BR/>3. The facility failed to ensure the treatment nurse and CNA N changed gloves when providing incontinent care for Resident #182. <BR/>4. The facility failed to ensure the treatment nurse performed hand hygiene between glove changes. <BR/>These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. <BR/>Findings Include:<BR/>1. During an observation on 2/07/23 at 9:16 p.m. RN M performed tracheostomy care on Resident #62. RN M removed his sterile gloves after removing Resident #62's inner cannula, took his cell phone out of his pocket, and then put another pair of sterile gloves. RN M did not perform hand hygiene after removing his sterile gloves and before putting on a clean pair of sterile gloves to complete Resident #62's tracheostomy care. <BR/>During an observation on 2/07/23 at 9:21 a.m. RN M performed suctioning on Resident #62. RN M removed his sterile gloves after he completed suctioning on Resident #62 and put another pair of sterile gloves. RN M did not perform hand hygiene after removing his sterile gloves and before putting on a clean pair of sterile gloves to replace Resident #62's inner cannula (a tube inside the outer tube of a tracheostomy that can be easily removed and cleaned) .<BR/>2. During an observation on 2/07/23 at 9:38 a.m. RN M knocked Resident #62's nebulizer onto the floor. RN M picked the nebulizer up off the floor with his gloved hands and then performed oral care and cleaned Resident #62's face. RN M did not remove his gloves or perform hand hygiene after picking up the nebulizer off the floor and before performing oral care and cleaning Resident #62's face.<BR/>During an interview on 1/07/23 at 9:48 a.m. RN M said hand hygiene should be performed after cleaning the inner cannula and before continuing tracheostomy care and when gloves were changed. RN M said proper hand hygiene was important to prevent the spread of bacteria and for infection control. RN M said when the nebulizer fell into the floor it would have been contaminated. RN M said picking up an item off the floor and then providing care to a resident without changing gloves or performing hand hygiene could introduce bacteria to the resident and cause an infection. RN M said he did not perform hand hygiene between glove changes or change gloves and perform hand hygiene after picking the nebulizer up out of the floor was because it slipped his mind. <BR/>During an interview on 2/08/23 at 2:29 p.m. the Infection Preventionist said she expected staff to perform hand hygiene after providing care, between residents, when hands were visibly soiled, and when gloves were changed. The Infection Preventionist said it was important to perform hand hygiene to keep infections down and to prevent the spread of infections. <BR/>During an interview on 2/08/23 at 6:08 p.m. the DON said he expected the staff to perform hand hygiene before and after entering a resident room and between glove changes. The DON said when staff removed a pair of gloves they did not know what they might accidentally touch when removing the gloves. The DON said the importance of proper hand hygiene was for infection control.<BR/>During an interview on 2/08/23 at 7:10 p.m. the Administrator said he expected staff to perform hand hygiene anytime hands were visibly soiled, before handling food, before and after providing care, and between glove changes. The Administrator said the DON and nursing management were responsible for ensuring staff were trained and performing appropriate hand hygiene. The Administrator said hand hygiene decreased the risk of infection.<BR/>3 and 4. During an observation on 02/06/23 starting at 11:00 AM, CNA N and the treatment nurse were providing incontinent care to Resident #182. During the incontinent care the treatment nurse was holding Resident #182 by buttocks with her two hands and had feces on her gloves. The treatment nurse wiped off the feces from her gloves and removed one glove. The treatment nurse put on a new glove. The treatment nurse did not change both gloves and she did not perform hand hygiene after removal of the one glove. CNA N continued to provide care and removed the dirty brief and applied a clean brief and finished the incontinent care. CNA N did not change her gloves and did not perform hand hygiene after removing the dirty brief. <BR/>During an interview on 02/06/23 at 11:31 AM, the treatment nurse said while providing incontinent care to Resident #182 she did not perform hand hygiene after removing one glove and putting on a new glove. The treatment nurse said she should have changed both gloves and performed hand hygiene. The treatment nurse said it was important to perform hand hygiene and change gloves when they were soiled to prevent cross contamination and so you do not accidentally spread germs. <BR/>During an interview on 02/06/23 at 11:39 AM, CNA N said she should have changed gloves when she took off Resident #182 dirty brief. CNA N said not changing gloves when going from dirty to clean and not performing hand hygiene placed the residents at risk for cross contamination.<BR/>During an interview on 02/08/23 at 5:05 PM, ADON K said there was currently no monitoring in place for incontinent care. ADON K said the DON did skill check offs for the staff, but she did not know how often. ADON said the charge nurses and nurse management were responsible for ensuring the facility staff performed hand hygiene and proper incontinent care. ADON K said not performing proper incontinent care and not performing hand hygiene could cause the residents to get urinary tract infections, skin breakdown, and placed the residents at risk of infection.<BR/>During an interview on 02/08/23 at 6:53 PM, the DON said the treatment nurse and CNA N should have changed gloves and performed hand hygiene when going from dirty to clean. The DON said the nurse overseeing the CNAs was responsible for making sure the CNAs performed hand hygiene and proper incontinent care. The DON said not performing hand hygiene and improper incontinent care placed the residents at risk for infection and skin breakdown.<BR/>During an interview on 02/08/23 at 8:13 PM, the administrator said the treatment nurse and CNA N should have changed gloves and performed hand hygiene while providing incontinent care. The administrator said nursing was responsible for ensuring proper incontinent care was provided and staff were performing hand hygiene. The administrator said improper incontinent care and not performing hand hygiene could cause the residents to have an infection.<BR/>Record review of the facility's policy titled, Incontinence Care, last reviewed 02/14/20, revealed, .8. If feces present, remove with toilet paper or disposable wipe by wiping from front perineum toward rectum. Discard soiled materials and gloves. Wash hands. 9. Put on non-sterile latex-free gloves .14. Remove linen/under pad and discard 15. Remove and discard gloves 16. Wash hands 17. Apply clean linen/underpad, briefs or other incontinent products as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of 20 residents (Residents #26, #14 and #1) reviewed for resident rights.<BR/>1. The facility failed to ensure RN F and CNA Z treated residents with dignity and respect by referring to them as feeders. <BR/>2. The facility failed to ensure the Environmental Service Manager knocked prior to entering Resident #26 room. <BR/>3. The facility failed to ensure LVN E provided privacy for Resident #14 while administering his insulin injection. <BR/>4. The facility failed to ensure Resident #1 had a privacy bag for his catheter drainage bag. <BR/>These failures could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.<BR/>The findings included: <BR/>1. During an observation on 02/06/2023 at 11:52 a.m., RN F stated where's the feeders in the dining hall while passing out food trays to the residents who required assistance with eating. <BR/>During an interview on 02/08/2023 at 1:58 p.m., RN F stated she did not know the word feeder was inappropriate until she was told by the DON. RN F stated the DON told her she should use the word assistance. RN F stated she had used the word feeder several times, but it was not set in her vocabulary. RN F stated the failure to residents for being referred to as a feeder was a dignity issue. <BR/>During an observation and interview on 02/06/2023 at 1:33 PM, CNA Z said, that's for my feeder. CNA Z was approximately 3 feet from several resident doors. CNA Z stated it was not appropriate to refer to a resident as a feeder. CNA Z stated she was trying to explain that was why she had one tray left on the cart. CNA Z stated referring to residents' as feeder could have made residents' feel disrespected.<BR/>2. During an observation on 02/06/2023 at 10:14 a.m., the Environmental Service Manager entered Resident #26 room without knocking. <BR/>During an interview on 02/06/2023 at 10:20 a.m., Resident #26 stated he did not feel he, and his wife had any privacy. Resident #26 stated the housekeepers never knocked prior to entering. <BR/>During an interview on 02/08/2023 at 1:52 p.m., the Environmental Service Manager stated she should have knocked prior to entering Resident #26 room. The Environmental Service Manager stated she was moving too fast and forgot to knock. The Environmental Service Manger stated she had never been told that some of her staff did not knock prior to entering resident's room. The Environmental Service Manager stated this failure was not providing privacy to residents. <BR/>3. During an observation and interview on 02/07/2023 at 11:20 a.m., LVN E administered Resident #14 insulin with the door open. Resident #14 did not have a roommate. LVN E stated it was not okay to administer medication to residents without providing privacy. LVN E was unable to say why she did not close the door prior to administering Resident #14 medication. LVN E stated this failure was a lack of dignity and respect.<BR/>During an interview on 02/08/2023 at 4:36 p.m., the DON stated he expected staff to knock prior to entering resident's room. The DON stated he expected staff to provide privacy when administering medications. The DON stated he expected staff to say assisted dining room instead of saying the word feeder. The DON stated this was monitored by weekly rounds and visiting with residents/family to ensure privacy has been provided. The DON stated staff were in serviced at least once a month. The DON stated he was unaware of any issues. The DON stated there was not a system in place for staff at nurse level to monitor for that specific dignity infarction related to administering medications without privacy. <BR/>During an interview on 02/08/2023 at 6:13 p.m., the Administrator stated he expected staff to knock prior to entering resident's room. The Administrator stated he expected staff to provide privacy when administering medications and expected staff to say assisted dining room instead of the word feeder. The Administrator stated this failure was an embarrassment to the residents and a dignity issue. <BR/>4. Record review of Resident #1's face sheet (undated) revealed he was a [AGE] year-old-male who admitted to the facility on [DATE] with diagnoses of senile degeneration of the brain (mental condition where your brain cells begin to degenerate), unspecified dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and benign prostatic hyperplasia with lower unitary tract symptoms, BPH (overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine). <BR/>Record review of Resident #1's order summary report, dated 02/08/2023, revealed an order which started on 10/31/2022 for May have suprapubic catheter for dx: Obstructive uropathy. The order summary report further revealed an order which started on 10/31/2022 for Suprapubic care q shift and prn. Check privacy bag every shift.<BR/>Record review of the MDS assessment, dated 11/08/2022, revealed Resident #1 had clear speech and was understood by staff. The MDS revealed Resident #1 was able to understand others. The MDS revealed Resident #1 had a BIMS score of 07 which indicated severe cognitive impairment. The MDS revealed Resident #1 had no behaviors or refusal of care. The MDS revealed Resident #1 had an indwelling catheter. <BR/>Record review of the comprehensive care plan, last revised on 01/03/2023, revealed Resident #1 had a suprapubic catheter. The interventions included: Privacy bag over the drainage bag. <BR/>During an observation and resident interview on 02/06/2023 at 10:25 AM, the catheter bag, with approximately 100 mL of clear, yellow urine, was hanging on Resident #1's wheelchair with no privacy bag noted. Resident #1 was non-interviewable related to severe cognitive impairment as evidenced by confused conversation. <BR/>During an observation on 02/06/2023 at 3:35 PM, catheter bag, with approximately 200 mL of clear, yellow urine, was hanging on Resident #1's wheelchair with no privacy bag noted.<BR/>During an observation on 02/07/2023 at 8:17 AM, Resident #1 was self-propelling his wheelchair down the hallway from the dining room, the catheter bag, with the tubing full of clear, yellow, urine, was hanging from wheelchair with no privacy bag noted.<BR/>During an interview on 02/08/2023 at 4:35 PM, CNA Q stated Resident #1 was supposed to have a privacy bag for his catheter drainage bag. CNA Q stated she had no clue why Resident #1 had no privacy bag for his catheter drainage bag. CNA Q stated CNAs were unable to provide the type of privacy bags the facility used. CNA Q stated CNAs were able to alert the nurse that one was needed. CNA Q stated the nurse was not notified that Resident #1 needed a privacy bag. CNA Q stated privacy bags were important so Resident #1 could have privacy and dignity. <BR/>During an interview on 02/08/2023 at 4:46 PM, NA R stated Resident #1 was supposed to have a privacy bag for his catheter drainage bag. NA R stated he was unsure why Resident #1 had no privacy bag on his catheter drainage bag. NA R stated the nurse was responsible for placing privacy bags. NA R stated he was unsure if the nurse was notified of the need for a privacy bag. NA R stated privacy bags were important so Resident #1 could have privacy and dignity. <BR/>During an interview on 02/08/2023 at 5:13 PM, LVN (ADON) H stated the nurses and ADONs were responsible for ensuring privacy bags were applied to catheter drainage bags. LVN (ADON) H stated nurses were responsible for monitoring to ensure privacy bags were applied to catheter drainage bags. LVN (ADON) H stated she was unsure why Resident #1 had no privacy bag. LVN (ADON) H stated privacy bags were important to maintain Resident #1's dignity. <BR/>During an interview on 02/08/2023 at 7:09 PM, the DON stated CNAs should have been aware when residents need a privacy bag to catheter drainage bags. The DON stated Resident #1 should not have been provided with a catheter drainage bag with no privacy ability. The DON stated this was monitored by looking at invoices for resident care equipment ordered by the facility. The DON stated ultimately the nurses were responsible for ensuring privacy bags were provided for catheter drainage bags. The DON stated the importance of privacy bags was to ensure dignity. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated he expected nursing staff to ensure Resident #1 had a privacy bag for his catheter drainage bag. The ADM stated privacy bags were important to ensure Resident #1's dignity and privacy. <BR/>Record review of the Urinary Catheter Management policy, last reviewed on 08/20/2021, revealed Fundamental Information 3.Provide privacy and dignity by covering urinary bag with a bag cover. <BR/>Record review of the Resident Rights policy, last reviewed on 02/20/2021, revealed 4. Respect and Dignity. The resident has a right to be treated with respect and dignity. The policy further revealed 7. Privacy and confidentiality. a. personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to ensure residents were free from abuse for 7 of 13 residents (Residents #3, #4, #5, #6, #7, #8 and #9) reviewed for resident abuse. <BR/>1. The facility did not ensure Resident #3 was free from abuse when Resident #9 shoved Resident #3 on 8/19/24. <BR/>2. The facility did not ensure Resident #6 was free from abuse when Resident #5 hit Resident #6 with her silverware packet on 8/28/24. <BR/>3. The facility did not ensure Resident #3 was free from abuse when Resident #4 hit Resident #3 on the back of the head 10/17/24. <BR/>4. The facility did not ensure Resident #7 was from abuse when Resident #8 hit Resident #7 on the head 12/20/24. <BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings included: <BR/>1. Resident #3<BR/>Record review of Resident #3's face sheet, dated 02/27/25, reflected Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included supraventricular tachycardia (abnormal fast heartbeat) and mild intellectual disabilities (developmental disability that affects a person's ability to think abstractly and learn new information). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 02/04/25, reflected Resident #3 usually made himself understood and understood others. Resident #3's BIMS score was 9, which indicated his cognition was moderately impaired. The MDS reflected Resident #3 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #3's comprehensive care plan revised 06/20/24 reflected Resident #3 had a behavior problem as evidenced by: verbal/physical behaviors, and rejection of care. The care plan interventions included: administer medications as ordered, monitor behavior episodes, and attempt to determine underlying cause and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Resident #9 <BR/>Record review of Resident #9's face sheet, dated 02/27/25, reflected Resident #9 an [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life).<BR/>Record review of the quarterly MDS assessment, dated 02/13/25, reflected Resident #9 made himself understood and understood others. Resident #9 BIMS score was 8, which indicated his cognition was moderately impaired. The MDS reflected Resident #9 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #9's comprehensive care plan revised 09/23/24 reflected Resident #9 had a behavior problem as evidence by noncompliance to policies despite numerous educational conversations, resident continues to go to Walmart and buy batteries, tools and OTC inhalers and constantly states people are getting handsy with women when they are just talking. The care plan interventions included: monitor behavior episodes and attempt to determine underlying cause and minimize potential for disruptive behaviors by offering tasks or activities which divert attention. <BR/>Record review of the facility's undated PIR with an incident category of abuse was signed by the Administrator on 08/23/24. The PIR reflected RN F witnessed Resident #9 shoved Resident #3 in the dining room. The PIR included a skin assessment completed 08/19/24, incident report for both residents completed 08/19/24, psychiatric assessment for Resident #9 completed on 08/19/24, psychiatric assessment for Resident #3 completed on 08/21/24, social services note for Resident #9 completed 8/19/24, safe surveys with no areas of concerns dated for 08/19/24 and a 1:1 schedule for Resident #9 completed 08/19/24. The PIR reflected staff was in-serviced promptly on abuse and neglect dated 08/19/24. <BR/>Record review of the physical aggression report dated 08/19/24 written by RN F indicated Resident #9 became verbally aggressive with Resident #3 in the dining room prior to breakfast. Resident #9 was cussing and insulating Resident #3. RN F instructed Resident #9, that if his behavior continued, he would have to leave the dining room. Resident #9 continued to cuss and insult Resident #3. RN F told the resident that he would have to leave the dining room and return to his room for breakfast due to his behavior. As Resident #9 was leaving the dining room he shoved Resident #3 the back and again insulted him. RN F immediately assisted Resident #9 back to his room and he was placed on 1:1 observation. <BR/>Record review of a statement dated 08/19/24 written by RN F stated she was in the dining room helping prepare breakfast. RN F stated Resident #3 was sitting at his usual table in his wheelchair. Resident #9 usually sat at another table, but that morning Resident #9 pulled his wheelchair up to the table and began trying to move an empty chair away from the table. Resident #3 became upset and told Resident #9 the chair he was trying to move belonged to another resident and she was coming back to sit in it in a few minutes after smoke break. Resident #9 became agitated and started cussing at Resident #3. Resident #9 called Resident #3 several names and told Resident #3 to shut the hell up. RN F stated she intervened and told Resident #9 that if he continued with this behavior, he would be asked to leave the dining room. Resident #9's foul language continued, and RN F asked him to return to his room for breakfast. On his way out of the dining room, as Resident #9 passed Resident #3 he shoved Resident #3 in the back. Another resident seated at another table told Resident #9 you can not put your hands on people like that, Resident #9 told her to shut her damn mouth as he exited the dining room. His agitation and foul language continued as he went down the hall to his room. RN F stated at no time did Resident #3 ever make any physical contact with Resident #9 or even attempt to. <BR/>An attempted telephone interview on 02/27/25 at 11:10 a.m. with RN F, the RN that witnessed the incident, was unsuccessful. <BR/>During an interview on 02/27/25 at 9:13 a.m., Resident #3 stated Resident #9 hit him on the back his neck when asked about the incident between him and Resident #9. Resident #3 stated He's mean. <BR/>During an interview on 02/27/25 at 9:22 a.m., Resident #9 stated he was trying to hit me when asked about the incident between him and Resident #3. Resident #9 stated Resident #3 was overbearing and if I didn't get up out the chair, he would've kick my ass. <BR/>2. Resident #5<BR/>Record review of Resident #5's face sheet, dated 02/27/25, reflected Resident #5 was a [AGE] year-old female, originally admitted to the facility 12/14/23 with a diagnosis which included heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). <BR/>Record review of Resident #5's annual MDS assessment, dated 01/10/25, reflected Resident #5 made herself understood and understood others. Resident #5's BIMS score was 5, which indicated her cognition was severely impaired. The MDS reflected Resident #5 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #5's comprehensive care plan revised on 09/06/24 reflected Resident #5 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to paranoid personality disorder, and depression adult failure to thrive. The care plan interventions included: monitor/document/report to physician any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes and reduce any distractions.<BR/>Resident #6<BR/>Record review of Resident #6's face sheet, dated 02/27/25, reflected Resident #6 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #6's quarterly MDS assessment, dated 02/01/25, reflected Resident #6 made herself understood and understood others. Resident #6's BIMS score was 15, which indicated her cognition was intact. The MDS reflected Resident #6 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #6's comprehensive care plan revised on 08/21/23 reflected Resident #6 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to dementia. The care plan interventions included: identify yourself at each interaction, reduce any distractions and provide instructions to resident using clear voice and simple sentences. <BR/>Record review of the undated PIR with an incident category of abuse was signed by the Administrator on 08/28/24. The PIR reflected LVN B witnessed Resident #5 hit Resident #6 with her silverware at the breakfast table. The PIR included a skin assessment completed 08/28/24, incident report for both residents completed 08/28/24, psychiatric assessment for both residents completed 08/28/24, safe surveys with no areas of concerns dated for 08/28/24, and a 1:1 schedule for Resident #5 completed 08/28/24-08/31/24. The PIR reflected staff was in-serviced promptly on abuse and neglect dated 08/28/24. <BR/>Record review of undated witnessed statement written by Resident #10 stated on 08/28/24 she was in the dining room around 7:30 a.m. Resident #6 came in and sat at the table she always sat at. Resident #10 stated at 7:00 a.m. her and Resident #6 went out to smoke and when they came back in Resident #5 was sitting where Resident #6 was sitting and would not move when asked to. Resident #10 stated Resident #5 suddenly grabbed her silverware and hit Resident #6 on the arm. Resident #5 was then asked to leave the table by an aide, and she refused. <BR/>During a telephone interview on 02/26/25 at 2:25 p.m., LVN B stated on the morning of 8/28/24 at approximately 7:30 a.m., she was in the dining room with another resident when she heard a noise and then heard Resident #6 state, she hit me referring to Resident #5. Resident #5 was sitting in the chair where Resident #6 normally sits. Resident #6 stated she asked Resident #5 to move, and Resident #5 picked up her silverware packet and hit her on her left arm. Resident #5 was questioned as to why she hit Resident #6 and she stated, she tried to take my silverware. LVN B stated she notified the DON, and the resident was assigned someone to stay with her while investigation was ongoing.<BR/>During an interview on 02/27/25 at 9:19 a.m., Resident #10 stated I didn't see it, I heard about it when asked about the incident between Resident #5 and Resident #6. Resident #10 appeared to be agitated when state surveyor introduced herself. <BR/>During an interview on 02/27/25 at 9:27 a.m., Resident #6 stated I can't remember why she hit me on my arm with her silverware when asked about the incident between Resident #5 and Resident #6. <BR/>During an interview on 02/27/25 at 9:30 a.m., Resident #5 stated It didn't happen with me I don't think, somebody would've told me I hit her when asked about the incident between Resident #5 and Resident #6. <BR/>3. Resident #3<BR/>Record review of Resident #3's face sheet, dated 02/27/25, reflected Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included supraventricular tachycardia (abnormal fast heartbeat). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 02/04/25, reflected Resident #3 usually made himself understood and understood others. Resident #3's BIMS score was 9, which indicated his cognition was moderately impaired. The MDS reflected Resident #3 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #3's comprehensive care plan revised 06/20/24 reflected Resident #3 had a behavior problem as evidenced by: verbal/physical behaviors, and rejection of care. The care plan interventions included: administer medications as ordered, monitor behavior episodes, and attempt to determine underlying cause and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Record review of Resident #4's face sheet, dated 02/27/25, reflected Resident #4 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #4's annual MDS assessment, dated 01/02/25, reflected Resident #4 made himself understood and usually understood others. Resident #4's BIMS score was 5, which indicated his cognition was severely impaired. The MDS reflected Resident #4 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #4's comprehensive care plan revised 04/05/24 reflected Resident #4 had a behavior problem as evidence by resident with physical aggression toward another resident when verbally antagonized. The care plan interventions included: administer medication as ordered and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Record review of the PIR dated 10/22/24 with an incident category of abuse was signed by the Administrator on 10/22/24. The PIR reflected both residents were sitting in the sitting area and Resident #4 asked Resident #3 if he would move his chair into his spot. Resident #4 then pushed Resident #3's wheelchair forward from behind. Resident #3 became upset because Resident #4 moved his chair. Resident #3 then went back into Resident #4 with his wheelchair because he moved him. Resident #4 hit Resident #3 on the back of the head due to him hitting his wheelchair. The PIR included a skin assessment for Resident #3 and Resident #4 completed 10/17/24, social services progress notes for both residents completed 10/18/24, incident report for both residents completed 10/17/24, psychiatric assessment for Resident #4 completed 10/18/24, psychiatric assessment for Resident #3 completed 10/7/24, safe surveys with no areas of concerns dated for 10/17/24, and a 1:1 schedule for Resident #4 completed 10/17/24 and 10/18/24. The PIR reflected staff was in-serviced promptly on abuse and neglect dated 10/17/24. <BR/>During an interview on 02/26/25 at 11:10 a.m., CNA G stated Resident #3 was sitting in the doorway of the TV room and Resident #4 rolled up in his wheelchair and pushed Resident #3 wheelchair and told him to move that was his spot. CNA G stated Resident #3 told him he was not moving that he was there first. CNA G stated Resident #4 stood up and punched Resident #3 in the back of the neck with his fist closed three times. CNA G stated her, and other staff members immediately separated the residents and took Resident #4 to his room. CNA G stated Resident #4 was placed on 1:1. <BR/>During an interview on 02/26/25 at 11:41 a.m., MA E stated Resident #3 was sitting in his wheelchair in the open frame of the tv room. MA E stated Resident #4 was trying to sit where Resident #3 was sitting and he told Resident #3 to move his wheelchair and Resident #3 stated no. MA E stated Resident #4 was trying to push Resident #3 wheelchair and that was when Resident #4 stood up behind Resident #3 and punched him in the back of head/neck three times fast before staff could intervene. MA E stated it happened so fast before staff could intervene. MA E stated Resident #4 had a history of arguing with residents and usually you could verbally intervene, and he would stop. MA E stated residents were separated immediately. <BR/>During a telephone interview on 02/27/25 at 11:11 a.m., LVN A stated she was sitting at the nursing station when the incident occurred. LVN A stated Resident #3 was sitting in his wheelchair right outside the tv room and Resident #4 was coming up behind him telling him to move because he wanted to sit there. LVN A stated Resident #3 did not want to move because he was already sitting there. LVN A stated they went back and forth for a few seconds before Resident #4 hit Resident #3 in the back of the head three times. LVN A stated residents were immediately separated, and Resident #4 placed on 1:1. <BR/>During an interview on 02/27/25 at 9:03 a.m., Resident #4 stated he just moved his wheelchair off his foot. Resident #4 stated He's retarded I just got him off my foot, I didn't put my hands on him when asked about the incident between him and Resident #3.<BR/>During an interview on 02/27/25 at 9:13 a.m., Resident #3 stated two weeks ago Resident #4 hit him on his neck because he would not talk to him. <BR/>4. Resident #7 <BR/>Record review of Resident #7's face sheet, dated 02/27/25, reflected Resident #7 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included senile degeneration of brain (progressive decline in cognitive functions, such as memory, reasoning, and judgement). <BR/>Record review of Resident #7's quarterly MDS assessment, dated 02/29/25, reflected Resident #7 usually made himself understood and usually understood others. Resident #7's BIMS score was 7, which indicated his cognition was severely impaired. The MDS reflected Resident #7 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #7's comprehensive care plan revised on 02/26/25 reflected Resident #7 had impaired cognition and is at risk for further decline in cognitive and functional abilities related to dementia. The care plan interventions included: monitor/document/report to physician any changes in cognitive function, identify yourself at each interaction, stop and return if the resident becomes agitated. <BR/>Resident #8 <BR/>Record review of Resident #8's face sheet, dated 02/27/25, reflected Resident #8 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life).<BR/>Record review of Resident #8's annual MDS assessment, dated 01/31/25, reflected Resident #8 made himself understood and understood others. Resident #8's BIMS score was 5, which indicated his cognition was severely impaired. The MDS reflected Resident #8 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #8's comprehensive care plan initiated on 10/18/24 reflected Resident #8 had a behavior problem as evidenced by aggressive behaviors. The care plan interventions included: assist resident to a calm quiet area if starts becoming agitated, consult psych services if needed concerning behaviors and monitor resident for increased agitation. Resident #8 exhibits verbally abusive behavior at times and is at risk for harm and not having their needs met in a timely manner. The care plan interventions included: administer medications as ordered by the physician and monitor for effectiveness/potential adverse side effects, monitor behavior episodes, and attempt to determine underlying cause. <BR/>Record review of the undated PIR with an incident category of abuse. The PIR reflected Resident #8 asked Resident #7 to stop going in his Christmas bag. Resident #7 went into Resident #8 bag again and Resident #8 asked him again to stop. Resident #8 asked staff for help but before the staff could move Resident #7 did it again and Resident #8 popped him on the head. The PIR included a skin assessment for Resident #7 completed 12/20/24, incident report for both residents completed 12/20/24, psychiatric assessment for Resident #8 completed 12/31/24, safe surveys with no areas of concerns dated for 12/20/24, and a 1:1 schedule for Resident #8 completed 12/20/24 and 12/21/24. The PIR reflected staff was in-serviced promptly on abuse and neglect dated 12/20/24. <BR/>During an interview on 022/26/25 at 11:36 a.m., Rehab Tech H stated as she was passing by the media room, she observed Resident #7 reaching into a Christmas gift bag that was sitting next to Resident #8's chair. Rehab Tech H stated upon Resident #8 realizing that Resident #7 was reaching into his bag, Resident #8 slapped Resident #7 on top of his head stating, get out of my shit. Rehab Tech H stated her, and other staff members immediately separated the residents, interviewed the residents to see what had happened and reported the incident to the Administrator. <BR/>During an interview on 02/26/25 at 11:59 a.m., OTA K stated she was walking with Rehab Tech H from a patient's room headed back to the rehab gym and as she was passing by the media room, she observed Resident #7 reaching into a Christmas gift bag that was sitting next to Resident #8's chair. OTA K stated upon Resident #8 realizing that Resident #7 was reaching into his bag, he slapped Resident #7 on top of his head stating, get out of my shit. OTA K Stated her, and other staff members immediately separated the residents, and asked Resident #8 why he slapped Resident #7 and told him it was not ok to do that. OTA K stated Resident #8 was taking to his room by another staff member. OTA K stated she immediately went to report the incident to the Administrator. <BR/>During an interview on 02/26/25 at 1:23 p.m., the Social Worker stated she had just walked up to the nursing station when she witnessed Resident #7 reaching into Resident #8 Christmas gift bag. The Social Worker stated it appeared Resident #8 had swung his arm at Resident #7, but she did not know if contact was made. The Social Worker stated there was two therapist staff present and they immediately separated the residents. <BR/>During an interview on 02/27/25 at 9:07 a.m., Resident #7 stated I don't recall that at all when asked about the incident between him and Resident #8. <BR/>During an interview on 02/27/25 at 9:24 a.m., Resident #8 stated I hit his stupid ass because he kept going in my bag when I told him not too. <BR/>During an interview on 02/27/25 at 11:25 a.m., the DON stated she was aware of the abuse allegations. The DON stated the victims did not have any changes in behavior or any type of emotional distress since the incident. The DON stated Resident #3 and Resident #8 both have behavioral disorders that was been monitored by psych services and PCP. The DON stated the social worker has tried to find Resident #8 alternate placement but at this time there was no other facility willing to accommodate him with his behaviors. The DON stated the facility tried to find alternate placement for Resident #3, but the family was against it due to location. The DON stated staff were provided education on abuse and neglect related to all allegations of abuse of neglect. The DON stated the last in-service on abuse and neglect was 2/24/25. <BR/>During an interview on 02/27/25 at 3:10 p.m., the Administrator stated she was the abuse coordinator for the facility. The Administrator stated she was responsible for overseeing by frequent rounding of the halls and dining room and trying to deescalate any agitation by residents as it arises. The Administrator stated when a resident-resident altercation occurred the residents were immediately separated, and aggressor kept on 1:1 monitoring until a psychiatric evaluation was completed or PCP did an evaluation. The Administrator stated Resident #3 had a dx of mild ID and intermittent explosive disorder that could causes him to be disruptive or have impulse control issues. The Administrator stated once the facility learned of any allegation, they acted appropriately to protect all the residents.<BR/>Record review of the facility's policy titled Policy and Procedures: Abuse, Neglect and Exploitation revised 09/06/24 indicated . 1. The facility provides resident protection that included: (a) prevention/prohibit resident abuse, neglect . 2. The facility's abuse prevention coordinator is responsible for reporting allegations or suspected abuse, neglect . to the state survey agency and other official in accordance with state law .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, 4 of 13 (Residents #3, #4, #5, and #6) reviewed for abuse.<BR/>1. The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 10/17/24 between Resident #3 and Resident #4<BR/>2. The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 08/28/24 between Resident #3 and Resident #4. <BR/>These deficient practices could place residents at risk for abuse, neglect, and not having their needs met.<BR/>Findings included:<BR/>Record review of the facility policy for Policy and Procedures: Abuse, Neglect and Exploitation revised 09/06/24, reflected . 2. The facility's abuse prevention coordinator is responsible for reporting allegations or suspected abuse, neglect . to the state survey agency and other official in accordance with state law .III. Prevention of Abuse, Neglect and Exploitation . A. (2.) Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: 2(a). Immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involves abuse (with or without bodily injury) .<BR/>1. Resident #3<BR/>Record review of Resident #3's face sheet, dated 02/27/25, reflected Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included supraventricular tachycardia (abnormal fast heartbeat). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 02/04/25, reflected Resident #3 usually made himself understood and understood others. Resident #3's BIMS score was 9, which indicated his cognition was moderately impaired. The MDS reflected Resident #3 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #3's comprehensive care plan revised 06/20/24 reflected Resident #3 had a behavior problem as evidenced by: verbal/physical behaviors, and rejection of care. The care plan interventions included: administer medications as ordered, monitor behavior episodes, and attempt to determine underlying cause and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet, dated 02/27/25, reflected Resident #4 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #4's annual MDS assessment, dated 01/02/25, reflected Resident #4 made himself understood and usually understood others. Resident #4's BIMS score was 5, which indicated his cognition was severely impaired. The MDS reflected Resident #4 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #4's comprehensive care plan revised 04/05/24 reflected Resident #4 had a behavior problem as evidence by resident with physical aggression toward another resident when verbally antagonized. The care plan interventions included: administer medication as ordered and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Record review of the PIR dated 10/22/24 reflected an allegation of resident-to-resident incident on Resident #3 and #4 that occurred on 10/17/24 at 10:50 a.m. The PIR reflected both residents were sitting in the sitting area and Resident #4 asked Resident #3 if he would move his chair into his spot. Resident #4 then pushed Resident #3's wheelchair forward from behind. Resident #3 became upset because Resident #4 moved his chair. Resident #3 then went back into Resident #4 with his wheelchair because he moved him. Resident #4 hit Resident #3 on the back of the head due to him hitting his wheelchair. The PIR reflected staff witnessed the incident. The incident was reported to the state agency on 10/17/24 at 1:20 p.m. <BR/>2. Resident #5<BR/>Record review of Resident #5's face sheet, dated 02/27/25, reflected Resident #5 was a [AGE] year-old female, originally admitted to the facility 12/14/23 with a diagnosis which included heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). <BR/>Record review of Resident #5's annual MDS assessment, dated 01/10/25, reflected Resident #5 made herself understood and understood others. Resident #5's BIMS score was 5, which indicated her cognition was severely impaired. The MDS reflected Resident #5 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #5's comprehensive care plan revised on 09/06/24 reflected Resident #5 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to paranoid personality disorder, and depression adult failure to thrive. The care plan interventions included: monitor/document/report to physician any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes and reduce any distractions. <BR/>Resident #6<BR/>Record review of Resident #6's face sheet, dated 02/27/25, reflected Resident #6 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #6's quarterly MDS assessment, dated 02/01/25, reflected Resident #6 made herself understood and understood others. Resident #6's BIMS score was 15, which indicated her cognition was intact. The MDS reflected Resident #6 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #6's comprehensive care plan revised on 08/21/23 reflected Resident #6 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to dementia. The care plan interventions included: identify yourself at each interaction, reduce any distractions and provide instructions to resident using clear voice and simple sentences. <BR/>Record review of the undated PIR reflected an allegation of resident-to-resident incident on Resident #5 and Resident #6 that occurred 8/28/24 around 7:30 a.m. per the witnessed statement written by LVN B. The PIR reflected Resident #5 hit Resident #6 with her silverware packet at the breakfast table. The PIR reflected the incident was witnessed. The incident was reported to the state agency on 8/28/24 at 10:00 a.m. The PIR stated the facility substantiate the allegation of abuse. <BR/>During a telephone interview on 02/26/25 at 2:25 p.m., LVN B stated on the morning of 8/28/24 at approximately 7:30 a.m., she was in the dining room with another resident when she heard a noise and then heard Resident #6 state, she hit me referring to Resident #5. Resident #5 was sitting in the chair where Resident #6 normally sits. Resident #6 stated she asked Resident #5 to move, and Resident #5 picked up her silverware packet and hit her on her left arm. Resident #5 was questioned as to why she hit Resident #6 and she stated, she tried to take my silverware. LVN B stated she notified the DON, and the resident was assigned someone to stay with her while investigation was ongoing. LVN B stated the abuse coordinator was the Administrator and she knew the Administrator was on her way to the facility that morning, so she was going to tell her when she got there. <BR/>During an interview on 02/27/25 at 3:10 p.m., the Administrator stated she was the abuse coordinator for the facility. The Administrator stated the incident between Resident #3 and Resident #4 was witnessed by several staff members including herself. The Administrator stated the incident took longer to diffuse that required multiple staff member including herself to calm both residents down. The Administrator stated Resident #3 did not respond well to other staff members, but she was one that he did respond well too. The Administrator stated she was aware of the incident on 8/28/24 due to Resident #6 been at her office door upon her arrival. The Administrator stated after Resident #6 made the allegation, she went down to talk to LVN B and she informed her of the allegation, but she expected LVN B to contact her immediately regarding the incident. The Administrator stated she did agree that the allegations should always be reported within 2 hours unless there are extenuating circumstances. The Administrator stated she was responsible for overseeing by frequent rounding of the halls and dining room and trying to deescalate any agitation by residents as it arises. The Administrator stated she was the only one in the facility who could report abuse allegations to HHSC. The Administrator stated it was important to report an allegation of abuse and neglect for safety and protection of the residents and try to circumvent other incidents of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 4 of 13 (Residents #3, #4, #5, and #6) residents reviewed for reporting.<BR/>1. The facility did not report the resident-to-resident altercation between Resident #3 and Resident #4 to the State Survey Agency within 2 hours of been notified. <BR/>2. The facility did not report the resident-to-resident altercation between Resident #5 and Resident #6 to the State Survey Agency within 2 hours of been notified. <BR/>These failures to report could place the residents at risk for abuse. <BR/>Findings included:<BR/>1. Resident #3<BR/>Record review of Resident #3's face sheet, dated 02/27/25, reflected Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included supraventricular tachycardia (abnormal fast heartbeat). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 02/04/25, reflected Resident #3 usually made himself understood and understood others. Resident #3's BIMS score was 9, which indicated his cognition was moderately impaired. The MDS reflected Resident #3 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #3's comprehensive care plan revised 06/20/24 reflected Resident #3 had a behavior problem as evidenced by: verbal/physical behaviors, and rejection of care. The care plan interventions included: administer medications as ordered, monitor behavior episodes, and attempt to determine underlying cause and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet, dated 02/27/25, reflected Resident #4 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #4's annual MDS assessment, dated 01/02/25, reflected Resident #4 made himself understood and usually understood others. Resident #4's BIMS score was 5, which indicated his cognition was severely impaired. The MDS reflected Resident #4 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #4's comprehensive care plan revised 04/05/24 reflected Resident #4 had a behavior problem as evidence by resident with physical aggression toward another resident when verbally antagonized. The care plan interventions included: administer medication as ordered and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Record review of the PIR dated 10/22/24 reflected an allegation of resident-to-resident incident on Resident #3 and #4 that occurred on 10/17/24 at 10:50 a.m. The PIR reflected both residents were sitting in the sitting area and Resident #4 asked Resident #3 if he would move his chair into his spot. Resident #4 then pushed Resident #3's wheelchair forward from behind. Resident #3 became upset because Resident #4 moved his chair. Resident #3 then went back into Resident #4 with his wheelchair because he moved him. Resident #4 hit Resident #3 on the back of the head due to him hitting his wheelchair. The PIR reflected staff witnessed the incident. The incident was reported to the state agency on 10/17/24 at 1:20 p.m. <BR/>2. Resident #5<BR/>Record review of Resident #5's face sheet, dated 02/27/25, reflected Resident #5 was a [AGE] year-old female, originally admitted to the facility 12/14/23 with a diagnosis which included heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). <BR/>Record review of Resident #5's annual MDS assessment, dated 01/10/25, reflected Resident #5 made herself understood and understood others. Resident #5's BIMS score was 5, which indicated her cognition was severely impaired. The MDS reflected Resident #5 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #5's comprehensive care plan revised on 09/06/24 reflected Resident #5 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to paranoid personality disorder, and depression adult failure to thrive. The care plan interventions included: monitor/document/report to physician any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes and reduce any distractions<BR/>. <BR/>Resident #6<BR/>Record review of Resident #6's face sheet, dated 02/27/25, reflected Resident #6 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #6's quarterly MDS assessment, dated 02/01/25, reflected Resident #6 made herself understood and understood others. Resident #6's BIMS score was 15, which indicated her cognition was intact. The MDS reflected Resident #6 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #6's comprehensive care plan revised on 08/21/23 reflected Resident #6 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to dementia. The care plan interventions included: identify yourself at each interaction, reduce any distractions and provide instructions to resident using clear voice and simple sentences. <BR/>Record review of the undated PIR reflected an allegation of resident-to-resident incident on Resident #5 and Resident #6 that occurred 8/28/24 around 7:30 a.m. per the witnessed statement written by LVN B. The PIR reflected Resident #5 hit Resident #6 with her silverware packet at the breakfast table. The PIR reflected the incident was witnessed. The incident was reported to the state agency on 8/28/24 at 10:00 a.m. The PIR stated the facility substantiate the allegation of abuse. <BR/>During a telephone interview on 02/26/25 at 2:25 p.m., LVN B stated on the morning of 8/28/24 at approximately 7:30 a.m., she was in the dining room with another resident when she heard a noise and then heard Resident #6 state, she hit me referring to Resident #5. Resident #5 was sitting in the chair where Resident #6 normally sits. Resident #6 stated she asked Resident #5 to move, and Resident #5 picked up her silverware packet and hit her on her left arm. Resident #5 was questioned as to why she hit Resident #6 and she stated, she tried to take my silverware. LVN B stated she notified the DON, and the resident was assigned someone to stay with her while investigation was ongoing. LVN B stated the abuse coordinator was the Administrator and she knew the Administrator was on her way to the facility that morning, so she was going to tell her when she got there. <BR/>During an interview on 02/27/25 at 3:10 p.m., the Administrator stated she was the abuse coordinator for the facility. The Administrator stated the incident between Resident #3 and Resident #4 was witnessed by several staff members including herself. The Administrator stated the incident took longer to diffuse that required multiple staff member including herself to calm both residents down. The Administrator stated Resident #3 did not respond well to other staff members, but she was one that he did respond well too. The Administrator stated she was aware of the incident on 8/28/24 due to Resident #6 been at her office door upon her arrival. The Administrator stated after Resident #6 made the allegation, she went down to talk to LVN B and she informed her of the allegation, but she expected LVN B to contact her immediately regarding the incident. The Administrator stated she did agree that the allegations should always be reported within 2 hours unless there are extenuating circumstances. The Administrator stated she was responsible for overseeing by frequent rounding of the halls and dining room and trying to deescalate any agitation by residents as it arises. The Administrator stated she was the only one in the facility who could report abuse allegations to HHSC. The Administrator stated it was important to report an allegation of abuse and neglect for safety and protection of the residents and try to circumvent other incidents of abuse.<BR/>Record review of the facility policy for Policy and Procedures: Abuse, Neglect and Exploitation revised 09/06/24, reflected . it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect . 1. The facility provides resident protection that included: (a) prevention/prohibit resident abuse, neglect . 2. The facility's abuse prevention coordinator is responsible for reporting allegations or suspected abuse, neglect . to the state survey agency and other official in accordance with state law .III. Prevention of Abuse, Neglect and Exploitation . A. (2.) Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: 2(a). Immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involves abuse (with or without bodily injury) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of 20 residents (Residents #26, #14 and #1) reviewed for resident rights.<BR/>1. The facility failed to ensure RN F and CNA Z treated residents with dignity and respect by referring to them as feeders. <BR/>2. The facility failed to ensure the Environmental Service Manager knocked prior to entering Resident #26 room. <BR/>3. The facility failed to ensure LVN E provided privacy for Resident #14 while administering his insulin injection. <BR/>4. The facility failed to ensure Resident #1 had a privacy bag for his catheter drainage bag. <BR/>These failures could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.<BR/>The findings included: <BR/>1. During an observation on 02/06/2023 at 11:52 a.m., RN F stated where's the feeders in the dining hall while passing out food trays to the residents who required assistance with eating. <BR/>During an interview on 02/08/2023 at 1:58 p.m., RN F stated she did not know the word feeder was inappropriate until she was told by the DON. RN F stated the DON told her she should use the word assistance. RN F stated she had used the word feeder several times, but it was not set in her vocabulary. RN F stated the failure to residents for being referred to as a feeder was a dignity issue. <BR/>During an observation and interview on 02/06/2023 at 1:33 PM, CNA Z said, that's for my feeder. CNA Z was approximately 3 feet from several resident doors. CNA Z stated it was not appropriate to refer to a resident as a feeder. CNA Z stated she was trying to explain that was why she had one tray left on the cart. CNA Z stated referring to residents' as feeder could have made residents' feel disrespected.<BR/>2. During an observation on 02/06/2023 at 10:14 a.m., the Environmental Service Manager entered Resident #26 room without knocking. <BR/>During an interview on 02/06/2023 at 10:20 a.m., Resident #26 stated he did not feel he, and his wife had any privacy. Resident #26 stated the housekeepers never knocked prior to entering. <BR/>During an interview on 02/08/2023 at 1:52 p.m., the Environmental Service Manager stated she should have knocked prior to entering Resident #26 room. The Environmental Service Manager stated she was moving too fast and forgot to knock. The Environmental Service Manger stated she had never been told that some of her staff did not knock prior to entering resident's room. The Environmental Service Manager stated this failure was not providing privacy to residents. <BR/>3. During an observation and interview on 02/07/2023 at 11:20 a.m., LVN E administered Resident #14 insulin with the door open. Resident #14 did not have a roommate. LVN E stated it was not okay to administer medication to residents without providing privacy. LVN E was unable to say why she did not close the door prior to administering Resident #14 medication. LVN E stated this failure was a lack of dignity and respect.<BR/>During an interview on 02/08/2023 at 4:36 p.m., the DON stated he expected staff to knock prior to entering resident's room. The DON stated he expected staff to provide privacy when administering medications. The DON stated he expected staff to say assisted dining room instead of saying the word feeder. The DON stated this was monitored by weekly rounds and visiting with residents/family to ensure privacy has been provided. The DON stated staff were in serviced at least once a month. The DON stated he was unaware of any issues. The DON stated there was not a system in place for staff at nurse level to monitor for that specific dignity infarction related to administering medications without privacy. <BR/>During an interview on 02/08/2023 at 6:13 p.m., the Administrator stated he expected staff to knock prior to entering resident's room. The Administrator stated he expected staff to provide privacy when administering medications and expected staff to say assisted dining room instead of the word feeder. The Administrator stated this failure was an embarrassment to the residents and a dignity issue. <BR/>4. Record review of Resident #1's face sheet (undated) revealed he was a [AGE] year-old-male who admitted to the facility on [DATE] with diagnoses of senile degeneration of the brain (mental condition where your brain cells begin to degenerate), unspecified dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and benign prostatic hyperplasia with lower unitary tract symptoms, BPH (overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine). <BR/>Record review of Resident #1's order summary report, dated 02/08/2023, revealed an order which started on 10/31/2022 for May have suprapubic catheter for dx: Obstructive uropathy. The order summary report further revealed an order which started on 10/31/2022 for Suprapubic care q shift and prn. Check privacy bag every shift.<BR/>Record review of the MDS assessment, dated 11/08/2022, revealed Resident #1 had clear speech and was understood by staff. The MDS revealed Resident #1 was able to understand others. The MDS revealed Resident #1 had a BIMS score of 07 which indicated severe cognitive impairment. The MDS revealed Resident #1 had no behaviors or refusal of care. The MDS revealed Resident #1 had an indwelling catheter. <BR/>Record review of the comprehensive care plan, last revised on 01/03/2023, revealed Resident #1 had a suprapubic catheter. The interventions included: Privacy bag over the drainage bag. <BR/>During an observation and resident interview on 02/06/2023 at 10:25 AM, the catheter bag, with approximately 100 mL of clear, yellow urine, was hanging on Resident #1's wheelchair with no privacy bag noted. Resident #1 was non-interviewable related to severe cognitive impairment as evidenced by confused conversation. <BR/>During an observation on 02/06/2023 at 3:35 PM, catheter bag, with approximately 200 mL of clear, yellow urine, was hanging on Resident #1's wheelchair with no privacy bag noted.<BR/>During an observation on 02/07/2023 at 8:17 AM, Resident #1 was self-propelling his wheelchair down the hallway from the dining room, the catheter bag, with the tubing full of clear, yellow, urine, was hanging from wheelchair with no privacy bag noted.<BR/>During an interview on 02/08/2023 at 4:35 PM, CNA Q stated Resident #1 was supposed to have a privacy bag for his catheter drainage bag. CNA Q stated she had no clue why Resident #1 had no privacy bag for his catheter drainage bag. CNA Q stated CNAs were unable to provide the type of privacy bags the facility used. CNA Q stated CNAs were able to alert the nurse that one was needed. CNA Q stated the nurse was not notified that Resident #1 needed a privacy bag. CNA Q stated privacy bags were important so Resident #1 could have privacy and dignity. <BR/>During an interview on 02/08/2023 at 4:46 PM, NA R stated Resident #1 was supposed to have a privacy bag for his catheter drainage bag. NA R stated he was unsure why Resident #1 had no privacy bag on his catheter drainage bag. NA R stated the nurse was responsible for placing privacy bags. NA R stated he was unsure if the nurse was notified of the need for a privacy bag. NA R stated privacy bags were important so Resident #1 could have privacy and dignity. <BR/>During an interview on 02/08/2023 at 5:13 PM, LVN (ADON) H stated the nurses and ADONs were responsible for ensuring privacy bags were applied to catheter drainage bags. LVN (ADON) H stated nurses were responsible for monitoring to ensure privacy bags were applied to catheter drainage bags. LVN (ADON) H stated she was unsure why Resident #1 had no privacy bag. LVN (ADON) H stated privacy bags were important to maintain Resident #1's dignity. <BR/>During an interview on 02/08/2023 at 7:09 PM, the DON stated CNAs should have been aware when residents need a privacy bag to catheter drainage bags. The DON stated Resident #1 should not have been provided with a catheter drainage bag with no privacy ability. The DON stated this was monitored by looking at invoices for resident care equipment ordered by the facility. The DON stated ultimately the nurses were responsible for ensuring privacy bags were provided for catheter drainage bags. The DON stated the importance of privacy bags was to ensure dignity. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated he expected nursing staff to ensure Resident #1 had a privacy bag for his catheter drainage bag. The ADM stated privacy bags were important to ensure Resident #1's dignity and privacy. <BR/>Record review of the Urinary Catheter Management policy, last reviewed on 08/20/2021, revealed Fundamental Information 3.Provide privacy and dignity by covering urinary bag with a bag cover. <BR/>Record review of the Resident Rights policy, last reviewed on 02/20/2021, revealed 4. Respect and Dignity. The resident has a right to be treated with respect and dignity. The policy further revealed 7. Privacy and confidentiality. a. personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to be informed of and participate in his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment and treatment alternatives or treatment options to choose the alternative or option he or she preferred for 1 of 4 residents (Resident #38) reviewed for right to be informed <BR/>The facility failed to obtain an informed consent based on the information of the benefits and risks for Resident #38 before administering Bupropion, an antidepressant medication, used to treat depression. <BR/>This failure could place residents at risk of receiving medications they had not consented to, experiencing potential adverse reactions, and a potential decline in physical and mental health status.<BR/>Findings included:<BR/>Record review of Resident #38's face sheet, dated 03/28/24, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses which included anxiety (a feeling of fear, dread, and uneasiness), Deep vein thrombosis {DVT} (a medical condition that occurs when a blood clot forms in a deep vein), diabetes and stroke.<BR/>Record review of Resident #38's admission MDS assessment, dated 02/04/24, indicated Resident #38 was usually understood and usually understood others. Resident #38's BIMS score was 08, which indicated he was cognitively moderately impaired. The MDS did not indicate Resident #38 was on an antianxiety medication. The MDS indicated Resident #38 required extensive assistance with bathing, limited assistance with toileting bed mobility, dressing, personal hygiene, transfers, and supervision assistance for eating.<BR/>Record review of Resident #38's physician order dated 01/29/24, indicated Bupropion HCI ER XL 300 MG Oral Tablet Extended Release 24 Hour, give 1 tablet by mouth in the morning for depression and smoking cessation. <BR/>Record review of Resident #38's care plan did not indicate the use of antidepression medication, Bupropion. <BR/>Record review for Resident #38's consent for the use of antidepression medication, Bupropion was not documented in her chart.<BR/>During an interview on 03/27/24 at 5:57 p.m., the DON said the charge nurses were responsible for getting consent. She said the ADONs were responsible for monitoring to ensure consent forms were completed. The DON looked throughout Resident #38's medical records via point-click care (facility electronic system) and did not see where his consent was in the chart. The DON said she was unsure why Resident #38 had no consent form for Bupropion. The DON stated it was important to ensure consent forms were filled out so Resident #38 or his representative could make an informed decision. <BR/>During an interview on 03/27/24 at 6:20 p.m., LVN P said consent should be obtained for all psychoactive medication before being given . She said once they received an order for any psychoactive medication, they would call the family if the resident was not aware and then get 2 nurses to verify their consent over the phone and then ask the family member to sign the consent when they came to the facility. LVN P said if the charge nurses were unable to get consent, then the ADONs would obtain the consent the following morning.<BR/>During an interview on 03/27/24 at 6:32 p.m., the ADON W said the charge nurses were responsible for getting the consents signed and she was supposed to follow up to ensure consents were received . She said she attended morning meeting where she learned of any new medication changes and reviewed consents and updated if needed from there. She said she was not sure why Resident #38 did not have his consent for Bupropion. She said it was important to ensure residents or representatives signed consent forms so they could make an informed decision about their care.<BR/>During an interview on 03/27/24 at 6:34 p.m., Resident #38 was unable to tell the State Surveyor if he had been educated on Bupropion. He said, I do not know what that is.<BR/>During an interview on 03/27/24 at 6:53 p.m., the Administrator said nurse management was responsible for ensuring psychotropic consent forms were signed and filled out. The Administrator said it was important to ensure consent forms were signed so the residents or representative understood and were able to give informed consent.<BR/>Record review of facility policy, titled, Clinical Practice Guideline Use of Psychotropic medication, dated 04/05/22 indicated, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: #1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. #5. Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 20 residents (Resident #73) reviewed for self-determination.<BR/>The facility failed to ensure RN M and CNA N assisted Resident #73 to the toilet when she requested to be put on the toilet. <BR/>This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that are import in their life and decrease their quality of life.<BR/>Findings included:<BR/>Record review of Resident #73's face sheet, dated 02/08/23, revealed a [AGE] year-old female initially admitted on [DATE] with diagnoses of metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and chronic obstructive pulmonary disease, unspecified (chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Record review of the MDS assessment, dated 01/30/23, revealed Resident #73 was usually understood and usually understood others. Resident #73's BIMS score was a 00, indicating severe mental impairment. Resident #73's MDS assessment indicated she required extensive assist for bed mobility, transfers, dressing, eating, and personal hygiene and total dependence for toilet use. Resident #73's MDS assessment indicated she was always incontinent of bowel and bladder. <BR/>Record review of Resident #73's care plan, last revised 11/16/22, indicated Resident #73 had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner with the goal of resident will participate to the best of their ability and maintain current level of functioning with ADLs through the next review date. Resident #73's care plan indicated she required extensive assistance with bed mobility, transfers, and toileting. Resident #73's care plan indicated the resident is incontinent of bowel/bladder related to active infections with symptoms of UTI (urinary tract infection), history of UTI, impaired mobility, physical limitations, recent surgery, CVA (stroke), with an intervention to assist to the toilet as needed. <BR/>Record review of Resident #73's order summary report did not reveal any physician's orders restricting Resident #73's activities. <BR/>During an observation and interview on 02/06/23 starting at 10:09 AM, Resident #73 was observed laying in the bed she said she needed to use the bathroom and they would not allow her to get up and go to the bathroom. Resident #73 said she had asked the aides for assistance to the bathroom, and they told her they could not get her up. Resident #73 was not able to give specific names of staff. Resident #73 said it was the nurses and CNAs. This surveyor informed CNA N Resident #73 had requested assistance to go to the bathroom. CNA N replied ok. After this, RN M approached this surveyor and said Resident #73 was incontinent and she was not supposed to get out of bed because her blood pressure would drop, therefore she had to stay in bed and the CNAs would provide incontinent care. Resident #73 remained in the bed and was not assisted to the bathroom. <BR/>During an observation and interview on 02/07/23 at 1:37 PM Resident #73 was observed laying in the bed and said she would like to get out of bed more and be assisted to the toilet instead of having to use her brief because she was trying to be more continent. Resident #73 said she had told the staff but was unable to provide names. <BR/>During an interview on 02/08/23 at 12:01 PM, CNA N said she did not assist Resident #73 to the toilet because RN M told her not to assist her to the toilet because she was incontinent. CNA N said if any resident asked her for assistance, she should assist the resident. <BR/>During an interview on 02/08/23 at 4:25 PM, LVN P said he was one of the nurses that provided care to Resident #73. LVN P said Resident #73 could get out of the bed and should be assisted to the toilet when she requested it. LVN P said Resident #73 had not complained of any dizziness or light headedness when placed on the toilet or in the wheelchair. LVN P said Resident #73 did not have any low blood pressures. <BR/>During an interview on 02/08/23 at 5:21 PM, ADON K said Resident #73 could get up and she should have been assisted to the toilet when she requested it. ADON K said there was no reason why Resident #73 could not have been assisted to the toilet. ADON K said it was Resident #73's right to get up when she chose to. ADON K said Resident #73 should have the choice of when to get out of bed and when to go to the toilet. ADON K said not providing Resident #73 the choice to get up and to go to the toilet could cause her to be depressed, could lead to falls and injuries. ADON K said the nurses and CNAs should be making sure the residents; choices were being respected. <BR/>During an interview on 02/08/23 at 5:25 PM LVN D said she was one of the nurses who provided care for Resident #73. LVN D said Resident #73 did not have low blood pressures. LVN D said Resident #73 had the right to make choices and to be placed on the toilet when she requested it. LVN D said not assisting Resident #73 to the toilet could make her more of a fall risk and if her choices were not respected it could make her angry and upset. <BR/>During an interview on 02/08/23 at 6:43 PM, the DON said Resident #73 should have been put on the toilet. The DON said Resident #73 should have a choice as to her daily activities. The DON said he made sure staff was respecting the residents' rights by doing in-services. The DON said Resident #73 not being assisted to the toilet could decrease her quality of life. <BR/>During an interview on 02/08/23 at 8:02 PM, the administrator said Resident #73 should be able to get up and go. The administrator said Resident #73 should have the choice to be put on the toilet and to get out of bed. The administrator said he did an in-service last week with all the staff on resident rights dignity and respect. The administrator said not assisting Resident #73 to the toilet could affect her dignity, self-esteem, and could make her feel like she did not have a voice, or a choice and it was not letting her keep her independence. <BR/>Phone call interview attempted with RN M on 02/08/23 at 8:27 PM and was unsuccessful. <BR/>Record review of the facility's policy titled Activities of Daily Living Care Guidelines, last reviewed 02/11/21, revealed, . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Residents participate in and receive the following person centered care . mobility: walking or receiving assistance with ambulation, transfer oneself or receiving assistance or use of wheelchair, moving oneself or receiving assistance with bed mobility, toileting/continence: toileting or receiving assistance with toileting . <BR/>Record review of the facility's policy titled Resident Rights, last reviewed 02/20/21, revealed, . The facility will ensure that all staff members are educated on the rights of the residents and the responsibility of the facility to properly care of its residents . Resident Rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility . Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: a. The resident has a right to choose activities, schedules (including sleeping and waking times), health care providers of health care services consistent with his or her interests, assessments ad plan of care and other applicable provisions of this part, b. the resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #62) of 18 residents reviewed for changes in condition, in that:<BR/>The facility failed to notify Resident #62's RP after she had abnormal hemoglobin lab values and required a blood transfusion. <BR/>This failure placed residents at risk of a delay in treatment and their responsible party not being informed and involved in care decisions.<BR/>Findings included:<BR/>Record review of Resident #62's face sheet dated 03/27/24 indicate she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Dementia (decline in cognitive abilities that impacts everyday activities), Type 2 Diabetes (blood sugar regulation disorder), and Hypertension (high blood pressure), and anxiety. Resident #62's face sheet also indicated she had 3 family members listed for emergency contact.<BR/>Record review of Resident #62's quarterly MDS assessment dated [DATE] indicated she had a BIMS score of 15 which means she was cognitively intact. <BR/>Record review of Resident #62's progress note dated 2/23/24-03/25/24 indicated no entries related to the notification of Resident #62's emergency contact that resident had appointment setup on 03/20/24 to go to another facility to get a blood transfusion related to her abnormal hemoglobin lab values. <BR/>Record review of Resident #62's encounter information from the infusion center dated 03/20/24 indicated she had a blood transfusion. <BR/>Record review of Resident #62's labs dated 03/15/24 indicated resident had a very abnormal lab value for her hemoglobin of 6.4. <BR/>Record review of Resident #62's labs dated 03/18/24 indicated resident had a very abnormal lab value for her hemoglobin of 6.3.<BR/>During an interview on 03/25/24 at 03:53 PM Resident #62's emergency contact said the facility never notified them that Resident #62 had gone to another facility for a blood transfusion related to abnormal hemoglobin lab values. They said they knew of the lab values because they called the facility to check on Resident #62 when she was not feeling well enough to speak to them on her personal phone. <BR/>During an interview on 03/27/24 at 10:37 AM RN A said she called the medical director about the abnormal lab values received and had begun the paperwork for getting the resident sent out to the infusion center on 3/19/24. She said she called the infusion center to check, and they had Resident #62 setup for the blood transfusion on 03/20/24 to go get the infusion. RN A said she did not notify Resident #62's emergency contacts about the labs nor the infusion because she told the resident, and she was cognitively intact to tell her emergency contacts. Responsible party should have been notified when abnormal values were received. RN A said the nurse who sent Resident #62 out to the appointment should have notified the emergency contact about the hospital visit. She said the failure of her not notifying the emergency contact placed the resident's family at risk of not being aware a change of condition that could have occurred, and the family would not be available for any decision making the resident may have needed. <BR/>During an interview on 03/27/24 at 05:12 PM the ADON said her expectation was for the resident's emergency contacts to be notified of the abnormal hemoglobin labs and transfer for the blood transfusion when the nurse received the information. She said it was important for them to be aware of what was going on with the resident. <BR/>During an interview on 03/27/24 at 05:41 PM the DON said the charge nurse should have contacted Resident #62's family with condition changes and any new orders received. She said the failure to notify the family placed Resident #62 at risk of the family not being aware and accident possibly happening while she was away from the facility.<BR/>During an interview on 03/27/24at 06:09 PM the Administrator said the family should have been notified of the labs and the transfer for the infusion as well. She said the charge nurse who took the orders was responsible for calling the family. The Administrator said with the family not being aware it placed Resident #62 at risk for something medical that could have happened while she was at the hospital and the family not being aware. <BR/>Record review of the facility policy for Notification of Changes dated 01/10/2020 indicated:<BR/>Policy<BR/>To provide guidance on when to communicate acute changes in status to MD, NP, and / responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following:<BR/>1. <BR/>An accident resulting in injury to the resident that potentially requires physician intervention.<BR/>2. <BR/>An emergency response situation that require EMS involvement<BR/>3. <BR/>A significant change in the physical, mental or psychosocial status of the resident.<BR/>4. <BR/>The need to significantly alter the resident's treatment.<BR/>5. <BR/>A decision to transfer or discharge the resident to another facility.<BR/>Policy Explanation and Compliance Guidelines:<BR/>1. In the case of a competent resident, the facility will contact the resident's physician and appropriate family member(s)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 4 residents (Resident's #30, 183 and 185) reviewed for Medicare/Medicaid coverage. <BR/>The facility failed to ensure Resident #30, Resident #183, and Resident #185 were given a Skilled Nursing Facility Advanced Beneficiary notice of non-coverage ({SNF ABN}, which is a document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility before covered days were exhausted. <BR/>This failure could place residents at risk for not being aware of changes to provided services.<BR/>Findings include:<BR/>1.Record review of Resident #30's face sheet, indicated he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included gastroenteritis (an inflammation of the lining of the stomach and intestines), anxiety (a feeling of fear, dread, and uneasiness), and depression (a low mood and a loss of interest in activities).<BR/>Record review of Resident #30's other MDS assessment dated [DATE], indicated Resident #30 had a BIMS score of 04, which indicated his cognition was severely impaired.<BR/>Record review of the SNF Beneficiary Protection Notification Review indicated Resident #30 was receiving Medicare Part A services starting on 12/28/23 and the last covered day of Part A services was 03/21/24, however, it was revealed that a SNF ABN was not completed which would have informed Resident #30 of the option to continue services at the risk of out-of-pocket cost. <BR/>2.Record review of Resident #183's face sheet indicated an [AGE] year-old female who admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included Dementia (forgetfulness), kidney failure (Loss of kidney function), and atrial fibrillation (AF), (a type of arrhythmia, or abnormal heartbeat).<BR/>Record review of Resident #183's annual MDS assessment dated [DATE], indicated Resident #183 was understood and understood others. The MDS assessment indicated Resident #183 had a BIMS score of 06, which indicated her cognition was moderately impaired.<BR/>Record review of the SNF Beneficiary Protection Notification Review indicated Resident #183 was receiving Medicare Part A services starting on 11/20/23 and the last covered day of Part A services was 01/25/24, however it was revealed that a SNF ABN was not completed which would have informed Resident #183 of the option to continue services at the risk of out-of-pocket cost.<BR/>3.Record review of Resident #185's face sheet indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Respiratory failure (a serious condition that makes it difficult to breathe on your own), Congestive heart failure, or heart failure, (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), and stroke.<BR/>Record review of Resident #185's quarterly MDS assessment dated [DATE], indicated Resident #185 was understood and understood others. The MDS assessment indicated Resident #185 had a BIMS score of 08, which indicated her cognition was moderately impaired.<BR/>Record review of the SNF Beneficiary Protection Notification Review indicated Resident #185 was receiving Medicare Part A services starting on 11/07/2023 and the last covered day of Part A services was 11/28/24, however it was revealed that a SNF ABN was not completed which would have informed Resident #185 of the option to continue services at the risk of out-of-pocket cost.<BR/>During an interview on 03/27/24 at 7:30 p.m., MDS Coordinator R said she was not aware she was supposed to complete an SNF ABN for Resident #30 and Resident #183. She said she was not employed when Resident #185 should have been given an SNF ABN form. MDS Coordinator R said she had been only trained on giving NOMNC (Notice of Medicare Non-Coverage) when a resident was coming off skilled services by prior MDS Coordinator. She said the NOMNC forms were in a drawer in her office but no SNF ABN forms were available. She said she was not sure why the residents needed an SNF ABN form.<BR/>During an interview on 03/27/24 at 7:35 p.m., MDS Coordinator Q said she was not aware she was supposed to complete an SNF ABN for Resident #30 Resident #185, and Resident #183. She said she called her regional MDS nurse today (03/27/24) and was told the BOM completed the SNF ABN because it was a financial issue. <BR/>During an interview on 03/27/24 at 7:40 p.m., the BOM said she was not aware of an SNF ABN form. She called her regional BOM today (03/27/24) and was told she was not responsible for completing the SNF ABN form, it was the MDS Coordinator's responsibility.<BR/>During an interview on 03/27/24 at 7:50 p.m., the DON said she was not aware of the SNF ABN forms. She said she did not know whose responsibility it was to complete the SNF ABN forms or why they needed to be completed. She said the Administrator was the overseer of the MDS Coordinator therefore she was not aware of the process.<BR/>During an interview on 03/27/24 at 8:00 p.m., the Administrator said she was not aware of the SNF ABN forms. She said she had been the Administrator since August but was not sure whose responsibility it was to complete the SNF ABN form . She said she would have to have more knowledge of this process to answer the surveyor's questions.<BR/>Record review of an undated document titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 (2018), indicated, Medicare requires SNFs to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: not medically reasonable and necessary; or considered custodial . The SNFABN provides information to the beneficiary so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 24 residents (Resident #36) reviewed for privacy.<BR/>The facility failed to ensure LVN F provided privacy for Resident #36 while she administered his g-tube medications (gastrostomy tube is a tube that gives direct access to the stomach for administration of medications and feedings). <BR/>This failure could place residents at risk of having their bodies exposed to the public, low self-esteem, and a diminished quality of life.<BR/>Findings included:<BR/>Record review of a face sheet dated 03/27/2024, indicated Resident #36 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included cerebral palsy (a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination) and autistic disorder (developmental disabilities that can cause significant social, communication and behavioral challenges). <BR/>Record review of Resident #36's Quarterly MDS assessment dated [DATE] indicated he was rarely/never understood by others, and he usually understood others. The MDS assessment indicated Resident #36 had a short-term and long-term memory problem. The MDS assessment indicated Resident #36 was dependent on staff for all ADLs. <BR/>Record review of Resident #36's care plan with a target date of 04/29/2024 indicated he had cognitive impairment with a goal to meet his needs in a timely manner and that his dignity would be maintained. <BR/>During an attempted interview on 03/24/2024 at 11:16 a.m., Resident #36 was non-interviewable. <BR/>During an observation and interview on 03/26/2024 starting at 2:11 p.m., LVN F uncovered Resident #36 to administer his medications by g-tube (gastrostomy tube is a tube that gives direct access to the stomach for administration of medications and feedings). Resident #36 was lying on his side with is buttocks facing the entry to the room. Resident #36 bottom was exposed (he was wearing a brief). A staff member knocked on the door and asked LVN F if it was ok for EMS to bring in his roommate. LVN F said it was ok for them to enter the room. 2 EMS providers entered the room with Resident #36's roommate. Resident #36 was exposed while the EMS providers entered the room and left Resident #36's roommate. LVN F failed to pull the curtain to provide privacy for Resident #36. LVN F said she should have told the staff member and EMS providers to wait a minute, since Resident #36 was exposed. LVN F said privacy should be provided when residents were exposed to ensure their dignity was maintained. <BR/>During an interview on 03/27/2024 at 3:23 p.m., ADON M said LVN F should not have allowed EMS providers to enter the room while Resident #36 was exposed. ADON M said it should not be allowed because the residents had the right for privacy and dignity. ADON M said anybody providing care should ensure the residents were treated with privacy, dignity, and respect. ADON M said she randomly walked the halls to ensure staff were providing privacy to the residents. <BR/>During an interview on 03/27/2024 at 4:11 p.m., the DON said LVN F should have provided privacy to Resident #36. The DON said the residents should have privacy, so they were not exposed. The DON said she provided constant education to the staff to ensure they were providing the residents privacy and dignity during care. The DON said she made rounds daily to ensure privacy was being provided to the residents. <BR/>During an interview on 03/27/2024 at 5:19 p.m., the Administrator said she expected for the nurses to provide privacy when providing resident care. The Administrator said LVN F should have pulled the privacy curtain to provide privacy for Resident #36 and prevent him from being exposed to others. The Administrator said the nurses were responsible for providing privacy, and the ADONs and DON were responsible for monitoring the nurses to ensure they were providing privacy. The Administrator said providing privacy was important to ensure the residents dignity was maintained. <BR/>Record review of the facility's policy reviewed, 02/20/2021, titled, Resident Rights, indicated, . 7. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. a. Personal privacy includes accommodations, medical treatment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #38's face sheet, dated 03/28/24, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses which included anxiety (a feeling of fear, dread, and uneasiness), Deep vein thrombosis {DVT} (a medical condition that occurs when a blood clot forms in a deep vein), diabetes and stroke.<BR/>Record review of Resident #38's admission MDS assessment, dated 02/04/24, indicated Resident #38 was usually understood and usually understood others. Resident #38's BIMS score was 08, which indicated he was cognitively moderately impaired. The MDS did indicate Resident #38 was on an anticoagulant medication. The MDS indicated Resident #38 required extensive assistance with bathing, limited assistance with toileting bed mobility, dressing, personal hygiene, transfers, and supervision assistance for eating.<BR/>Record review of Resident #38's physician's orders dated 01/29/24, indicated: Aspirin EC (enteric coated) Tablet delayed release 81 MG, Give 1 tablet by mouth in the morning for high blood pressure. <BR/>Record review of Resident #38's physician's orders dated 01/29/24, indicated: Clopidogrel Bisulfate (Plavix) 75 MG tablet, give 1 tablet by mouth in the morning for blood clot prevention.<BR/>Record review of Resident #38's comprehensive care plan, dated 01/29/23 indicates he took an anticoagulant medication. The interventions were for staff to educate resident/family/caregiver to include the following: Take/give medication at the same time each day, use a soft toothbrush, use electric razor, avoid activities that could result in injury, take precautions to avoid falls, Signs/symptoms of bleeding, Avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk, and cheese.<BR/>During an interview and observation on 03/27/24 at 11:20 a.m., the MDS Coordinator R said she was responsible for the completion of the MDS for Resident #17 and Resident #38. She looked at Resident #38's quarterly MDS assessment dated [DATE] and Resident #17's on 01/30/24 on section N and said she coded them both as taking an anticoagulant medication. The MDS coordinator said she coded it that way because Aspirin and Plavix fell under the category of anticoagulant medication . She said she would go fix the MDS assessments. She said it was a mistake. She said it was important to code the MDS assessment correctly because it reflected their care. <BR/>During an interview on 03/27/24 at 5:57 p.m., the DON said the MDS Coordinator was responsible for completing the MDS. The DON said she expected the assessments to be reflected in the MDS because it could be misleading if coded incorrectly.<BR/>During an interview on 03/27/24 at 6:32 p.m., the ADON W said the MDS Coordinator was responsible for completing the MDS. She said she expected the MDS nurses to do an accurate assessment because it affects the resident's care and it needs to be accurate. She said she was not aware of who was responsible to ensure MDS's were accurate.<BR/>During an interview on 03/27/24 at 6:53 p.m., the Administrator said the MDS Coordinator was responsible for the completion of the MDS. She said she expected the MDS assessment for any resident to be completed thoroughly and correctly based on the resident assessment.<BR/>3. Record review of a face sheet dated 03/27/2024 indicated Resident #49 was a [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (condition where the lungs cannot supply enough oxygen or remove enough carbon dioxide from the blood) and chronic diastolic congestive heart failure (condition in which the heart cannot fill up with blood properly). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #49 understood others and was able to make herself understood. The MDS assessment indicated Resident #49 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #49 received an anticoagulant medication during the last 7 days or since admission/entry or reentry if less than 7 days.<BR/>Record review of Resident #49's Order Summary Report dated 03/24/2024 did not indicate an order for an anticoagulant medication. Resident #49's Order Summary Report indicated she had an order for aspirin 81 mg give 1 tablet by mouth in the morning for antiplatelet (medications that stop blood cells (called platelets) from sticking together and forming a blood clot) with a start date of 01/13/2024. <BR/>Record review of Resident #49's comprehensive care plan with a target date of 05/10/2024 did not indicate the use of an anticoagulant medication. <BR/>Record review of the January 2024 MAR did not indicate Resident #49 was administered an anticoagulant medication.<BR/>4. Record review of a face sheet dated 03/27/2024 indicated Resident #53 was a [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (condition where the lungs cannot supply enough oxygen or remove enough carbon dioxide from the blood) and type 2 diabetes mellitus with hyperglycemia (chronic condition that affects the way the body processes blood sugar which results in high blood sugars). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #53 understood others and was able to make herself understood. The MDS assessment indicated Resident #53 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #53 received an anticoagulant medication during the last 7 days or since admission/entry or reentry if less than 7 days. <BR/>Record review of Resident #53's Order Summary Report dated 03/24/2024 did not indicate an order for an anticoagulant medication. Resident #53's Order Summary Report indicated she had an order for aspirin enteric coated tablet delayed release 81 mg give 1 tablet by mouth in the morning with a start date of 12/07/2022. <BR/>Record review of Resident #53's comprehensive care plan with a target date of 05/10/2024 did not indicate the use of an anticoagulant medication. <BR/>Record review of the January 2024 MAR did not indicate Resident #53 was administered an anticoagulant medication.<BR/>During an interview on 03/27/2024 at 8:56 a.m., the RN MDS Coordinator and LVN MDS Coordinator both said they had started as MDS Coordinators in the facility in December of 2024. Both MDS Coordinators said they thought aspirin could be coded as an anticoagulant medication. The RN MDS Coordinator said she would review Resident # 17's, Resident #38's, Resident #49's, and Resident #53's medical records to ensure they were coded correctly on the MDS assessment, and provide evidence of their anticoagulant use, if available.<BR/>During an interview on 03/27/2024 at 11:52 a.m., the RN MDS Coordinator said she had not found evidence that indicated Resident # 17, Resident #26, Resident #38, Resident #47, Resident #49, and Resident #53 had received an anticoagulant medication. The RN MDS Coordinator said it was important for the MDS assessments to be coded accurately to get an accurate representation of what they were doing for the residents. The RN MDS Coordinator said in the past she had always coded aspirin as an anticoagulant medication, and she was not aware aspirin was no longer considered an anticoagulant medication. The RN MDS Coordinator said corporate did random audits on the MDS assessments to ensure accuracy. <BR/>During an interview on 03/27/2024 at 5:27 p.m., the Administrator said regional overlooked the MDS Coordinators and assessments, and she expected for them to be accurate. The Administrator said it was important for the MDS assessments to be coded accurately because that was how the facility was paid. <BR/>Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (used to complete resident assessments, MDS assessments) dated October 2023 indicated in Chapter 3 pg. N-8, . Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel as N0415E, Anticoagulant .<BR/>Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 4 of 24 residents (Resident # 17, Resident #38, Resident #49, and Resident #53) reviewed for MDS assessment accuracy. <BR/>The facility failed to ensure Resident # 17's, Resident #38's, Resident #49's, and Resident #53's anticoagulant (blood thinner) use was accurately coded. <BR/>These failures could place residents at risk for not receiving care and services to meet their needs.<BR/>1. Record review of a face sheet dated 3/27/24 indicated Resident #17 was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), Parkinson's (brain disorder that causes unintended or uncontrollable movements), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), gastro-esophageal reflux disease (stomach acid or bile irritates the food pipe lining) and essential hypertension (high blood pressure). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #17 able to make herself understood and understood others. The MDS assessment indicated Resident #17 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #17 required independent assistance with eating; Partial/moderate assistance with oral hygiene; Substantial/maximal assistance with toilet use, bathing, upper body dressing, lower bathing dressing, putting on/taking off footwear and moderate assistance with personal hygiene. The MDS assessment indicated that Resident #17 was taking anticoagulant medication. <BR/>Record review of the care plan last revised 1/24/24 indicated Resident #17 used oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. The Care plan interventions included, administer oxygen therapy per physician's orders and monitor for signs and symptoms of respiratory distress and report to the physician as needed. Respiratory distress could include an increased respiratory rate, tachycardia(abnormally fast heart rate), diaphoresis (excessive Sweating), lethargy, confusion, persistent cough, pleuritic pain, accessory muscle use, decreased oxygen saturation, or changes in skin color such as a bluish or grey tint.<BR/>Record Review of the Medication Review Report dated 3/26/24 at 9:31 a.m., did not indicate Resident #17 was taking anticoagulant medication. Medication Review Report indicated Resident #17 was prescribed Aspirin dated 1/23/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 20 residents (Resident #44) reviewed for care plans. <BR/>The facility did not implement Resident #44's fall management care plan to ensure she always wore non-skid footwear and have a fall mat at bedside. <BR/>This failure could place residents at risk of not having their individual needs met. <BR/>Findings include:<BR/>Record review of Resident #44's order summary report, dated 02/08/2023, indicated Resident #44 was a [AGE] year-old female, originally admitted on [DATE] with a diagnosis which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (high blood pressure), and history of falling. <BR/>Record review of Resident #44's significant change in status MDS assessment, dated 10/07/2022, indicated Resident #44 rarely/never understood others and rarely/never made herself understood. The assessment did not address Resident #44 cognitive status. The assessment indicated Resident #44 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #44 had a fall in the last month, last 2-6 months, and obtained a fracture related to a fall in the 6 months prior to admission/entry or reentry. <BR/>Record review of Resident #44's care plan, with an initiated date of 08/05/2022, indicated Resident #44 had a history of falls related to dementia with behaviors, pain, medications, immobility, unsteady/poor balance, and recent fall with injuries. The care plan interventions included, always ensure non-skid footwear, fall mat at bedside and increase staff rounding. <BR/>Record review of the fall risk assessment tool dated 11/24/2022 indicated Resident #44 had multiple falls within the previous six months, on three high risk drugs, unable to independently come to a standing position, required hands-on assistance to move from place to place, use an assistive device and decrease in muscle coordination. The fall risk assessment indicated Resident #44 was a high risk for falls. <BR/>During observations of Resident #44's room the following was noted: <BR/>02/06/2023 at 10:00 a.m. Resident lying in bed with no fall mat at bedside. <BR/>02/06/2023 at 3:34 p.m. Resident lying in bed with no fall mat at bedside. <BR/>02/07/2023 at 2:37 a.m. Resident lying in bed with no fall mat at bedside. <BR/>During an observation on 02/07/2023 at 9:08 a.m., Resident #44 was sitting in her wheelchair in the tv room wearing a pair of off-white socks with no grip on the bottom. <BR/>During an observation, interview, and record review on 02/08/2023 at 2:46 p.m., LVN A stated she was Resident #44's 6a-6p charge nurse. LVN A stated she was unaware that Resident #44 should have a fall mat at bedside. After reviewing Resident #44 electronic medical records, LVN A stated she should have a fall mat at bedside and always wore nonskid socks. LVN A observed with the surveyor Resident #44's fall mat was not at bedside. LVN A stated nursing staff were responsible for ensuring a fall mat was at Resident #44 bedside and ensure Resident #44 always wear non-skid footwear. LVN A stated there was not a system at this time that staff could review what devices were needed for residents. LVN A stated this failure could potentially put Resident #44 at risk for a serious injury. <BR/>During an interview on 02/08/2023 at 4:14 p.m., NA C stated she was Resident #44's 2p-10p aide. NA C stated she unaware that Resident #44 was a high risk for falls. NA C stated she did not know that Resident #44 needed a fall mat at bedside and should always wear non-skid socks. NA C stated there was times Resident #44 did not have on non-skid socks. NA C stated she did not have access to resident's care plan. NA C stated this failure could potentially cause an injury (concussion) to Resident #44. <BR/>During an interview on 02/08/2023 at 4:36 p.m., the DON stated he expected Resident #44 to have a fall mat at bedside and always wear non-skid socks. The DON stated the aides and nurses were responsible for ensuring care plan items were in place. The DON stated daily rounds were made by LVN H to ensure safety measures are in place. The DON stated currently there was a system being put in place to inform staff of care plan needs. The DON stated this failure could potentially put Resident #44 at risk for injury. <BR/>During an interview on 02/08/2023 at 5:47 p.m., LVN H stated herself and the department heads were responsible for daily rounds. LVN H stated she could not say the last time rounds were done on Resident #44 due to frequent room changes. LVN H stated she expected the nursing staff to ensure fall preventions measure are in place. LVN H stated this failure could potentially put Resident #44 at risk for injury. <BR/>During an interview on 02/08/2023 at 6:13 p.m., the Administrator stated he expected the care plan to be followed. The Administrator stated ultimately the DON or designee was responsible for ensuring safety measures were in place. The Administrator stated this failure could potentially put Resident #44 at risk for injury. <BR/>Record review of the facility's Fall Management System policy, revised 01/03/2017, indicated, . it is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan implemented based on the resident's assessed needs Procedure (3) A care plan is implemented for residents at risk for falls . Investigation and follow up of accidents involving falls (2) Interventions will be implemented in an attempt to prevent the resident from sustaining further falls

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 3 (Resident #44) residents reviewed for care plan revisions.<BR/>The facility failed to update Resident #44's care plan for her Bipap (a machine that helps you breathe) being discontinued. <BR/>This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.<BR/>1.Record review of Resident #44's face sheet, dated 03/28/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses which included anxiety (a feeling of fear, dread, and uneasiness), diabetes, chronic obstructive pulmonary disease (no airflow for breathing), and stroke.<BR/>Record review of Resident #44's change in condition MDS assessment, dated 03/11/24, indicated Resident #44 was understood and understood by others. Resident #44's BIMS score was 12, which indicated she was cognitively intact. The MDS indicated Resident #44 required extensive assistance with bathing, toileting bed mobility, dressing, personal hygiene, transfers, and supervision assistance for eating. The MDS did not indicate Resident #44 was on a Bipap.<BR/>Record review of Resident #44's comprehensive care plan dated 10/25/23 revealed o Resident #44 had an altered sleep pattern related to sleep apnea and required a sleep machine. She also had impaired Respiratory Status related to COPD, Asthma, respiratory failure, and obesity with alveolar hypoventilation (a rare disorder in which a person does not take enough breaths per minute). Resident #44 had a history of refusing to wear her Bipap as ordered. The resident is at risk for shortness of breath, respiratory distress, increased anxiety, and hypoxia (low levels of oxygen in your body) The interventions were for staff to Introduce relaxing nonpharmacologic interventions: calm music, reading a book, and relaxation exercises before bedtime. Help the resident identify and understand the main cause of sleep difficulties. Encourage and assist residents to keep the head of the bed elevated to decrease the effects needed for effective air exchange. <BR/>Record review of Resident #44's Physician order did not reveal an order for a Bipap .<BR/>Record review of Resident #44's MAR dated 03/01/24-03/27/24 did not include a Bipap order.<BR/>During an interview and observation on 03/27/24 at 8:51 a.m., Resident #44 was lying in her bed with RN A at her bedside. Resident #44 said she had not been on her Bipap for a long time. RN A said she was not using her Bipap and it had been a while since she wore it. RN A said she was not aware it was still on her care plan.<BR/>During an interview on 03/27/24 at 5:57 p.m., the DON said Resident #44 had refused her Bipap and it should have been taken off her care plan. She said it was an oversite. She said if someone looked at Resident #44's care plan and wondered where the Bipap was they might would have tried to find it and apply it.<BR/>During an interview on 03/27/24 at 6:32 p.m., the ADON W said anytime a new order or discontinued order was received it should be added or removed to update the care plan. She said usually the ADONs or the MDS Coordinators would update a care plan. She said it was important to remove the BiPAP because it was no longer part of Resident #44 care.<BR/>During an interview on 03/27/24 at 6:42 p.m., The DON said she was not able to find a policy on the revision of care plans, but she gave a policy on care planning.<BR/>During an interview on 03/27/24 at 6:53 p.m., the Administrator said the care plan should be updated when the order was received to discontinue the Bipap. She said the charge nurses, ADONs, MDS Coordinators, and DON should update care plans. The administrator said she was not sure why the care plan for Resident #44 was missed. The Administrator said the MDS Coordinators were the overseers of all care plans. The administrator said care plans should be updated to inform staff of residents' needs and what interventions have been put in place or need to be followed. <BR/>Record Review of the facility's Comprehensive care plan policy dated 2/10/21 indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; definitions: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives; (1) The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed; #2 Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care.<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 3 of 20 residents reviewed for ADLs (Residents #24, Resident #25, and Resident #182).<BR/>The facility failed to ensure Resident #24, and Resident #182 received showers or bed baths as scheduled. <BR/>The facility failed to provide assistance with facial hair removal for Resident #25.<BR/>These failures could place residents at risk of not receiving services and care, and a decreased quality of life.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #24's face sheet dated 02/08/23 revealed an [AGE] year old male initially admitted on [DATE] with diagnoses of pneumonia, unspecified organism (an infection of the lungs), chronic combined systolic (congestive) and diastolic (congestive) heart failure (heart does not pump blood well enough to meet the body's demand for blood and oxygen), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with no behaviors). <BR/>Record review of Resident #24's quarterly MDS assessment with an ARD of 12/30/22 revealed Resident #24 was understood and understood others. The MDS assessment indicated Resident #24 had a BIMS score of 8, indicating cognition was moderately impaired. The MDS assessment indicated Resident #24 required extensive assist for bed mobility, transfer, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence of one person assist for bathing. <BR/>Record review of the care plan last revised on 08/24/22 revealed Resident #24 had a focus of Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner with a goal of resident will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date and resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date and interventions included personal hygiene: extensive assistance, bathing: extensive assistance and provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Resident #24's care plan did not indicate Resident #24 refused ADL care or baths/showers. <BR/>During an observation on 02/06/23 at 12:08 PM, Resident #24 was lying in bed sleeping wearing a hospital gown, hair was messy and disheveled.<BR/>During an observation and interview on 02/07/23 at 9:32 AM, Resident #24 was lying in bed in a hospital gown, hair appeared messy and disheveled. Resident #24 said he had not received a shower or a bed bath since last week. <BR/>During an observation and interview on 02/08/23 at 9:29 AM, Resident #24 was lying in bed wearing a hospital gown, hair appeared messy and disheveled, and he said he still had not received a shower or a bed bath. <BR/>Record review of Resident #24's shower sheets revealed he received showers or bed baths on Tuesday, Thursday, and Saturday. Record review of Resident #24's shower sheets revealed:<BR/>Thursday 01/26/23- shower sheet not signed<BR/>Saturday 01/28/23- no shower sheet was provided by the DON<BR/>Tuesday 01/31/23- no shower sheet was provided by the DON<BR/>Thursday 02/02/23- shower sheet signed refused<BR/>Saturday 02/04/23- no shower sheet was provided by the DON<BR/>Tuesday 02/07/23- shower sheet signed bed bath <BR/>2. <BR/>Record review of a face sheet dated 02/08/23 revealed Resident #182 was a [AGE] year-old male admitted on [DATE] with diagnoses of quadriplegia (paralysis of all four extremities), paroxysmal atrial fibrillation (rapid, erratic heart rate), and neurogenic bladder (bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves).<BR/>Record review of the electronic health record on 02/08/23 revealed Resident #182's MDS assessment was not yet completed. <BR/>Record review of Resident #182's care plan revealed a focus with date initiated of 02/08/23, resident has an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner, goal of resident will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date and resident will participate to the best of their ability and maintain current level of functioning with<BR/>activities of daily living (ADLs) through the next review date, and interventions including dressing: extensive assistance, personal hygiene: extensive assistance, bathing: dependent on staff, and provide shower, shave, oral care, hair care, and nail care per schedule and when needed. <BR/>During an observation and interview on 02/06/23 9:59 AM, Resident #182 said he had not had a shower or a bed bath since he admitted on Friday 02/03/23. Resident #182 was wearing a navy-blue long sleeve shirt. <BR/>During an observation on 02/07/23 at 8:21 AM, Resident #182 was in bed wearing a navy-blue long sleeve shirt. <BR/>During an observation on 02/08/23 at 8:19 AM, Resident #182 was in bed wearing a navy-blue long sleeve shirt crumbs and white particles were all over the shirt. Resident #182 said he still had not received a bed bath or shower. <BR/>Record review of Resident #182's shower sheets revealed only one shower sheet for 02/07/23 and the shower sheet indicated he had a bed bath.<BR/>During an interview on 02/08/23 at 9:45 AM, ADON H said the CNAs do the showers and bed baths. ADON H said there was a shower aide, but if the shower aide was not able to give a shower/bed bath she should let the CNAs on the floor know for them to do it. ADON H said she was responsible for overseeing Resident #24's showers/bed baths. ADON H said she was not aware Resident #24 had not received bed baths/showers. ADON H said she randomly checked with residents and asked them if they were getting their showers/bed baths. ADON H said it was important for the residents to receive showers/bed baths to keep them clean, free of infection, looking good and for overall good health. <BR/>During an interview on 02/08/23 at 10:13 AM, ADON K said the nurses were responsible for making sure the residents received a bed bath/shower. ADON K said she was not aware Resident #182 had not received a shower/bed bath. ADON K said she trusted the CNAs to do the showers/bed baths, and that CNA O had told her she had given Resident #182 a bed bath on Tuesday (02/07/23). ADON K said it was important for the residents to have their clothes changed daily and to receive their showers/bed baths for hygiene, and not receiving showers/bed baths could cause skin breakdown and infections from not being clean. <BR/>During an interview on 02/08/23 at 11:08 AM, CNA O said she had not given Resident #182 a bed bath on Tuesday (02/07/23). CNA O said she was not able to go back and change her charting on the shower sheet to reflect she did not give Resident #182 a bed bath. CNA O said the residents' clothes should be changed every day and the residents should get there baths as scheduled. <BR/>During an interview on 02/08/23 at 12:01 PM CNA N said she had not offered Resident #182 a shower or bed bath and she had not changed his clothes on Monday (02/06/23) because she ran out of time and did not get to it. CNA N said it was necessary to change the residents clothes every day and give them showers/bed baths to prevent odor, bacteria and to prevent neglect. <BR/>During an interview on 02/08/23 at 5:31 PM, CNA L said she was the shower aide and gave the showers Monday-Friday and if she was not at the facility the CNAs on the floor were responsible for giving the showers/bed baths. CNA L said she was not responsible for giving Resident #24 and Resident #182 their showers/bed baths because they were not assigned to her. CNA L said the CNAs on the floor should have done them. CNA L said it was important for the residents to receive a shower/bed bath for them to be clean and to make them feel better, and if they did not get a shower/bed bath this could cause residents to get an infection, sores, or yeast. <BR/>During an interview on 02/08/23 at 5:40 PM, LVN D said the residents' clothes should be changed every day, and the aides and the nurses should make sure the residents' clothes were changed every day and showers/bed baths were given as scheduled. LVN D said it was important for the residents' clothes to be changed and for them to receive their bed baths/showers for clean hygiene and for their health and skin. <BR/>During an interview on 02/08/23 at 5:55 PM, RN B said sometimes Resident #24 refused his showers/bed baths and care. RN B said if Resident #24 refused his showers/bed baths staff was supposed to document the refusals, and it should be in his care plan. RN B said it was important for the residents to have showers/bed baths to prevent illness and odor. <BR/>During an interview on 02/08/23 at 6:29 PM, the DON said the nurse aides were responsible for providing showers/bed baths and the nurses should oversee this. The DON said not providing showers/bed baths was a dignity problem. The DON said he was not aware Resident #24 and Resident #182 had not received a shower/bed bath. The DON said he was not aware Resident #24 refused showers/bed baths, and if Resident #24 did refuse, it should be in his care plan. <BR/>During an interview on 02/08/23 at 7:54 PM, the administrator said the nurses were responsible for ensuring ADL care was provided. The administrator said he expected the CNAs to change the residents clothes every day and provide showers/bed baths as scheduled. The administrator said not changing the residents' clothes every day and not providing showers/bed baths as scheduled would affect the residents' dignity.<BR/>3. Record review of consolidated physician orders dated 2/08/23 indicated Resident #25 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, heart failure, lack of coordination, dementia, and hypertension (elevated blood pressure).<BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #25 understood others and was understood by others. The MDS indicated Resident #25 had a BIMS score of 04 indicating she was severely cognitively impaired. The MDS indicated Resident #25 was not resistive to evaluation or care. The MDS indicated Resident #25 required extensive assistance with dressing and personal hygiene. <BR/>Record review of the most recent comprehensive care plan updated 2/06/23 indicated Resident #25 had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner. The care plan indicated interventions for Resident #25 included provide shower, shave, oral care, hair care, and nail care per schedule and when needed.<BR/>Record review of Resident #25's shower schedule indicated she was to be provided showers on Mondays, Wednesdays, and Fridays.<BR/>Record review of Resident #25's showers sheets dated 1/30/22 through 2/06/23 indicated she had received all her schedule showers. <BR/>During an observation on 2/06/23 at 11:54 a.m. Resident #25 was observed with thick silver colored chin hair approximately 0.5cm in length.<BR/>During an observation and interview on 2/07/23 at 9:58 a.m. Resident #25 was observed with thick silver colored chin hair approximately 0.5cm in length. Resident #25 was confused and unable to be interviewed.<BR/>During an observation on 2/08/23 at 8:33 a.m. Resident #25 was observed with thick silver colored chin hair approximately 0.5cm in length.<BR/>During an interview on 2/08/23 at 1:54 p.m. CNA L said she had given Resident #25 her shower on 2/06/23. CNA L said she did not assist Resident #25 with facial hair removal during her shower. CNA L said she did not notice the Resident #25 having facial hair during her shower. CNA L said another CNA later that day told her about Resident #25's facial hair needing removed. CNA L said she did not go back and assist Resident #25 with her facial hair removal after the other CNA informed of the facial hair. CNA L said Resident #25 was not resistive to care. CNA L said the importance of assisting residents with facial hair removal was for their dignity.<BR/>During an interview on 2/08/23 at 2:20 p.m. LVN D said residents were assisted with facial hair removal during showers. LVN D said Resident #25 was not resistive to care including showers and facial hair removal. LVN D said the importance of assisting residents with facial hair removal was the resident's dignity. <BR/>During an interview on 2/08/23 at 6:08 p.m. the DON said he expected facial hair removal to be performed with resident showers. The DON said Resident #25 sometimes refused care but was easily redirected. The DON said assisting resident with facial hair removal was for dignity.<BR/>During an interview on 2/08/23 at 7:10 p.m. the Administrator he expected staff to assist with residents with facial hair removal during showers and as needed. The Administrator said it was the CNAs responsibility to perform grooming including facial hair removal and showering. The Administrator said all staff responsible for reporting issues including facial hair needing groomed to the appropriate staff. The Administrator said facial hair not being removed was a dignity issue.<BR/>Record review the facility's Activities of Daily Living Care Guidelines policy last reviewed, 2/11/21 indicated, Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene Residents participate in and receive the following person-centered care: Bathing includes grooming activities such as shaving, and brushing teeth and hair, Dressing: wearing garments appropriate to season dress and undress .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this was not possible or resident preferences indicate otherwise for 3 of 8 residents (Resident #1, Resident #34, and Resident #49) reviewed for nutrition.<BR/>The facility failed to ensure Resident #1 received his magic cup with his meals.<BR/>The facility failed to ensure Resident #34 received his health shake.<BR/>The facility failed to ensure Resident #49 received her Nutritious Shake. <BR/>These failures could place residents at risk for malnourishment, weight loss, skin breakdown, and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet dated 03/27/24 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses senile degeneration of the brain (., anxiety, dementia (decline in cognitive abilities that impacts everyday activities), and protein-calorie malnutrition (inadequate food intake). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated that he had a BIMS score of 10 which indicated moderate cognitive impairment. The MDS also indicated he required supervision with toileting and transfers, setup with eating and dressing, and he was independent with bed mobility. The MDS also indicated Resident #1 was on hospice care. <BR/>Record review of Resident #1's undated care plan indicated he was at risk for nutritional and hydration problems with a goal to maintain adequate nutritional and hydration status, and interventions that included: Provide, serve diet as ordered. <BR/>Record review of Resident #1's order audit report dated 03/26/24 indicated resident had an order for: <BR/>1. Mechanical soft texture, thin liquids consistency, frozen nutritional treat with all meals and magic cup dated 01/03/24.<BR/>2. Mechanical soft texture, thin liquids consistency, frozen nutritional treat with all meals and gelatin dated 03/26/24 after surveyor intervention.<BR/>During an observation on 03/24/24 at 12:09 PM Resident #1 was sitting in the dining room with his tray. The tray did not have a magic cup on it. <BR/>During an observation on 03/25/24 at 12:12 PM Resident #1 was sitting in the dining room with his tray. The tray included an Ensure but there was no magic cup on his tray. <BR/>During an interview on 03/27/24 at 05:17 PM ADON W said the residents should receive the supplements as ordered by the physician. She said the kitchen should have the items in stock, but the charge nurses were responsible for ensuring the residents received the supplements. ADON W said the risk to Resident #1 was weight loss.<BR/>2.Record review of Resident #34's face sheet, dated 03/28/24, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included malnutrition (lack of proper nutrition), depression (mood disorder that causes a persistent feeling of sadness), and stroke.<BR/>Record review of Resident #34's quarterly MDS assessment, dated 02/07/24, indicated Resident #34 was usually understood and understood by others. Resident #34's BIMS score was 05, which indicated he was severely cognitively impaired. The MDS indicated Resident #34 required total assistance with bathing, toileting bed mobility, dressing, personal hygiene, transfers, supervision, and eating. The MDS did not indicate Resident #34 had weight loss.<BR/>Resident #34's physician order dated 02/27/23 revealed a pureed textured diet, mildly thick-nectar consistency, and a house shake with all meals.<BR/>Record review of Resident #34's comprehensive care plan target date of 04/14/23 indicated, Resident #34 received a puree textured, mildly thick nectar consistency diet and was at risk for a decline in nutrition and hydration status related to his dementia, impaired vision, communication, medication respiratory complication, dysphasia (difficulty swallowing), history of alcohol abuse, poor dentation, acid reflux, contractures of the right, left wrist, and elbow, and recent amputation. The interventions were for staff to provide and serve supplements as ordered.<BR/>During an observation on 03/24/24 at 12:50 p.m., Resident #34 was in the dining room being assisted with lunch by CNA X. Resident #34 did not have a health shake on his meal tray as indicated on his meal ticket. CNA X went to the kitchen door and asked about the health shake but was told they were out.<BR/>During an observation on 03/25/24 at 12:40 p.m., Resident #34 was in the dining room being assisted with lunch and no health shake on his tray.<BR/>During an observation and interview on 03/26/24 at 1:43 p.m., The DM said she had ordered the house shake and they were supposed to be delivered on 3/25/24. On 3/25/24 Resident #34 had Ensure on his tray but not a health shake as ordered. <BR/>During an interview on 03/26/24 at 1:49 p.m., LVN B said he was responsible for checking the meal tickets before the trays were delivered to the tables. He said if the residents were missing an item from their tray card, he was supposed to ask the kitchen to supply it. He said he asked the kitchen about the health shake and was told they were out. He said he did not notify anyone because at the time he did not think about it. He said most residents were on health shakes because of weight loss or to maintain their current weight. He said he should have notified the doctor when they were out of health shakes, but he did not. He said today (03/26/24) they served Ensure in place of health shakes.<BR/>During an interview on 03/26/24 at 1:57 p.m., the DM said she usually ordered 2-3 cases at a time of magic cups. She said when she attempted to order last week (03/11/24) they were out of stock. She said she was not sure of the exact date that she was completely out of magic cups. She said she ordered health shakes weekly and when she went to order Friday (03/22/24) they were out of stock. She said she did not notify the Administrator of them being out of magic cups or on backorder. She said she did not notify anyone about being out of health shakes because it had only been 2 days. She said she did notify the cooperate dietitian yesterday (03/25/24) about the back order of magic cups and health shakes. She said she recommended that she offer the Gelatin unless they were on thickened liquids because it was too thin. She said most residents do not like the Gelatin. The DM said to her knowledge the purpose of magic cups was to help them maintain their weight or prevent them from losing more weight. She said they did not have an alternate place to order supplies. She said it was very important for the residents to receive the magic cup or health shake as ordered because they could lose weight. <BR/>During a phone interview on 03/26/24 at 2:36 p.m., the cooperate dietitian said the DM called her yesterday about being out of house shakes and magic cups. She said she expected the DM to let her know on the day she was out of any supplies. She said if resident were not receiving their health shakes or magic cups it could be a potential for weight loss or lack of wound healing. She said they did not have another supplier or a sister facility they could get supplies from. She said she had to check on a few things to see what the facility could do and reach out to the area manager.<BR/>During an interview on 03/26/24 at 3:36 p.m., the Administrator said she was not aware the facility was out of magic cups or health shakes. She said the DM did not mention they were out until after surveyors started questioning staff. She said she expected the DM to notify her if they were out of any supplies in the kitchen. She said if residents were not receiving magic cups or health shakes as ordered they could lose weight.<BR/>3. Record review of a face sheet dated 03/27/2024 indicated Resident #49 was a [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (condition where the lungs cannot supply enough oxygen or remove enough carbon dioxide from the blood), type 2 diabetes mellitus with diabetic neuropathy (insulin resistance leading to high blood sugars which results in nerve damage caused by prolonged high blood sugar levels), and chronic diastolic congestive heart failure (condition in which the heart cannot fill up with blood properly). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #49 understood others and was able to make herself understood. The MDS assessment indicated Resident #49 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #49 was independent for eating, oral personal, and toileting hygiene and required supervision for showering/bathing herself. The MDS assessment indicated Resident #49 had a loss of 5% or more in the last month or loss of 10% or more in last 6 months. The MDS assessment indicated Resident #49 required a therapeutic diet. <BR/>Record review of the comprehensive care plan with a target date of 05/10/2024 indicated Resident #49 received a controlled carbohydrate and no added salt diet and was at risk for decline in nutrition and hydration status related to dementia, mental illness, congestive heart failure, respiratory status, pain, arthritis, constipation, and gastroesophageal reflux disease (condition that occurs when stomach acid repeatedly flows back in to the tube connecting your mouth and stomach). The goal was for Resident #49 to maintain adequate nutritional and hydration status as evidenced by weight being stable with no signs or symptoms of malnutrition or dehydration being present through the next review date. The interventions included provide and serve diet as ordered and registered dietician to evaluate and make diet/supplement change recommendations as needed. Resident #49's care plan indicated she had an unplanned/unexpected weight loss related to recent hospitalization. Resident #49 did not prefer facility food., and she would eat cereal and lunchmeat. The goal was for Resident #49 to have no further weight loss through the next review date. The interventions include for the registered dietician to evaluate and make diet/supplement change recommendations as needed. <BR/>Record review of Resident #49's Order Summary Report dated 03/24/2024 did not indicate an order for Nutritious Shake. <BR/>Record review of a meal ticket dated 03/23/2024, Sunday, lunch indicated Nutritious Shake-4 ounces. <BR/>During an observation of the lunch meal and interview on 03/23/2024 beginning at 12:10 p.m., Resident #49 received her lunch tray, and requested her Nutritious Shake from the staff in the dining room. The staff told her there were no Nutritious Shakes to give her. RN A said the Dietary Manager (who was in the kitchen that day) told her there were no Nutritious Shakes to give to the residents. RN A brought the Dietary Manager out of the kitchen. The Dietary Manager said when she left on Friday (03/22/2024) there were Nutritious Shakes in the kitchen for the residents, therefore, the Nutritious Shakes must have run out after she left. The Dietary Manager said the Nutritious Shakes had been ordered and would arrive on Monday 03/25/2024. The Dietary Manager said they did not have any Magic Cups for the residents either. The Dietary Manager said the Magic Cups were on back order, and she had been trying to order them for the past 2 weeks. The Dietary Manager said none of the residents that required a Nutritious Shake or Magic Cup had received one.<BR/>During an interview on 03/24/2024 at 3:03 p.m., Resident #49 said she had not received a Nutritious Shake for the past 3 days. She said the staff had told her they did not have any Nutritious Shakes. <BR/>During an interview on 03/25/2024 at 9:02 a.m., NP G said the Nutritious Shakes and Magic Cups were recommended by the Dietician and nursing put the orders in. NP G said he had not been notified the Magic Cups were back ordered, and he had not been notified the facility had not had any Magic Cups for the past 2 weeks. NP G said he had not been notified that the facility did not have any Nutritious Shakes. NP G said it was unacceptable for the facility to be out of Magic Cups for that long. NP G said the staff should have let him know and he could have discussed with the Dietician an alternate nutritional supplement for the residents. NP G said it was extremely important for the residents to get the Magic Cups and Nutritious Shakes for them to get the nutritional intake they needed. NP G said not providing the Magic Cups and Nutritional Shakes could lead to weight loss. <BR/>During an interview on 03/27/2024 at 10:58 a.m., RN A said the kitchen told her they did not have any Nutritious Shakes or Magic Cups. RN A said she had not notified the physician that the facility did not have any Nutritious Shakes or Magic Cups. RN A said she should have let the physician know, but she did not because she was confused about whose responsibility it was to ensure the nutritional supplements were available for the residents. RN A said she was not aware she should have notified the ADONs or DON that there were no Nutritious Shakes or Magic Cups to give to the residents. RN A said not giving the residents Nutritious Shakes and the Magic Cups could lead to weight loss. <BR/>During an interview on 03/27/2024 at 3:20 p.m., ADON M said she had not been notified that there were no Magic Cups or Nutritious Shakes for the residents. ADON M said she had not run into that before, but the nurses should have notified the Administrator or the DON and contacted the physician for orders. ADON M said the residents not receiving nutritional supplements could lead to weight loss and the residents not getting enough nutrition. <BR/>Record review of the facility Diets, Nutrition, and Hydration policy revised on 08/2023 indicated:<BR/>Policy <BR/>Diet and hydration orders for newly admitted residents and changes to existing diets or fluids will be written as reflected in the Facility Diet Manual. <BR/>Fundamental Information <BR/>The facility will provide each resident with three meals daily and a nourishing snack at bedtime. Each meal will be provided according to physician orders, Facility Diet Manual, and menu spread sheet .<BR/>House Supplements: The physician, practitioner, or Dietitian may choose to order House supplements to provide residents with additional Calories and Protein. The term house supplement will cover all items listed in the supplement rotation guide, this allows for rotating of various supplements and foods, so that residents do not become dissatisfied with the same shake day after day. The physician order should state frequency of the supplement. All procedures for supplements should be followed. One serving will be provided per ordered supplement .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided with professional standards of practice for 3 of 16 residents (Residents #26, #47, and #61) reviewed for respiratory care and services. <BR/>1. The facility failed to administer oxygen at 2 via nasal cannula as prescribed by the physician for Resident #26. <BR/>2. The facility failed to properly store Resident #26's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask while not in use. <BR/>3. The facility failed to ensure Resident #47's nasal cannula tubing was changed weekly.<BR/>4. The facility failed to ensure Resident #61's oxygen concentrator had a filter in place. <BR/>These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. <BR/>Findings include: <BR/>1. Record review of Resident #26's order summary report, dated 02/08/2023, indicated Resident #26 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and obstructive sleep apnea (intermittent airflow blockage during sleep). <BR/>Record review of Resident #26's order summary report, dated 02/08/2023, indicated Resident #26 received oxygen at 2 liters per minute via nasal cannula every shift for shortness of breath with a start date 02/13/2021. The order summary indicated Resident #26 received Ipratropium-Albuterol solution 0/5-2.5 (3) mg/ml, inhale orally three times a day for SOB related to COPD with a start date 11/11/2022. <BR/>Record review of Resident #26's annual MDS assessment, dated 02/06/2023, indicated Resident #26 understood others and made himself understood. The assessment indicated Resident #26 was cognitively intact with a BIMS score of 15. The assessment indicated Resident #26 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #26 was receiving oxygen therapy. <BR/>Record review of Resident #26's care plan, with a revision date of 06/22/2022, indicated Resident #26 had an impaired respiratory status related to respiratory failure with hypoxia (low level of oxygen in blood tissues), and sleep apnea. The care plan interventions included oxygen at 2 liter per minute via NC at HS related to sleep apnea, provide oxygen therapy as ordered by the physician, and provide nebulizer therapy as ordered. <BR/>During an observation and interview on 02/06/2023 at 10:14 a.m., Resident #26 was lying in bed wearing oxygen via nasal cannula. Resident #26's five-liter oxygen concentrator was set on 3 liters per minute. Resident #26 stated he wore his oxygen all the time for SOB. Resident #26 stated he did not know what rate the oxygen should be on. Resident #26's nebulizer mask was on the bedside dresser not covered. Resident #26 stated he received a breathing treatment daily for SOB. <BR/>During an observation on 02/06/2023 at 2:24 p.m., Resident #26 was lying in bed wearing oxygen via nasal cannula. Resident #26's five-liter oxygen concentrator was set on 3 liters per minute. Resident #26's nebulizer mask was on the bedside dresser not covered.<BR/>During an observation on 02/07/2023 at 1:20 p.m., Resident #26 was lying in bed wearing oxygen via nasal cannula. Resident #26's five-liter oxygen concentrator was set on 3 liters per minute. Resident #26's nebulizer mask was on the bedside dresser not covered.<BR/>2. Record review of Resident #47's order summary report, dated 02/08/2023, indicated Resident #47 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), dependence on supplemental oxygen, and acute respiratory failure with hypercapnia (buildup of carbon dioxide in bloodstream). <BR/>Record review of Resident #47's order summary report, dated 02/08/2023, indicated Resident #47 received oxygen at 3 liters per minute via nasal cannula continuously every shift with start date 11/11/2022. The order summary indicated to change O2 tubing every night, every Sunday with a start date 09/11/2022. <BR/>Record review of Resident #47's significant change status MDS assessment, dated 11/03/2022, indicated Resident #47 understood others and made herself understood. The assessment indicated Resident #47 was cognitively intact with a BIMS score of 14. The assessment indicated Resident #47 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #47 was receiving oxygen therapy. <BR/>Record review of Resident #47's care plan, with a revision date of 04/21/2022, indicated Resident #47 had an impaired respiratory status and was at risk for shortness of breath, respiratory distress, increased anxiety, and hypoxia. The care plan interventions included provide oxygen therapy as ordered by the physician, provide nebulizer therapy as ordered and encouraged resident to take rest as needed. <BR/>Record review of the MAR dated 01/01/2023-01/31/2023, indicated Resident #47's oxygen tubing was changed on 01/15/2023 on the 6p-6a shift. <BR/>Record review of the MAR dated 01/01/2023-01/31/2023, indicated RN B signed off she changed Resident #47's oxygen tubing 01/22/2023 on the 6p-6a shift. <BR/>Record review of the MAR dated 01/01/2023-01/31/2023, indicated LVN H signed off she changed Resident #47's oxygen tubing 01/29/2023 on the 6p-6a shift. <BR/>Record review of the MAR dated 02/01/2023-02/28/2023, indicated RN G signed off she changed Resident #47's oxygen tubing 02/05/2023 on the 6p-6a shift. <BR/>During an observation on 02/06/2023 at 11:42 a.m., Resident #47 was lying in bed and oxygen was in use via nasal cannula. Resident #47's portable oxygen tank attached to her electric wheelchair had a nasal cannula tubing dated 01/15/2023. <BR/>During an observation on 02/07/2023 at 12:10 p.m., Resident #47's portable oxygen tank attached to her electric wheelchair had a nasal cannula tubing dated 01/15/2023. <BR/>During an observation and interview on 02/08/2023 at 1:50 p.m., Resident #47's portable oxygen tank attached to her wheelchair had a nasal cannula dated 01/15/2023. Resident #47 stated she used the nasal cannula tubing on her electric wheelchair daily for SOB. <BR/>During an observation and interview on 02/08/2023 at 2:12 p.m., RN B stated nurse staff on Sunday's night were responsible for changing and labeling tubing. RN B stated she was Resident #47's 6p-6a charge nurse on 01/22/2023. RN B observed with the surveyor Resident #47's portable oxygen tank nasal cannula tubing dated 01/15/2023. RN B stated she checked off on the MAR that she changed Resident #47's oxygen tubing. RN B stated, honestly I usually don't work a lot of night shifts. RN B stated she got busy and forgot to change the tubing. RN B stated this failure could place residents at risk for respiratory infection. <BR/>During an observation and interview on 02/08/2023 at 2:25 p.m., LVN H stated she was Resident #47's 6p-6a charge nurse on 01/29/2023. LVN H stated she was responsible for changing the nasal cannula tubing. LVN H observed with the surveyor Resident #47's portable oxygen tank nasal cannula tubing dated 01/15/2023. LVN H stated she checked off on the MAR that she changed Resident #47's oxygen tubing but was unable to say why she did not physically change the tubing on 01/29/2023. LVN H stated this failure could place residents at risk for respiratory infection. <BR/>During an interview on 02/08/2023 at 3:45 p.m., RN G stated she was Resident #47's 6p-6a charge nurse on 02/05/2023. RN G stated she was unaware that she was responsible for changing nasal cannula tubing on resident's wheelchair. RN G stated after surveyor intervention it did make sense that she would be responsible for changing all tubing whether it was on the concentrator or portable tank. RN G stated this failure could place residents at risk for respiratory infection. <BR/>3. Record review of Resident #61's order summary report, dated 02/08/2023, indicated Resident #61 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), essential hypertension (high blood pressure), and atrial fibrillation (irregular, often rapid heart rate). <BR/>Record review of Resident #61's order summary report, dated 02/08/2023, indicated Resident #61 received oxygen at 4 liters per minute via nasal cannula to maintain O2 sats greater than 92% with start date 03/16/2022. The order summary report did not address oxygen concentrator filters. <BR/>Record review of Resident #61's admission MDS assessment, dated 03/22/2022, indicated Resident #61 understood others and made himself understood. The assessment indicated Resident #61 was moderately cognitive impaired with a BIMS score of 8. The assessment indicated Resident #61 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #61 became short of breath or trouble breathing with exertion. The MDS indicated Resident #61 was receiving oxygen therapy.<BR/>Record review of Resident #61's care plan, with a revision date of 08/04/2022, indicated Resident #61 had an impaired respiratory status related to COPD, asthma (airway in the lungs become narrowed and swollen, making it difficult to breath). The care plan interventions included provide oxygen therapy as ordered by the physician and provide nebulizer therapy as ordered. The care plan did not address oxygen filters.<BR/>During an observation and interview on 02/06/2023 at 10:05 a.m., Resident #61 was sitting in his wheelchair. Resident #61's oxygen concentrator did not have a filter in place. Resident #61 stated he wore his oxygen at night and PRN. <BR/>During an observation on 02/06/2023 at 3:50 p.m., Resident #61 was sitting in his wheelchair. Resident #61's oxygen concentrator did not have a filter in place.<BR/>During an observation on 02/07/2023 at 8:57 a.m., Resident #61 was sitting in his wheelchair. Resident #61's oxygen concentrator did not have a filter in place.<BR/>During an observation, interview, and record review on 02/08/2023 at 2:46 p.m., LVN A stated she was Resident #26 and #61's 6a-6p charge nurse, LVN A stated Resident #26 used O2 continuously for SOB. LVN A observed with the surveyor Resident #26's oxygen concentrator rate at 3 liters per minute and nebulizer mask on the bedside dresser not covered. LVN A stated she was under the impression that Resident #26 oxygen rate should be at 3 liters per minute. After reviewing Resident #26 electronic medical records, LVN A stated the rate should be at 2 liters per minute. LVN A stated the risk associated with not setting the oxygen at prescribed rate could potentially put residents at risk for hypoxia. LVN A stated Resident #26's nebulizer mask should be covered when not in use. LVN A stated she administered Resident #26 a breathing treatment this morning and to her knowledge she placed the mask back in the plastic bag. LVN A stated all nursing staff were responsible for ensuring oxygen concentrators had filters in place. LVN A said she unaware that Resident #61 filter was missing from his concentrator. LVN A stated these failures could potentially put residents at risk for respiratory infection. <BR/>During an interview om 02/08/2023 at 4:36 p.m., the DON stated he expected Resident #26's nebulizer mask be stored in a bag when not in use. The DON stated he expected Resident #26 oxygen to be set at 2 liters per minute per the physician orders. The DON stated he expected the portable nasal tank cannula tubing to changed/dated and filter in place. The DON stated the 6p-6a charge nurses were responsible for changing and labeling tubing. The DON stated the charge nurses were responsible for ensuring the rate was at 2 liters per minute, filters in place and nebulizers stored in bags when not in use. The DON stated LVN H was responsible ensuring nurses are competent enough to read and carry out a MD order. The DON stated LVN H was responsible for monitoring to ensure respiratory equipment was returned to designed bag after each use. The DON stated LVN H was responsible for monitoring every Monday morning that all O2 tubing has been replaced and properly date. The DON stated LVN H was responsible for following up and ensuring equipment was in proper working order. The DON stated ultimately, he was responsible for monitoring the ADON. The DON stated these failures could potentially cause a decrease in respiratory status. <BR/>During an interview on 02/08/2023 at 5:47 p.m., LVN H stated she was responsible for ensuring charge nurses were following the physicians' orders by making multiple rounds throughout the day and spot checking the O2 concentrators. LVN H stated she could not remember the last time rounds were made to ensure Resident #26 oxygen rate was set at 2 liters per minute. LVN H stated rounds were made this week to ensure masks were bagged when not in use. LVN H stated she did not notice any respiratory equipment laying out when not in use. LVN H stated she could not say if she did or not checked to ensure Resident #61's filter was in place. LVN H stated if rounds were made it was not missed on purposely. <BR/>During an interview on 02/08/2023 at 6:13 p.m., the Administrator stated he expected physician's orders to be followed, nebulizers stored in bags when not in use, tubing to be changed and dated per orders and filters to be placed on O2 concentrators. The Administrator stated this was monitored by the DON or designee. The DON stated these failures put residents at risk for respiratory infection. <BR/>Record review of the facility's Oxygen Administration policy, revised 10/24/2022, indicated, .to describe methods for delivering oxygen to improve tissue oxygenation . Procedure (1) Verify physician order .Simple face mask (3) Set flow rate Completion of Procedure (2) When oxygen not in use, store oxygen tubing and nasal cannula or mask in small plastic bag Concentrator (2) Remove filter from back of concentrator . (3) Rinse filter with water (4) Shake off excess water. Replace filter .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards and to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 20 residents (Resident #47) reviewed for medication storage and 1 of 8 medication carts (Hall 200) reviewed for drugs and biologicals. <BR/>1. The facility did not keep medication being administered under the direct observation of the person administering medications. Resident #47 had 1 bottle of Fluticasone Propionate nasal spray (allergies) and 1 bottle of Azelastine nasal spray (allergies) on her bedside table. <BR/>2. The facility failed to date insulin pens and vials on the hall 200 medication cart. <BR/>These failures could place residents at risk for health complications and not receiving the intended therapeutic benefit of their medication.<BR/>Findings included:<BR/>1. Record review of Resident #47's order summary report, dated 02/08/2023, indicated Resident #47 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included essential hypertension (high blood pressure), COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and acute respiratory failure with hypercapnia (buildup of carbon dioxide in bloodstream). <BR/>Record review of the order summary report dated 02/08/2023 indicated Resident #47 was ordered to receive Azelastine HCL Solution 0.1% (two sprays in both nostrils two times a day) for allergies with a start date 11/01/2022 and Fluticasone Propionate 50 MCG/ACT (two sprays in both nostrils in the morning) for allergies with a start date 11/01/2022. <BR/>Record review of Resident #47's significant change status MDS assessment, dated 11/03/2022, indicated Resident #47 understood others and made herself understood. The assessment indicated Resident #47 was cognitively intact with a BIMS score of 14. The assessment indicated Resident #47 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #47 required supervision with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The assessment indicated Resident #47 required total dependence with bathing. <BR/>Record review of Resident #47's care plan did not address allergies or medications left at bedside. <BR/>During an observation on 02/06/2023 at 11:42 a.m., Resident #47 was lying in bed watching tv. There was 1 brown bottle with a white lid labeled Fluticasone Propionate lying on the floor next to Resident #47's bed. <BR/>During an observation on 02/06/2023 at 12:10 p.m., Resident #47 was lying in bed. There was 1 brown bottle with a white lid labeled Fluticasone Propionate and 1 white bottle labeled Azelastine HCL Solution sitting on Resident #47's bedside table. <BR/>During an interview and observation on 02/07/2023 at 1:50 p.m., Resident #47 was lying in bed. There was 1 brown bottle with a white lid labeled Fluticasone Propionate and 1 white bottle labeled Azelastine HCL Solution sitting on Resident #47's bedside table. Resident #47 stated she used both medications on a daily basis due to allergies. <BR/>During an interview on 02/08/2023 at 2:12 p.m., RN B stated she was Resident #47 6a-6p charge nurse. RN B stated Resident #47 was allowed to have medications at bedside. RN B stated she did not know if Resident #47 had a physician's orders to self-administer medications. After reviewing Resident #47 electronic medical records, RN B stated Resident #47 did not have a physician's order to self-administer medications. RN B stated Resident #47 needed to be educated, assessed, and able to demonstrate she can safely administer her medications by the interdisciplinary team before medications were left at bedside to administer. RN B stated this could potentially cause an overdose and not using medication correctly. <BR/>2. During an observation of the hall 200 medication cart with LVN D starting at 02/08/2023 at 9:25 a.m., the following insulins were observed with no open date:<BR/>* Resident #187's Levemir Flex Touch (diabetic medication), no open date, instructions to discard after 30 days of the open date.<BR/>* Resident #187's Insulin Detemir Solution (diabetic medication), no open date, instructions to discard after 30 days of the open date.<BR/>* Resident #73's Humulin R (diabetic medication), no open date, instructions to discard after 30 days of the open date.<BR/>During an interview on 02/08/2023 at 3:15 p.m., LVN D stated insulins should have been dated upon opening, LVN D stated charge nurses were responsible for ensuring the medication was labeled and dated before administering the first dose. LVN D stated the person opening the medication should date it. LVN D stated this failure could potentially cause the medication to not work properly. <BR/>During an interview on 02/08/2023 at 4:36 p.m., the DON stated Resident #47 was able to keep her medication at bedside if she had a physician's order and had been educated, assessed, and able to demonstrate she could safely administer her medications by the Interdisciplinary Team to allow medications at bedside. The DON stated the Maintenance Manager was responsible for monitoring to ensure medications were not left at bedside by conducting daily rounds. The DON stated this failure could potentially put residents at risk for safety, potential overdose and not taking the medication at the correct time. The DON stated he expected the nurse to date the insulin when first opened. The DON stated carts were checked once a month by RN K. The DON stated there had been times nurses had to be reminded to date a recent opened medication. The DON stated this failure could potentially give a resident an outdated medication. <BR/>During an attempted interview on 02/08/2023 at 5:27 p.m., the Maintenance Manager refused to be interviewed about monitoring to ensure medications were not left at bedside. <BR/>During an interview on 02/08/2023 at 5:39 p.m., RN K stated she was responsible for checking the cart for expiration dates, insulin vials/pen dated when opened. RN K stated rounds are done at least once a month. RN stated the last round was done at the end of January 2023. RN K stated charge nurses are responsible for dating insulins when the medication was first opened. RN K stated she did not look at Resident #187's insulin (diabetic medication) in the past week. RN K stated she did not look at Resident #73's insulin (diabetic medication) since the last round was done in January. RN K stated these failures could potentially cause a medication not to be as effective. <BR/>During an interview on 02/08/2023 at 6:13 p.m., the Administrator stated unless Resident #47 had an order and had been educated, assessed, able to demonstrate they can safely administer their medications, and a locked box to keep medications stored safely, medications should be kept in the med cart. The Administrator stated ultimately the DON or designee was responsible for ensuring residents had an order for medications at bedside. The Administrator stated he knew there was a potential failure but due to him not having a clinical background he was unable to say. The Administrator stated he expected the insulin to be dated when first opened. The Administrator stated this failure could potentially cause a medication not to be as effective. <BR/>Record review of the facility's Bedside Medication Storage policy, revised 08/2020, indicated, .bedside medication storage is permitted for residents who wish to self-administer medications, upon written order of the prescriber and once self -administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team 1. A written order for the bedside storage of medication is present in the resident's medical record 2. Bedside storage of medications is indicated on the resident MAR and in the care plan for the appropriate medications. 4. The resident is instructed in the proper use of bedside medications . the completion of this instructions is documented in the resident's medical record 6. All nurses and aides are required to report to the charge nurse on duty any medications found at bedside not authorized for bedside storage . 8. Bedside medication storage is routinely monitored during medication storage review <BR/>During an interview and record review on 02/08/2023 at 3:31 p.m., the Regional Nurse Consultant stated there was not a policy regarding labeling and dating medication. The Regional Consultant stated the facility used a guidance that indicated . (1) Insulin and removed in 28 or 42 days . (7) Unopened insulin stored without refrigeration remove after 30 days .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.<BR/>The facility failed to ensure:<BR/>1. An open bag of dinner rolls and cookie dough, in a box dated 1/30/23, was stored properly.<BR/>2. A container cooked of ham, dated 1/23/2023, was discarded after 7 days.<BR/>3. A container of cheese, dated 1/4/23, was discarded after 7 days.<BR/>4. An expired container of chocolate pudding, good by date of 1/25/2023, was discarded. <BR/>5. A container of pears was labeled and dated. <BR/>6. The deep fryer was clean and had clear grease. <BR/>7. The ice scoop was stored appropriately when not in use. <BR/>These failures could place residents at risk for food-borne illness. <BR/>The findings included:<BR/>Observation and interview during the brief initial kitchen tour on 02/06/2023 at 9:22 AM, the following was revealed:<BR/>1. An open bag of dinner rolls in a box dated 1/30/2023 was observed in the freezer.<BR/>2. Two open bags of cookie dough in a box dated 1/30/2023 was observed in the freezer.<BR/>3. A container of cooked ham dated 1/23/2023 was observed in the refrigerator. The FSS stated the container of ham was good for 7 days.<BR/>4. A container of cheese dated 1/4/2023 was observed in the refrigerator. The FSS stated she was unsure how long it was good for.<BR/>5. A container of chocolate pudding dated 1/18/2023 was observed in the refrigerator. The good by date was 1/25/2023.<BR/>6. A container of pears had no label or date. The FSS stated she was unsure how long they had been in the refrigerator. <BR/>7. A container of jelly dated 1/18/2023 was observed in the refrigerator. The FSS stated she was unsure how long it was good for. <BR/>8. The deep fryer had multiple white streaks and oil spots on the outside. The grease observed in the deep fryer was a solid dark brown and had numerous food crumbs observed on the inside surfaces. The FSS stated the deep fryer, and the grease was supposed to have been changed weekly. The FSS stated it was supposed to have been cleaned last week. The FSS was unable to provide the date of the last cleaning. The FSS stated the cooks were responsible for ensuring the deep fryer was cleaned. The FSS stated had no log. The FSS stated it was important to keep the deep fryer and grease clean to prevent food-borne illness.<BR/>During an observation and interview on 02/06/2023 at 12:19 PM, the ice scoop was observed in the ice cooler used to pass ice to the residents. The Staffing Coordinator stated it was not supposed to have been left in the ice cooler. The Staffing Coordinator stated it was supposed to be in a bag located on the side. The Staffing Coordinator stated the importance for ensuring the ice scoop was not left inside the cooler was to prevent cross-contamination.<BR/>During an observation and interview on 02/07/2023 at 11:15 AM, the deep fryer had multiple white streaks and oil spots on the outside. The grease observed in the deep fryer was a solid dark brown and had numerous food crumbs observed on the inside surfaces. [NAME] S stated the cooks were responsible for ensuring the deep fryer and the grease was cleaned. [NAME] S stated this was supposed to be completed every other week and as needed. [NAME] S stated she was unsure when the last time it was completed. [NAME] S stated the importance of keeping the deep fryer and grease cleaned was to prevent bacterial growth that would make the residents sick.<BR/>During an interview on 02/08/2023 at 4:46 PM, NA R stated the ice scoop should not have been left in the ice cooler. NA R stated the ice scoop should have been stored in a bag on the side of the cooler. NA R stated it was important to ensure the ice scoop was not left in the ice cooler to prevent cross-contamination. <BR/>During an interview on 02/08/2023 at 5:58 PM, [NAME] S stated all dietary staff were responsible for ensuring everything in the refrigerator, freezer, and dry storage area was labeled, dated, not expired, and stored appropriately. [NAME] S stated food was checked for proper storage and expiration dates every 2 days. [NAME] S stated food should be labeled and dated when supplies were delivered and when placed into a container. [NAME] S stated the importance of labeling, dating, and proper storage was to prevent food-borne illness. <BR/>During an interview on 02/08/2023 at 6:15 PM, the FSS stated the dietary staff was responsible for ensuring all food items were labeled, dated, and stored appropriately. The FSS stated she expected the dietary staff to check this daily. The FSS stated this was monitored by performing spot checks. The FSS stated she was unsure why this was not completed. The FSS stated labeling, dating, and storing food was important to prevent food-borne illness. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated he expected the dietary staff to ensure food items were labeled, dated, and stored appropriately. The ADM stated he expected the FSS to monitor the dietary staff. The ADM stated the importance of labeling, dating, and storing food appropriately was to prevent cross contamination and food-borne illness. <BR/>Record review of the Safe Ice Handling policy, last revised in March of 2012, revealed Scoops must be stored outside of the ice in a manner which protects them from contamination.<BR/>Record review of the Frozen and Refrigerated Food Storage policy, last revised on 12/5/2017, revealed 7. Proper labeling of cooked foods includes the date placed in the refrigerator, and an expiration or use by date. Refrigerated products that are opened must be labeled with an opened on date. The use by date is 7 days from when the product was opened, unless there is a manufacturer's use by, expiration or sell by date. The policy further revealed 10. Packaged frozen items that are opened and not used in their entirety must be properly sealed, labeled and dated for continued storage. <BR/>Record review of the Food Safety and Sanitation Plan policy, last revised on 10/24/2022, did not address cleaning kitchen equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to arrange an appointment with an outside resource for 1 of 24 residents (Resident #66) reviewed for the use of outside resources.<BR/>The facility failed to ensure Resident #66's appointments with nephrology (specialty for kidneys/kidney disease, function) and with hematology (specialty for blood and blood diseases) were scheduled after she discharged from the hospital on [DATE].<BR/>This failure could place residents at risk of not receiving needed medical care. <BR/>Findings included:<BR/>Record review of a face sheet dated 03/27/2024 indicated Resident #66 was a [AGE] year old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system), type 2 diabetes mellitus with hyperglycemia (chronic condition that affects the way the body processes blood sugar which leads to high blood sugars), thrombocytopenia (low blood platelet (blood cells help blood clot) count), and acquired absence of kidney. <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #66 had reentered from a short-term general hospital on [DATE]. The MDS assessment indicated Resident #66 was able to make herself understood and understood others. The MDS assessment indicated Resident #66 had a BIMS score of 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #66 was independent for eating, required set up or clean up assistance with toileting hygiene and personal hygiene, and supervision or touching assistance with bathing. <BR/>Record review of Resident #66's discharge orders from her hospitalization, admit date [DATE] and discharge date [DATE], indicated discharge patient instructions, no heparin products to be given and needed to add heparin as an allergy. Follow-up appts within 1 to 2 weeks with nephrology and within 1 week Resident #66 needed the next available hematology evaluation. <BR/>Record review of the Order Summary Report dated 03/24/2024, did not indicate an order to follow-up with nephrology (specialty for kidneys/kidney disease, function) or to follow up with hematology (specialty for blood and blood diseases) for an evaluation. <BR/>Record review of Resident #66's care plan with a target date of 06/06/2024 did not address referrals to nephrology or appointments with nephrology, and the care plan did not address an appointment with hematology. <BR/>During an interview on 03/27/2024 at 10:17 a.m., RN L said he was not aware Resident #66 required follow up appointments with nephrology and hematology. RN L checked the transport book and said there were no appointments scheduled for Resident #66. RN L said if a resident required a follow-up appointment the nurses would put an order in the electronic medical record for an appointment, schedule the appointment, and put it in the transport book. RN L said the nurses were responsible for scheduling follow-up appointments and the ADONs assisted if needed. RN L said it was important for follow-up appointments to be scheduled to ensure the treatment the residents were receiving was working, to help them improve, and so they could have necessary labs drawn for the appointments.<BR/>During an interview on 03/27/2024 at 3:54 p.m., ADON M said as of right now she did not think Resident #66's had any appointments scheduled. ADON M said the nurses reviewed the discharge orders and follow-up appointments, and then the ADONs and the DON looked over them after to ensure things were not missed. ADON M said she had reviewed Resident #66's discharge orders, and she was not aware of the follow-up appointments. ADON M said she had not noticed them that it got missed.<BR/>During an interview on 03/27/2024 at 4:35 p.m., the DON said the nurses received the discharge orders, reviewed them, and put the orders into the residents' electronic medical records. The DON said depending on the time of the day the resident was re-admitted if the orders were reviewed by the ADONs the same day of the next morning. The DON said the ADONs reviewed the orders after the nurses to ensure they were put in correctly. The DON said she was not aware of Resident #66's discharge orders to follow up with nephrology and hematology. The DON said it was important for follow-up appts to be scheduled because if the residents had something going on the diagnoses needed to be addressed. The DON said Resident #66's follow-up appointments to nephrology and hematology not being scheduled could be life threatening for her.<BR/>During an interview on 03/26/2024 at 5:29 p.m., the Administrator said she expected the nurses to follow discharge orders and schedule follow-up appointments. The Administrator said she was not clinical and could not address what it placed residents at risk for. <BR/>Record review of the facilities policy implemented, 09/24/2022, titled, Medication Reconciliation, indicated, .compare orders to hospital records, home or orders from healthcare entity, etc. obtain clarification orders as needed c. transcribe orders in accordance with procedures for admission orders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 20 residents (Resident #187) reviewed for resident records. <BR/>The facility failed to ensure Resident #187 had a physician order for contact precautions. <BR/>This failure could place residents at risk of infections and not receiving individualized care and services to meet their needs. <BR/>Findings included:<BR/>Record review of a face sheet dated 02/08/23, revealed Resident #187 was a [AGE] year-old male initially admitted [DATE] with diagnoses of metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), type 2 diabetes mellitus with diabetic neuropathy (high blood sugars with nerve damage), and chronic kidney disease stage 4 (severe kidney damage).<BR/>Record review of Resident #187's Care Plan date initiated 02/03/23 did not indicate Resident #187 was on contact precautions. <BR/>Record review of Resident #187's Comprehensive MDS Assessment with an assessment reference date of 01/27/23 revealed Resident #187 was understood and understood others. Resident #187 had a BIMs score of 9, indicating cognition was moderately impaired. The MDS assessment indicated Resident #187 required extensive assistance for bed mobility, dressing, eating, personal hygiene, and total dependence for transfers, toilet use and bathing. The MDS assessment indicated Resident #187 was on isolation or quarantine for active infections disease (does not include standard body/fluid precautions) while a resident at the facility during the last 14 days. <BR/>Record review of Resident #187's Order Summary report dated 02/08/23 revealed, Resident #187 had an order for Bactrim DS Oral Tablet 800-160 milligrams (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for UTI (urinary tract infection) for 14 Days with a start date of 02/04/23. Record review of the order summary report did not indicate Resident #187 has a physician order for contact precautions. <BR/>During an observation on 02/06/23 at 10:26 AM, personal protective equipment was observed hanging from Resident #187's door and there was a sign posted to see the nurse prior to entering the room. <BR/>During an observation on 02/06/23 at 11:47 AM, CNA N was observed putting on a gown and gloves prior to entering Resident #187 room to provide care. <BR/>During an interview on 02/06/23 at 3:04 PM, Nurse M said Resident #187 was not on any type of isolation. <BR/>During an interview on 02/08/23 at 4:50 PM, ADON H, also the Infection Preventionist, said Resident #187 was supposed to be on contact precautions due to VRE (Vancomycin-resistant Enterococci bacteria) or ESBL (Extended spectrum beta-lactamase bacteria) in the urine. ADON H said the charge nurse was supposed to put a physician order in for contact precautions. ADON H said ADON K was responsible for overlooking Resident #187 physician orders. ADON H said Resident #187 not having a physician order for contact precautions could result in a spread of infection if the staff was not putting on the proper personal protection equipment while providing personal care. <BR/>During an interview on 02/08/23 at 4:55 PM, ADON K said Resident #187 should have a physician order for contact precautions. ADON K said the nurse who received the order should have put it in the electronic health record. ADON K said she did not know why Resident #187 did not have a physician order for contact precautions. ADON K said Resident #187 not having a physician order for contact precautions placed the other residents at risk of getting the infection. <BR/>During an interview on 02/08/23 at 6:49 PM, the DON said Resident #187 was on contact precautions and he should have a physician order for contact precautions. The DON said the nurse who received the physician order should have put it in the electronic health record, and the ADONs were responsible for overseeing this was done. The DON said he did not know why the physician order was not put in the electronic health record for Resident #187. The DON said Resident #187 not having a physician order for contact precautions was a lack of communication and could cause infection issues. <BR/>During an interview on 02/08/23 at 8:08 PM, the administrator said the nurses were responsible for putting in the order for contact precautions in the electronic health record. The administrator said he expected the nurses to place all physician orders in the electronic health record and the DON or designee to oversee this. The administrator said not putting physician orders in the electronic health record placed residents at risk for not getting what they needed. <BR/>Record review of the facility's policy titles, Following Physician Orders, date implemented 09/28/2021, revealed, Policy: The policy provide guidance on receiving and following physician orders . 2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Document the order by entering the order and the time, date, and signature on the physician order sheet. b. follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. 3. For consulting physician/practitioner orders received via telephone, the nurse will: a. Document the order on the physician order form, notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order. b. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. c. Carry out and implement physician order d. Document resident response to physician order in the medical record as indicated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #1) reviewed for hospice services.<BR/>The facility failed to obtain Resident #1's physician's order for hospice services, most recent physician order, and the most recent hospice plan of care. <BR/>The facility failed to obtain the most recent hospice certification.<BR/>This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet dated 03/27/24 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of senile degeneration of the brain, anxiety, dementia (decline in cognitive abilities that impacts everyday activities), and protein-calorie malnutrition (inadequate food intake). <BR/>Record review of Resident #1's quarterly MDS dated [DATE] indicated he had a BIMS score of 10 which indicated moderate cognitive impairment. The MDS also indicate he required supervision with toileting and transfers, setup with eating and dressing and he was independent with med mobility. The MDS also indicated Resident #1 was on hospice care. <BR/>Record review of Resident #1's undated care plan indicated he had a terminal illness and was receiving hospice services related to the diagnosis of senile degeneration of the brain with interventions in place to coordinate with hospice to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met.<BR/>Record review of Resident #1's order summary report dated 03/27/24 did not reveal an order for hospice care. <BR/>Record review of Resident #1's hospice binder on 03/27/24 at 4:00 PM, indicated the last written certification was completed 06/20/23 that was certified from 06/20/23-08/23/23. There was not a recent plan of care update noted in the facility's hospice binder. The last plan of care order noted was dated 01/15/24. <BR/>Record review of Resident #1's EMR on 03/27/24 at 04:02 PM, indicated the hospice administration record and the facility's physician orders did not match. The following orders were noted on the hospice medication record and not in Resident #10's facility's order summary report:<BR/>1. <BR/>Fluvoxamine Maleate oral tablet 100mg 1 tab daily for schizophrenia dated 10/28/21.<BR/>During an interview on 03/27/24 at 3:50 PM RN A said Resident #1 receives hospice services and he should have had an order for hospice in the EMR. She said she could not locate the order for hospice. RN A said the hospice binder should have been up to date and orders should have matched the facility orders, but she was not responsible for the notebook. RN A said the hospice binder not being updated placed Resident #1 at risk for a medication error. <BR/>During an interview on 03/27/24 at 4:12 PM the hospice company RN said the nurses were at the facility weekly and the binders should have been updated every certification. The hospice company RN said the plan of care should have been updated every 2 weeks and with any changes to Resident #1's medications or care. She said the nurse that was at the facility on 03/27/24 quit on 03/27/24 and another RN that had seen Resident #1 would bring updated documents on 03/28/24. The hospice company RN said the failure placed Resident #1 at risk of medications being given to in error and the nursing home not being made aware of the frequency of the visits (nurses or aides) or plan of care for Resident #1. <BR/>During an interview on 03/27/24 at 05:00 PM ADON W said the hospice was responsible for ensuring the hospice binder was up to date and the facility relied on hospice to come in and do their part. ADON W said the responsibility for ensuring the book was updated would have probably fallen on her. She said the medication list should be updated at least every 2 weeks when the hospice company completed their meeting as well as when any changes were made. She said the risk to Resident #1 was medications not up to date, possible errors, and it could have caused issues with resident care he received from nurses or aides coming in the facility from hospice. ADON W said she had never really read through a hospice binder. <BR/>During an interview on 03/27/24 at 05:48 PM the DON said the hospice company was responsible for ensuring the hospice binder, medications, and care plans were up to date. She said the hospice nurses came in weekly and should have been updating care plans bi-weekly and medications monthly or with any changes. The DON said it placed Resident #1 at risk for medication errors and a break in continuity of care. <BR/>During an interview on 03/27/24 at 06:12 PM the Administrator said her expectation was for the hospice binders to be up to date and the hospice company was responsible, but the nursing staff should also monitor to ensure the binder was up to date. She said the risk to the resident was an issue with continuity of care and errors being made with care.<BR/>Record review of the facility Coordination of Hospice Services Policy dated 04/21/2021 indicated:<BR/>Policy:<BR/> When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being. <BR/>Policy Explanation and Compliance Guidelines: <BR/>1. The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the resident's care. <BR/>2. The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident's representative, to the extent possible.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 staff (RN M, CNA N, and Treatment Nurse) viewed for infection control.<BR/>1. The facility failed to ensure RN M performed hand hygiene after removing his gloves and before putting on clean gloves during tracheostomy care for Resident #62<BR/>2. The facility failed to ensure RN M changed gloves and performed hand hygiene after picking up a nebulizer machine off the ground and before performing oral care and washing Resident #62's face.<BR/>3. The facility failed to ensure the treatment nurse and CNA N changed gloves when providing incontinent care for Resident #182. <BR/>4. The facility failed to ensure the treatment nurse performed hand hygiene between glove changes. <BR/>These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. <BR/>Findings Include:<BR/>1. During an observation on 2/07/23 at 9:16 p.m. RN M performed tracheostomy care on Resident #62. RN M removed his sterile gloves after removing Resident #62's inner cannula, took his cell phone out of his pocket, and then put another pair of sterile gloves. RN M did not perform hand hygiene after removing his sterile gloves and before putting on a clean pair of sterile gloves to complete Resident #62's tracheostomy care. <BR/>During an observation on 2/07/23 at 9:21 a.m. RN M performed suctioning on Resident #62. RN M removed his sterile gloves after he completed suctioning on Resident #62 and put another pair of sterile gloves. RN M did not perform hand hygiene after removing his sterile gloves and before putting on a clean pair of sterile gloves to replace Resident #62's inner cannula (a tube inside the outer tube of a tracheostomy that can be easily removed and cleaned) .<BR/>2. During an observation on 2/07/23 at 9:38 a.m. RN M knocked Resident #62's nebulizer onto the floor. RN M picked the nebulizer up off the floor with his gloved hands and then performed oral care and cleaned Resident #62's face. RN M did not remove his gloves or perform hand hygiene after picking up the nebulizer off the floor and before performing oral care and cleaning Resident #62's face.<BR/>During an interview on 1/07/23 at 9:48 a.m. RN M said hand hygiene should be performed after cleaning the inner cannula and before continuing tracheostomy care and when gloves were changed. RN M said proper hand hygiene was important to prevent the spread of bacteria and for infection control. RN M said when the nebulizer fell into the floor it would have been contaminated. RN M said picking up an item off the floor and then providing care to a resident without changing gloves or performing hand hygiene could introduce bacteria to the resident and cause an infection. RN M said he did not perform hand hygiene between glove changes or change gloves and perform hand hygiene after picking the nebulizer up out of the floor was because it slipped his mind. <BR/>During an interview on 2/08/23 at 2:29 p.m. the Infection Preventionist said she expected staff to perform hand hygiene after providing care, between residents, when hands were visibly soiled, and when gloves were changed. The Infection Preventionist said it was important to perform hand hygiene to keep infections down and to prevent the spread of infections. <BR/>During an interview on 2/08/23 at 6:08 p.m. the DON said he expected the staff to perform hand hygiene before and after entering a resident room and between glove changes. The DON said when staff removed a pair of gloves they did not know what they might accidentally touch when removing the gloves. The DON said the importance of proper hand hygiene was for infection control.<BR/>During an interview on 2/08/23 at 7:10 p.m. the Administrator said he expected staff to perform hand hygiene anytime hands were visibly soiled, before handling food, before and after providing care, and between glove changes. The Administrator said the DON and nursing management were responsible for ensuring staff were trained and performing appropriate hand hygiene. The Administrator said hand hygiene decreased the risk of infection.<BR/>3 and 4. During an observation on 02/06/23 starting at 11:00 AM, CNA N and the treatment nurse were providing incontinent care to Resident #182. During the incontinent care the treatment nurse was holding Resident #182 by buttocks with her two hands and had feces on her gloves. The treatment nurse wiped off the feces from her gloves and removed one glove. The treatment nurse put on a new glove. The treatment nurse did not change both gloves and she did not perform hand hygiene after removal of the one glove. CNA N continued to provide care and removed the dirty brief and applied a clean brief and finished the incontinent care. CNA N did not change her gloves and did not perform hand hygiene after removing the dirty brief. <BR/>During an interview on 02/06/23 at 11:31 AM, the treatment nurse said while providing incontinent care to Resident #182 she did not perform hand hygiene after removing one glove and putting on a new glove. The treatment nurse said she should have changed both gloves and performed hand hygiene. The treatment nurse said it was important to perform hand hygiene and change gloves when they were soiled to prevent cross contamination and so you do not accidentally spread germs. <BR/>During an interview on 02/06/23 at 11:39 AM, CNA N said she should have changed gloves when she took off Resident #182 dirty brief. CNA N said not changing gloves when going from dirty to clean and not performing hand hygiene placed the residents at risk for cross contamination.<BR/>During an interview on 02/08/23 at 5:05 PM, ADON K said there was currently no monitoring in place for incontinent care. ADON K said the DON did skill check offs for the staff, but she did not know how often. ADON said the charge nurses and nurse management were responsible for ensuring the facility staff performed hand hygiene and proper incontinent care. ADON K said not performing proper incontinent care and not performing hand hygiene could cause the residents to get urinary tract infections, skin breakdown, and placed the residents at risk of infection.<BR/>During an interview on 02/08/23 at 6:53 PM, the DON said the treatment nurse and CNA N should have changed gloves and performed hand hygiene when going from dirty to clean. The DON said the nurse overseeing the CNAs was responsible for making sure the CNAs performed hand hygiene and proper incontinent care. The DON said not performing hand hygiene and improper incontinent care placed the residents at risk for infection and skin breakdown.<BR/>During an interview on 02/08/23 at 8:13 PM, the administrator said the treatment nurse and CNA N should have changed gloves and performed hand hygiene while providing incontinent care. The administrator said nursing was responsible for ensuring proper incontinent care was provided and staff were performing hand hygiene. The administrator said improper incontinent care and not performing hand hygiene could cause the residents to have an infection.<BR/>Record review of the facility's policy titled, Incontinence Care, last reviewed 02/14/20, revealed, .8. If feces present, remove with toilet paper or disposable wipe by wiping from front perineum toward rectum. Discard soiled materials and gloves. Wash hands. 9. Put on non-sterile latex-free gloves .14. Remove linen/under pad and discard 15. Remove and discard gloves 16. Wash hands 17. Apply clean linen/underpad, briefs or other incontinent products as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, 4 of 13 (Residents #3, #4, #5, and #6) reviewed for abuse.<BR/>1. The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 10/17/24 between Resident #3 and Resident #4<BR/>2. The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 08/28/24 between Resident #3 and Resident #4. <BR/>These deficient practices could place residents at risk for abuse, neglect, and not having their needs met.<BR/>Findings included:<BR/>Record review of the facility policy for Policy and Procedures: Abuse, Neglect and Exploitation revised 09/06/24, reflected . 2. The facility's abuse prevention coordinator is responsible for reporting allegations or suspected abuse, neglect . to the state survey agency and other official in accordance with state law .III. Prevention of Abuse, Neglect and Exploitation . A. (2.) Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: 2(a). Immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involves abuse (with or without bodily injury) .<BR/>1. Resident #3<BR/>Record review of Resident #3's face sheet, dated 02/27/25, reflected Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included supraventricular tachycardia (abnormal fast heartbeat). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 02/04/25, reflected Resident #3 usually made himself understood and understood others. Resident #3's BIMS score was 9, which indicated his cognition was moderately impaired. The MDS reflected Resident #3 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #3's comprehensive care plan revised 06/20/24 reflected Resident #3 had a behavior problem as evidenced by: verbal/physical behaviors, and rejection of care. The care plan interventions included: administer medications as ordered, monitor behavior episodes, and attempt to determine underlying cause and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet, dated 02/27/25, reflected Resident #4 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #4's annual MDS assessment, dated 01/02/25, reflected Resident #4 made himself understood and usually understood others. Resident #4's BIMS score was 5, which indicated his cognition was severely impaired. The MDS reflected Resident #4 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #4's comprehensive care plan revised 04/05/24 reflected Resident #4 had a behavior problem as evidence by resident with physical aggression toward another resident when verbally antagonized. The care plan interventions included: administer medication as ordered and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Record review of the PIR dated 10/22/24 reflected an allegation of resident-to-resident incident on Resident #3 and #4 that occurred on 10/17/24 at 10:50 a.m. The PIR reflected both residents were sitting in the sitting area and Resident #4 asked Resident #3 if he would move his chair into his spot. Resident #4 then pushed Resident #3's wheelchair forward from behind. Resident #3 became upset because Resident #4 moved his chair. Resident #3 then went back into Resident #4 with his wheelchair because he moved him. Resident #4 hit Resident #3 on the back of the head due to him hitting his wheelchair. The PIR reflected staff witnessed the incident. The incident was reported to the state agency on 10/17/24 at 1:20 p.m. <BR/>2. Resident #5<BR/>Record review of Resident #5's face sheet, dated 02/27/25, reflected Resident #5 was a [AGE] year-old female, originally admitted to the facility 12/14/23 with a diagnosis which included heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). <BR/>Record review of Resident #5's annual MDS assessment, dated 01/10/25, reflected Resident #5 made herself understood and understood others. Resident #5's BIMS score was 5, which indicated her cognition was severely impaired. The MDS reflected Resident #5 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #5's comprehensive care plan revised on 09/06/24 reflected Resident #5 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to paranoid personality disorder, and depression adult failure to thrive. The care plan interventions included: monitor/document/report to physician any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes and reduce any distractions. <BR/>Resident #6<BR/>Record review of Resident #6's face sheet, dated 02/27/25, reflected Resident #6 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #6's quarterly MDS assessment, dated 02/01/25, reflected Resident #6 made herself understood and understood others. Resident #6's BIMS score was 15, which indicated her cognition was intact. The MDS reflected Resident #6 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #6's comprehensive care plan revised on 08/21/23 reflected Resident #6 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to dementia. The care plan interventions included: identify yourself at each interaction, reduce any distractions and provide instructions to resident using clear voice and simple sentences. <BR/>Record review of the undated PIR reflected an allegation of resident-to-resident incident on Resident #5 and Resident #6 that occurred 8/28/24 around 7:30 a.m. per the witnessed statement written by LVN B. The PIR reflected Resident #5 hit Resident #6 with her silverware packet at the breakfast table. The PIR reflected the incident was witnessed. The incident was reported to the state agency on 8/28/24 at 10:00 a.m. The PIR stated the facility substantiate the allegation of abuse. <BR/>During a telephone interview on 02/26/25 at 2:25 p.m., LVN B stated on the morning of 8/28/24 at approximately 7:30 a.m., she was in the dining room with another resident when she heard a noise and then heard Resident #6 state, she hit me referring to Resident #5. Resident #5 was sitting in the chair where Resident #6 normally sits. Resident #6 stated she asked Resident #5 to move, and Resident #5 picked up her silverware packet and hit her on her left arm. Resident #5 was questioned as to why she hit Resident #6 and she stated, she tried to take my silverware. LVN B stated she notified the DON, and the resident was assigned someone to stay with her while investigation was ongoing. LVN B stated the abuse coordinator was the Administrator and she knew the Administrator was on her way to the facility that morning, so she was going to tell her when she got there. <BR/>During an interview on 02/27/25 at 3:10 p.m., the Administrator stated she was the abuse coordinator for the facility. The Administrator stated the incident between Resident #3 and Resident #4 was witnessed by several staff members including herself. The Administrator stated the incident took longer to diffuse that required multiple staff member including herself to calm both residents down. The Administrator stated Resident #3 did not respond well to other staff members, but she was one that he did respond well too. The Administrator stated she was aware of the incident on 8/28/24 due to Resident #6 been at her office door upon her arrival. The Administrator stated after Resident #6 made the allegation, she went down to talk to LVN B and she informed her of the allegation, but she expected LVN B to contact her immediately regarding the incident. The Administrator stated she did agree that the allegations should always be reported within 2 hours unless there are extenuating circumstances. The Administrator stated she was responsible for overseeing by frequent rounding of the halls and dining room and trying to deescalate any agitation by residents as it arises. The Administrator stated she was the only one in the facility who could report abuse allegations to HHSC. The Administrator stated it was important to report an allegation of abuse and neglect for safety and protection of the residents and try to circumvent other incidents of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 20 residents (Resident #44) reviewed for care plans. <BR/>The facility did not implement Resident #44's fall management care plan to ensure she always wore non-skid footwear and have a fall mat at bedside. <BR/>This failure could place residents at risk of not having their individual needs met. <BR/>Findings include:<BR/>Record review of Resident #44's order summary report, dated 02/08/2023, indicated Resident #44 was a [AGE] year-old female, originally admitted on [DATE] with a diagnosis which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (high blood pressure), and history of falling. <BR/>Record review of Resident #44's significant change in status MDS assessment, dated 10/07/2022, indicated Resident #44 rarely/never understood others and rarely/never made herself understood. The assessment did not address Resident #44 cognitive status. The assessment indicated Resident #44 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #44 had a fall in the last month, last 2-6 months, and obtained a fracture related to a fall in the 6 months prior to admission/entry or reentry. <BR/>Record review of Resident #44's care plan, with an initiated date of 08/05/2022, indicated Resident #44 had a history of falls related to dementia with behaviors, pain, medications, immobility, unsteady/poor balance, and recent fall with injuries. The care plan interventions included, always ensure non-skid footwear, fall mat at bedside and increase staff rounding. <BR/>Record review of the fall risk assessment tool dated 11/24/2022 indicated Resident #44 had multiple falls within the previous six months, on three high risk drugs, unable to independently come to a standing position, required hands-on assistance to move from place to place, use an assistive device and decrease in muscle coordination. The fall risk assessment indicated Resident #44 was a high risk for falls. <BR/>During observations of Resident #44's room the following was noted: <BR/>02/06/2023 at 10:00 a.m. Resident lying in bed with no fall mat at bedside. <BR/>02/06/2023 at 3:34 p.m. Resident lying in bed with no fall mat at bedside. <BR/>02/07/2023 at 2:37 a.m. Resident lying in bed with no fall mat at bedside. <BR/>During an observation on 02/07/2023 at 9:08 a.m., Resident #44 was sitting in her wheelchair in the tv room wearing a pair of off-white socks with no grip on the bottom. <BR/>During an observation, interview, and record review on 02/08/2023 at 2:46 p.m., LVN A stated she was Resident #44's 6a-6p charge nurse. LVN A stated she was unaware that Resident #44 should have a fall mat at bedside. After reviewing Resident #44 electronic medical records, LVN A stated she should have a fall mat at bedside and always wore nonskid socks. LVN A observed with the surveyor Resident #44's fall mat was not at bedside. LVN A stated nursing staff were responsible for ensuring a fall mat was at Resident #44 bedside and ensure Resident #44 always wear non-skid footwear. LVN A stated there was not a system at this time that staff could review what devices were needed for residents. LVN A stated this failure could potentially put Resident #44 at risk for a serious injury. <BR/>During an interview on 02/08/2023 at 4:14 p.m., NA C stated she was Resident #44's 2p-10p aide. NA C stated she unaware that Resident #44 was a high risk for falls. NA C stated she did not know that Resident #44 needed a fall mat at bedside and should always wear non-skid socks. NA C stated there was times Resident #44 did not have on non-skid socks. NA C stated she did not have access to resident's care plan. NA C stated this failure could potentially cause an injury (concussion) to Resident #44. <BR/>During an interview on 02/08/2023 at 4:36 p.m., the DON stated he expected Resident #44 to have a fall mat at bedside and always wear non-skid socks. The DON stated the aides and nurses were responsible for ensuring care plan items were in place. The DON stated daily rounds were made by LVN H to ensure safety measures are in place. The DON stated currently there was a system being put in place to inform staff of care plan needs. The DON stated this failure could potentially put Resident #44 at risk for injury. <BR/>During an interview on 02/08/2023 at 5:47 p.m., LVN H stated herself and the department heads were responsible for daily rounds. LVN H stated she could not say the last time rounds were done on Resident #44 due to frequent room changes. LVN H stated she expected the nursing staff to ensure fall preventions measure are in place. LVN H stated this failure could potentially put Resident #44 at risk for injury. <BR/>During an interview on 02/08/2023 at 6:13 p.m., the Administrator stated he expected the care plan to be followed. The Administrator stated ultimately the DON or designee was responsible for ensuring safety measures were in place. The Administrator stated this failure could potentially put Resident #44 at risk for injury. <BR/>Record review of the facility's Fall Management System policy, revised 01/03/2017, indicated, . it is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan implemented based on the resident's assessed needs Procedure (3) A care plan is implemented for residents at risk for falls . Investigation and follow up of accidents involving falls (2) Interventions will be implemented in an attempt to prevent the resident from sustaining further falls

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards and to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 20 residents (Resident #47) reviewed for medication storage and 1 of 8 medication carts (Hall 200) reviewed for drugs and biologicals. <BR/>1. The facility did not keep medication being administered under the direct observation of the person administering medications. Resident #47 had 1 bottle of Fluticasone Propionate nasal spray (allergies) and 1 bottle of Azelastine nasal spray (allergies) on her bedside table. <BR/>2. The facility failed to date insulin pens and vials on the hall 200 medication cart. <BR/>These failures could place residents at risk for health complications and not receiving the intended therapeutic benefit of their medication.<BR/>Findings included:<BR/>1. Record review of Resident #47's order summary report, dated 02/08/2023, indicated Resident #47 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included essential hypertension (high blood pressure), COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and acute respiratory failure with hypercapnia (buildup of carbon dioxide in bloodstream). <BR/>Record review of the order summary report dated 02/08/2023 indicated Resident #47 was ordered to receive Azelastine HCL Solution 0.1% (two sprays in both nostrils two times a day) for allergies with a start date 11/01/2022 and Fluticasone Propionate 50 MCG/ACT (two sprays in both nostrils in the morning) for allergies with a start date 11/01/2022. <BR/>Record review of Resident #47's significant change status MDS assessment, dated 11/03/2022, indicated Resident #47 understood others and made herself understood. The assessment indicated Resident #47 was cognitively intact with a BIMS score of 14. The assessment indicated Resident #47 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #47 required supervision with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The assessment indicated Resident #47 required total dependence with bathing. <BR/>Record review of Resident #47's care plan did not address allergies or medications left at bedside. <BR/>During an observation on 02/06/2023 at 11:42 a.m., Resident #47 was lying in bed watching tv. There was 1 brown bottle with a white lid labeled Fluticasone Propionate lying on the floor next to Resident #47's bed. <BR/>During an observation on 02/06/2023 at 12:10 p.m., Resident #47 was lying in bed. There was 1 brown bottle with a white lid labeled Fluticasone Propionate and 1 white bottle labeled Azelastine HCL Solution sitting on Resident #47's bedside table. <BR/>During an interview and observation on 02/07/2023 at 1:50 p.m., Resident #47 was lying in bed. There was 1 brown bottle with a white lid labeled Fluticasone Propionate and 1 white bottle labeled Azelastine HCL Solution sitting on Resident #47's bedside table. Resident #47 stated she used both medications on a daily basis due to allergies. <BR/>During an interview on 02/08/2023 at 2:12 p.m., RN B stated she was Resident #47 6a-6p charge nurse. RN B stated Resident #47 was allowed to have medications at bedside. RN B stated she did not know if Resident #47 had a physician's orders to self-administer medications. After reviewing Resident #47 electronic medical records, RN B stated Resident #47 did not have a physician's order to self-administer medications. RN B stated Resident #47 needed to be educated, assessed, and able to demonstrate she can safely administer her medications by the interdisciplinary team before medications were left at bedside to administer. RN B stated this could potentially cause an overdose and not using medication correctly. <BR/>2. During an observation of the hall 200 medication cart with LVN D starting at 02/08/2023 at 9:25 a.m., the following insulins were observed with no open date:<BR/>* Resident #187's Levemir Flex Touch (diabetic medication), no open date, instructions to discard after 30 days of the open date.<BR/>* Resident #187's Insulin Detemir Solution (diabetic medication), no open date, instructions to discard after 30 days of the open date.<BR/>* Resident #73's Humulin R (diabetic medication), no open date, instructions to discard after 30 days of the open date.<BR/>During an interview on 02/08/2023 at 3:15 p.m., LVN D stated insulins should have been dated upon opening, LVN D stated charge nurses were responsible for ensuring the medication was labeled and dated before administering the first dose. LVN D stated the person opening the medication should date it. LVN D stated this failure could potentially cause the medication to not work properly. <BR/>During an interview on 02/08/2023 at 4:36 p.m., the DON stated Resident #47 was able to keep her medication at bedside if she had a physician's order and had been educated, assessed, and able to demonstrate she could safely administer her medications by the Interdisciplinary Team to allow medications at bedside. The DON stated the Maintenance Manager was responsible for monitoring to ensure medications were not left at bedside by conducting daily rounds. The DON stated this failure could potentially put residents at risk for safety, potential overdose and not taking the medication at the correct time. The DON stated he expected the nurse to date the insulin when first opened. The DON stated carts were checked once a month by RN K. The DON stated there had been times nurses had to be reminded to date a recent opened medication. The DON stated this failure could potentially give a resident an outdated medication. <BR/>During an attempted interview on 02/08/2023 at 5:27 p.m., the Maintenance Manager refused to be interviewed about monitoring to ensure medications were not left at bedside. <BR/>During an interview on 02/08/2023 at 5:39 p.m., RN K stated she was responsible for checking the cart for expiration dates, insulin vials/pen dated when opened. RN K stated rounds are done at least once a month. RN stated the last round was done at the end of January 2023. RN K stated charge nurses are responsible for dating insulins when the medication was first opened. RN K stated she did not look at Resident #187's insulin (diabetic medication) in the past week. RN K stated she did not look at Resident #73's insulin (diabetic medication) since the last round was done in January. RN K stated these failures could potentially cause a medication not to be as effective. <BR/>During an interview on 02/08/2023 at 6:13 p.m., the Administrator stated unless Resident #47 had an order and had been educated, assessed, able to demonstrate they can safely administer their medications, and a locked box to keep medications stored safely, medications should be kept in the med cart. The Administrator stated ultimately the DON or designee was responsible for ensuring residents had an order for medications at bedside. The Administrator stated he knew there was a potential failure but due to him not having a clinical background he was unable to say. The Administrator stated he expected the insulin to be dated when first opened. The Administrator stated this failure could potentially cause a medication not to be as effective. <BR/>Record review of the facility's Bedside Medication Storage policy, revised 08/2020, indicated, .bedside medication storage is permitted for residents who wish to self-administer medications, upon written order of the prescriber and once self -administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team 1. A written order for the bedside storage of medication is present in the resident's medical record 2. Bedside storage of medications is indicated on the resident MAR and in the care plan for the appropriate medications. 4. The resident is instructed in the proper use of bedside medications . the completion of this instructions is documented in the resident's medical record 6. All nurses and aides are required to report to the charge nurse on duty any medications found at bedside not authorized for bedside storage . 8. Bedside medication storage is routinely monitored during medication storage review <BR/>During an interview and record review on 02/08/2023 at 3:31 p.m., the Regional Nurse Consultant stated there was not a policy regarding labeling and dating medication. The Regional Consultant stated the facility used a guidance that indicated . (1) Insulin and removed in 28 or 42 days . (7) Unopened insulin stored without refrigeration remove after 30 days .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 staff (RN M, CNA N, and Treatment Nurse) viewed for infection control.<BR/>1. The facility failed to ensure RN M performed hand hygiene after removing his gloves and before putting on clean gloves during tracheostomy care for Resident #62<BR/>2. The facility failed to ensure RN M changed gloves and performed hand hygiene after picking up a nebulizer machine off the ground and before performing oral care and washing Resident #62's face.<BR/>3. The facility failed to ensure the treatment nurse and CNA N changed gloves when providing incontinent care for Resident #182. <BR/>4. The facility failed to ensure the treatment nurse performed hand hygiene between glove changes. <BR/>These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. <BR/>Findings Include:<BR/>1. During an observation on 2/07/23 at 9:16 p.m. RN M performed tracheostomy care on Resident #62. RN M removed his sterile gloves after removing Resident #62's inner cannula, took his cell phone out of his pocket, and then put another pair of sterile gloves. RN M did not perform hand hygiene after removing his sterile gloves and before putting on a clean pair of sterile gloves to complete Resident #62's tracheostomy care. <BR/>During an observation on 2/07/23 at 9:21 a.m. RN M performed suctioning on Resident #62. RN M removed his sterile gloves after he completed suctioning on Resident #62 and put another pair of sterile gloves. RN M did not perform hand hygiene after removing his sterile gloves and before putting on a clean pair of sterile gloves to replace Resident #62's inner cannula (a tube inside the outer tube of a tracheostomy that can be easily removed and cleaned) .<BR/>2. During an observation on 2/07/23 at 9:38 a.m. RN M knocked Resident #62's nebulizer onto the floor. RN M picked the nebulizer up off the floor with his gloved hands and then performed oral care and cleaned Resident #62's face. RN M did not remove his gloves or perform hand hygiene after picking up the nebulizer off the floor and before performing oral care and cleaning Resident #62's face.<BR/>During an interview on 1/07/23 at 9:48 a.m. RN M said hand hygiene should be performed after cleaning the inner cannula and before continuing tracheostomy care and when gloves were changed. RN M said proper hand hygiene was important to prevent the spread of bacteria and for infection control. RN M said when the nebulizer fell into the floor it would have been contaminated. RN M said picking up an item off the floor and then providing care to a resident without changing gloves or performing hand hygiene could introduce bacteria to the resident and cause an infection. RN M said he did not perform hand hygiene between glove changes or change gloves and perform hand hygiene after picking the nebulizer up out of the floor was because it slipped his mind. <BR/>During an interview on 2/08/23 at 2:29 p.m. the Infection Preventionist said she expected staff to perform hand hygiene after providing care, between residents, when hands were visibly soiled, and when gloves were changed. The Infection Preventionist said it was important to perform hand hygiene to keep infections down and to prevent the spread of infections. <BR/>During an interview on 2/08/23 at 6:08 p.m. the DON said he expected the staff to perform hand hygiene before and after entering a resident room and between glove changes. The DON said when staff removed a pair of gloves they did not know what they might accidentally touch when removing the gloves. The DON said the importance of proper hand hygiene was for infection control.<BR/>During an interview on 2/08/23 at 7:10 p.m. the Administrator said he expected staff to perform hand hygiene anytime hands were visibly soiled, before handling food, before and after providing care, and between glove changes. The Administrator said the DON and nursing management were responsible for ensuring staff were trained and performing appropriate hand hygiene. The Administrator said hand hygiene decreased the risk of infection.<BR/>3 and 4. During an observation on 02/06/23 starting at 11:00 AM, CNA N and the treatment nurse were providing incontinent care to Resident #182. During the incontinent care the treatment nurse was holding Resident #182 by buttocks with her two hands and had feces on her gloves. The treatment nurse wiped off the feces from her gloves and removed one glove. The treatment nurse put on a new glove. The treatment nurse did not change both gloves and she did not perform hand hygiene after removal of the one glove. CNA N continued to provide care and removed the dirty brief and applied a clean brief and finished the incontinent care. CNA N did not change her gloves and did not perform hand hygiene after removing the dirty brief. <BR/>During an interview on 02/06/23 at 11:31 AM, the treatment nurse said while providing incontinent care to Resident #182 she did not perform hand hygiene after removing one glove and putting on a new glove. The treatment nurse said she should have changed both gloves and performed hand hygiene. The treatment nurse said it was important to perform hand hygiene and change gloves when they were soiled to prevent cross contamination and so you do not accidentally spread germs. <BR/>During an interview on 02/06/23 at 11:39 AM, CNA N said she should have changed gloves when she took off Resident #182 dirty brief. CNA N said not changing gloves when going from dirty to clean and not performing hand hygiene placed the residents at risk for cross contamination.<BR/>During an interview on 02/08/23 at 5:05 PM, ADON K said there was currently no monitoring in place for incontinent care. ADON K said the DON did skill check offs for the staff, but she did not know how often. ADON said the charge nurses and nurse management were responsible for ensuring the facility staff performed hand hygiene and proper incontinent care. ADON K said not performing proper incontinent care and not performing hand hygiene could cause the residents to get urinary tract infections, skin breakdown, and placed the residents at risk of infection.<BR/>During an interview on 02/08/23 at 6:53 PM, the DON said the treatment nurse and CNA N should have changed gloves and performed hand hygiene when going from dirty to clean. The DON said the nurse overseeing the CNAs was responsible for making sure the CNAs performed hand hygiene and proper incontinent care. The DON said not performing hand hygiene and improper incontinent care placed the residents at risk for infection and skin breakdown.<BR/>During an interview on 02/08/23 at 8:13 PM, the administrator said the treatment nurse and CNA N should have changed gloves and performed hand hygiene while providing incontinent care. The administrator said nursing was responsible for ensuring proper incontinent care was provided and staff were performing hand hygiene. The administrator said improper incontinent care and not performing hand hygiene could cause the residents to have an infection.<BR/>Record review of the facility's policy titled, Incontinence Care, last reviewed 02/14/20, revealed, .8. If feces present, remove with toilet paper or disposable wipe by wiping from front perineum toward rectum. Discard soiled materials and gloves. Wash hands. 9. Put on non-sterile latex-free gloves .14. Remove linen/under pad and discard 15. Remove and discard gloves 16. Wash hands 17. Apply clean linen/underpad, briefs or other incontinent products as needed .

Based on interview and record review the facility failed to not employee and individual that was found guilty of mistreatment in a court of law for 1 of 6 employees reviewed (Kitchen Staff A) <BR/>The facility allowed Kitchen Staff A to work at the facility for about 18 months without accurate criminal history check. Kitchen Staff A had a conviction with an absolute bar to employment.<BR/>This facility failure put residents at risk for mistreatment. <BR/>Finding included: <BR/>Record review of employee records for Kitchen Staff A indicated she was hired on 7/11/22. Her initial criminal history check was done on 7/11/22 and indicated no criminal issues. She had a second criminal history check completed on 2/7/23 that indicated no criminal issues. Review of Kitchen Staff A driver's license indicated those criminal history checks were completed with the wrong birthday. Review of a criminal history check dated 1/7/24 with the correct birthdate indicated she had a charge of abandoning or endangering a child. <BR/>During an interview on 1/10/23 at 5:50 a.m. the HR Manager said she worked at the facility for 8 years and this was her first time missing a conviction. She said she had to let an employee go on 1/8/24 due to her criminal record, Kitchen Staff A. She said the kitchen staff were contracted by a staffing company and did not work for the facility. However, the HR Manager said she still did the criminal history checks. She said she had done an initial check on Kitchen Staff A on 7/11/22 but had apparently put in the wrong birth date. The HR Manager said that criminal history check came back clear. She said she had done another criminal history check on Kitchen Staff A on 2/7/23 and used the same birth date. She said that criminal history check also came back clear. The HR Manager said she did not know how she had used the wrong birth date. She said on Sunday, 1/7/24 she had completed a criminal history check on Kitchen Staff A and used her correct birth date. She said that criminal history had come back with a charge that was listed as not employable. The HR manager said she made a mistake, it was her fault she had informed the Administrator, and her corporate supervisor. She said Kitchen Staff A was terminated on 1/8/24. The HR manager said Kitchen Staff A had worked at the facility for about 18 months. <BR/>During an interview on 1/10/24 at 8:04 a.m. the Dietary Manager said she worked for a contracted company; she did not work for the facility. She said Kitchen Staff A came in and she interviewed her. The Dietary Manager said she presented the required paperwork to HR with Kitchen Staff's application. She said she did not do the criminal history checks. The Dietary Manager said she knew the Kitchen Staff had a criminal history, but she did not know why she was in prison. She said she did not know the bars to employment. She assumed if the contracted company and the facility HR said Kitchen Staff A was fine, she hired her. She said Kitchen Staff A worked about 18 months and she was terminated on 1/8/24. She said that was the first time anything like that had happened since she worked at the facility and she had been there for about 5 years. <BR/>During an interview on 1/10/24 at 9:50 a.m. the Administrator said she was aware of the issue with Kitchen Staff A. She said on 1/8/24 the HR Manger informed her of the issue. The Administrator said it was a onetime occurrence and the HR Manger took extreme care in her work and record keeping. The Administrator said they had fixed the problem that day by terminating the employee. <BR/>During an interview on 1/10/24 at 6:18 a.m. ,the HR Manager provided a Criminal Convictions list that Bar Employment she stated she used the list to make the determinations about criminal convictions to employment. <BR/>Record review of Criminal Convictions that Bar Employment indicated September 1, 2009, House [NAME] 2191 amended and Health and Safety Code Chapter 250 indicated, Absolute Bars to Employment. Number 8- Section 22.041 Penal Code ( abandoning or endangering a child)<BR/>Record review of the facility Abuse Policy dated 10/24/22 indicated, they would screen their employees. Potential employees would be screen for a history of abuse, neglect, exploitation, or misappropriation of property. Background, reference, credentials checks would be conducted on potential employee, contracted, temporary staff, students affiliated with academic institutions, volunteers, and consultants. Screening could be conducted by the facility itself, third party agency or academic institution. The facility would maintain documentation of proof that the screening occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of 20 residents (Residents #26, #14 and #1) reviewed for resident rights.<BR/>1. The facility failed to ensure RN F and CNA Z treated residents with dignity and respect by referring to them as feeders. <BR/>2. The facility failed to ensure the Environmental Service Manager knocked prior to entering Resident #26 room. <BR/>3. The facility failed to ensure LVN E provided privacy for Resident #14 while administering his insulin injection. <BR/>4. The facility failed to ensure Resident #1 had a privacy bag for his catheter drainage bag. <BR/>These failures could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.<BR/>The findings included: <BR/>1. During an observation on 02/06/2023 at 11:52 a.m., RN F stated where's the feeders in the dining hall while passing out food trays to the residents who required assistance with eating. <BR/>During an interview on 02/08/2023 at 1:58 p.m., RN F stated she did not know the word feeder was inappropriate until she was told by the DON. RN F stated the DON told her she should use the word assistance. RN F stated she had used the word feeder several times, but it was not set in her vocabulary. RN F stated the failure to residents for being referred to as a feeder was a dignity issue. <BR/>During an observation and interview on 02/06/2023 at 1:33 PM, CNA Z said, that's for my feeder. CNA Z was approximately 3 feet from several resident doors. CNA Z stated it was not appropriate to refer to a resident as a feeder. CNA Z stated she was trying to explain that was why she had one tray left on the cart. CNA Z stated referring to residents' as feeder could have made residents' feel disrespected.<BR/>2. During an observation on 02/06/2023 at 10:14 a.m., the Environmental Service Manager entered Resident #26 room without knocking. <BR/>During an interview on 02/06/2023 at 10:20 a.m., Resident #26 stated he did not feel he, and his wife had any privacy. Resident #26 stated the housekeepers never knocked prior to entering. <BR/>During an interview on 02/08/2023 at 1:52 p.m., the Environmental Service Manager stated she should have knocked prior to entering Resident #26 room. The Environmental Service Manager stated she was moving too fast and forgot to knock. The Environmental Service Manger stated she had never been told that some of her staff did not knock prior to entering resident's room. The Environmental Service Manager stated this failure was not providing privacy to residents. <BR/>3. During an observation and interview on 02/07/2023 at 11:20 a.m., LVN E administered Resident #14 insulin with the door open. Resident #14 did not have a roommate. LVN E stated it was not okay to administer medication to residents without providing privacy. LVN E was unable to say why she did not close the door prior to administering Resident #14 medication. LVN E stated this failure was a lack of dignity and respect.<BR/>During an interview on 02/08/2023 at 4:36 p.m., the DON stated he expected staff to knock prior to entering resident's room. The DON stated he expected staff to provide privacy when administering medications. The DON stated he expected staff to say assisted dining room instead of saying the word feeder. The DON stated this was monitored by weekly rounds and visiting with residents/family to ensure privacy has been provided. The DON stated staff were in serviced at least once a month. The DON stated he was unaware of any issues. The DON stated there was not a system in place for staff at nurse level to monitor for that specific dignity infarction related to administering medications without privacy. <BR/>During an interview on 02/08/2023 at 6:13 p.m., the Administrator stated he expected staff to knock prior to entering resident's room. The Administrator stated he expected staff to provide privacy when administering medications and expected staff to say assisted dining room instead of the word feeder. The Administrator stated this failure was an embarrassment to the residents and a dignity issue. <BR/>4. Record review of Resident #1's face sheet (undated) revealed he was a [AGE] year-old-male who admitted to the facility on [DATE] with diagnoses of senile degeneration of the brain (mental condition where your brain cells begin to degenerate), unspecified dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and benign prostatic hyperplasia with lower unitary tract symptoms, BPH (overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine). <BR/>Record review of Resident #1's order summary report, dated 02/08/2023, revealed an order which started on 10/31/2022 for May have suprapubic catheter for dx: Obstructive uropathy. The order summary report further revealed an order which started on 10/31/2022 for Suprapubic care q shift and prn. Check privacy bag every shift.<BR/>Record review of the MDS assessment, dated 11/08/2022, revealed Resident #1 had clear speech and was understood by staff. The MDS revealed Resident #1 was able to understand others. The MDS revealed Resident #1 had a BIMS score of 07 which indicated severe cognitive impairment. The MDS revealed Resident #1 had no behaviors or refusal of care. The MDS revealed Resident #1 had an indwelling catheter. <BR/>Record review of the comprehensive care plan, last revised on 01/03/2023, revealed Resident #1 had a suprapubic catheter. The interventions included: Privacy bag over the drainage bag. <BR/>During an observation and resident interview on 02/06/2023 at 10:25 AM, the catheter bag, with approximately 100 mL of clear, yellow urine, was hanging on Resident #1's wheelchair with no privacy bag noted. Resident #1 was non-interviewable related to severe cognitive impairment as evidenced by confused conversation. <BR/>During an observation on 02/06/2023 at 3:35 PM, catheter bag, with approximately 200 mL of clear, yellow urine, was hanging on Resident #1's wheelchair with no privacy bag noted.<BR/>During an observation on 02/07/2023 at 8:17 AM, Resident #1 was self-propelling his wheelchair down the hallway from the dining room, the catheter bag, with the tubing full of clear, yellow, urine, was hanging from wheelchair with no privacy bag noted.<BR/>During an interview on 02/08/2023 at 4:35 PM, CNA Q stated Resident #1 was supposed to have a privacy bag for his catheter drainage bag. CNA Q stated she had no clue why Resident #1 had no privacy bag for his catheter drainage bag. CNA Q stated CNAs were unable to provide the type of privacy bags the facility used. CNA Q stated CNAs were able to alert the nurse that one was needed. CNA Q stated the nurse was not notified that Resident #1 needed a privacy bag. CNA Q stated privacy bags were important so Resident #1 could have privacy and dignity. <BR/>During an interview on 02/08/2023 at 4:46 PM, NA R stated Resident #1 was supposed to have a privacy bag for his catheter drainage bag. NA R stated he was unsure why Resident #1 had no privacy bag on his catheter drainage bag. NA R stated the nurse was responsible for placing privacy bags. NA R stated he was unsure if the nurse was notified of the need for a privacy bag. NA R stated privacy bags were important so Resident #1 could have privacy and dignity. <BR/>During an interview on 02/08/2023 at 5:13 PM, LVN (ADON) H stated the nurses and ADONs were responsible for ensuring privacy bags were applied to catheter drainage bags. LVN (ADON) H stated nurses were responsible for monitoring to ensure privacy bags were applied to catheter drainage bags. LVN (ADON) H stated she was unsure why Resident #1 had no privacy bag. LVN (ADON) H stated privacy bags were important to maintain Resident #1's dignity. <BR/>During an interview on 02/08/2023 at 7:09 PM, the DON stated CNAs should have been aware when residents need a privacy bag to catheter drainage bags. The DON stated Resident #1 should not have been provided with a catheter drainage bag with no privacy ability. The DON stated this was monitored by looking at invoices for resident care equipment ordered by the facility. The DON stated ultimately the nurses were responsible for ensuring privacy bags were provided for catheter drainage bags. The DON stated the importance of privacy bags was to ensure dignity. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated he expected nursing staff to ensure Resident #1 had a privacy bag for his catheter drainage bag. The ADM stated privacy bags were important to ensure Resident #1's dignity and privacy. <BR/>Record review of the Urinary Catheter Management policy, last reviewed on 08/20/2021, revealed Fundamental Information 3.Provide privacy and dignity by covering urinary bag with a bag cover. <BR/>Record review of the Resident Rights policy, last reviewed on 02/20/2021, revealed 4. Respect and Dignity. The resident has a right to be treated with respect and dignity. The policy further revealed 7. Privacy and confidentiality. a. personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop the baseline care plan within 48 hours of admission for 4 of 20 residents (Resident #'s 49, 130, 182, and 188) reviewed for baseline care plans.<BR/>Resident #'s 49, 130, 182, and 188 did not have a baseline care plan completed within 48 hours of admission.<BR/>This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome.<BR/>The findings included: <BR/>1. Record review of Resident #49's face sheet (undated) revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of end stage renal disease (occurs when chronic kidney disease - the gradual loss of kidney function - reaches an advanced state), dependence of renal dialysis (clinical way of purifying the blood by removing unwanted substances and extra water - a function that kidneys normal do), and surgical aftercare following surgery on the circulatory system. <BR/>Record review of Resident #49's baseline care plan revealed it was initiated on 01/17/2023. <BR/>2. Record review of Resident #130's face sheet (undated) revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure (heart conditions caused by high blood pressure that led to heart failure), atherosclerotic heart disease of native coronary artery without angina pectoris (the buildup of fats, cholesterol and other substances in and on the artery walls that does not cause chest pain), and generalized osteoarthritis (degenerative disease that worsens over time, often resulting in chronic pain). <BR/>Record review of Resident #130's baseline care plan revealed it was initiated on 1/30/2023. <BR/>During an interview on 02/08/2023 at 5:13 PM, ADON H stated baseline care plans were an interdisciplinary team (IDT) effort. ADON H stated baseline care plans should have been completed within 48 - 72 hours. ADON H stated she was unsure why Resident #49 and Resident #130's baseline care plans were initiated late. ADON H stated all management staff was responsible for ensuring the baseline care plans were completed. ADON H stated the nurses were responsible for starting the baseline care plan. ADON H stated the importance of completing baseline care plans was so the staff would know how to care for the resident. <BR/>During an interview on 02/08/2023 at 7:09 PM, the DON stated the admitting nurse should have started the baseline care plans. The DON stated the IDT was responsible for ensuring baseline care plans were completed. The DON stated baseline care plans were monitored by the IDT in morning stand up meetings. The DON was unsure why Resident #49 and Resident #130's baseline care plans were completed late. The DON stated baseline care plans were important because they give staff a basic understanding on how to care for a resident. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated he expected the IDT to complete the baseline care plan. The ADM stated he expected nursing management to ensure the baseline care plans were completed. The ADM stated baseline care plans were important, so staff knew what care the resident required. <BR/>3. Record review of a face sheet dated 02/08/23 revealed Resident #182 was a [AGE] year-old male admitted on [DATE] with diagnoses of quadriplegia (paralysis of all four extremities), paroxysmal atrial fibrillation (rapid, erratic heart rate), and neurogenic bladder (bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves).<BR/>Record review of the assessments in the electronic health record on 02/07/23 revealed Resident #182's baseline care plan had not been initiated. <BR/>Record review of a face sheet dated 02/08/23 revealed Resident #188 was a [AGE] year-old male admitted on [DATE] with diagnoses of neoplasm of uncertain behavior of bladder (bladder cancer), essential (primary) hypertension (high blood pressure), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>4. Record review of Resident #188's electronic health record on 02/07/23 revealed an in-progress baseline care plan with effective date of 02/04/23. The baseline care plan was blank. <BR/>During an interview on 02/08/23 at 10:13 AM ADON K said the baseline care plan should be completed within 72 hours of admission. ADON K said the admitting nurse should have started Resident #182 and Resident #188's the baseline care plan and she was responsible for ensuring baseline care plans were completed. ADON K said usually on Monday's the DON printed the baseline care plans that needed to be completed, but it had not been a good week and that is why it had not been done yet. ADON K said she did not know why the baseline care plans needed to be completed all she knew was it was an assessment that should be done on admission. ADON K said not doing the baseline care plan caused the residents no harm. <BR/>During an interview on 02/08/23 at 6:36 PM, the DON said he did not remember when the baseline care plan should be completed. The DON said he believed it was 24 hours. The DON said the admitting nurse should do the baseline care plan and the ADONs were responsible for overseeing this The DON said the baseline care plan was important to complete because it gave basic understanding of how to care for the residents. The DON said in the morning meetings there was a form that was filled out by the interdisciplinary team to ensure the residents' baseline care plans were completed. The DON said the baseline care plans for Resident #182 and Resident #188 were probably not done because it was the weekend and there was a lack of communication. <BR/>During an interview on 2/8/23 at 7:59 PM, the administrator said the baseline care plan should have been done within 48 hours of admission. The administrator said the nurses were responsible for completing baseline care plans. The administrator said it was important for the baseline care plan to be completed within 48 hours of admission because it instructed the staff on the care for the residents. The administrator said the baseline care plan was necessary to provide proper care specific to the resident.<BR/>Record review of the facility's policy title, Baseline Care Plan, implemented on 09/20/20, revealed, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provided effective and person-centered care of the resident that meet professional standards of quality care . 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission . 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. 4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand the summary shall include, at a minimum, the following: a. The initial goals of the resident. b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 20 residents (Resident #44) reviewed for care plans. <BR/>The facility did not implement Resident #44's fall management care plan to ensure she always wore non-skid footwear and have a fall mat at bedside. <BR/>This failure could place residents at risk of not having their individual needs met. <BR/>Findings include:<BR/>Record review of Resident #44's order summary report, dated 02/08/2023, indicated Resident #44 was a [AGE] year-old female, originally admitted on [DATE] with a diagnosis which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (high blood pressure), and history of falling. <BR/>Record review of Resident #44's significant change in status MDS assessment, dated 10/07/2022, indicated Resident #44 rarely/never understood others and rarely/never made herself understood. The assessment did not address Resident #44 cognitive status. The assessment indicated Resident #44 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #44 had a fall in the last month, last 2-6 months, and obtained a fracture related to a fall in the 6 months prior to admission/entry or reentry. <BR/>Record review of Resident #44's care plan, with an initiated date of 08/05/2022, indicated Resident #44 had a history of falls related to dementia with behaviors, pain, medications, immobility, unsteady/poor balance, and recent fall with injuries. The care plan interventions included, always ensure non-skid footwear, fall mat at bedside and increase staff rounding. <BR/>Record review of the fall risk assessment tool dated 11/24/2022 indicated Resident #44 had multiple falls within the previous six months, on three high risk drugs, unable to independently come to a standing position, required hands-on assistance to move from place to place, use an assistive device and decrease in muscle coordination. The fall risk assessment indicated Resident #44 was a high risk for falls. <BR/>During observations of Resident #44's room the following was noted: <BR/>02/06/2023 at 10:00 a.m. Resident lying in bed with no fall mat at bedside. <BR/>02/06/2023 at 3:34 p.m. Resident lying in bed with no fall mat at bedside. <BR/>02/07/2023 at 2:37 a.m. Resident lying in bed with no fall mat at bedside. <BR/>During an observation on 02/07/2023 at 9:08 a.m., Resident #44 was sitting in her wheelchair in the tv room wearing a pair of off-white socks with no grip on the bottom. <BR/>During an observation, interview, and record review on 02/08/2023 at 2:46 p.m., LVN A stated she was Resident #44's 6a-6p charge nurse. LVN A stated she was unaware that Resident #44 should have a fall mat at bedside. After reviewing Resident #44 electronic medical records, LVN A stated she should have a fall mat at bedside and always wore nonskid socks. LVN A observed with the surveyor Resident #44's fall mat was not at bedside. LVN A stated nursing staff were responsible for ensuring a fall mat was at Resident #44 bedside and ensure Resident #44 always wear non-skid footwear. LVN A stated there was not a system at this time that staff could review what devices were needed for residents. LVN A stated this failure could potentially put Resident #44 at risk for a serious injury. <BR/>During an interview on 02/08/2023 at 4:14 p.m., NA C stated she was Resident #44's 2p-10p aide. NA C stated she unaware that Resident #44 was a high risk for falls. NA C stated she did not know that Resident #44 needed a fall mat at bedside and should always wear non-skid socks. NA C stated there was times Resident #44 did not have on non-skid socks. NA C stated she did not have access to resident's care plan. NA C stated this failure could potentially cause an injury (concussion) to Resident #44. <BR/>During an interview on 02/08/2023 at 4:36 p.m., the DON stated he expected Resident #44 to have a fall mat at bedside and always wear non-skid socks. The DON stated the aides and nurses were responsible for ensuring care plan items were in place. The DON stated daily rounds were made by LVN H to ensure safety measures are in place. The DON stated currently there was a system being put in place to inform staff of care plan needs. The DON stated this failure could potentially put Resident #44 at risk for injury. <BR/>During an interview on 02/08/2023 at 5:47 p.m., LVN H stated herself and the department heads were responsible for daily rounds. LVN H stated she could not say the last time rounds were done on Resident #44 due to frequent room changes. LVN H stated she expected the nursing staff to ensure fall preventions measure are in place. LVN H stated this failure could potentially put Resident #44 at risk for injury. <BR/>During an interview on 02/08/2023 at 6:13 p.m., the Administrator stated he expected the care plan to be followed. The Administrator stated ultimately the DON or designee was responsible for ensuring safety measures were in place. The Administrator stated this failure could potentially put Resident #44 at risk for injury. <BR/>Record review of the facility's Fall Management System policy, revised 01/03/2017, indicated, . it is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan implemented based on the resident's assessed needs Procedure (3) A care plan is implemented for residents at risk for falls . Investigation and follow up of accidents involving falls (2) Interventions will be implemented in an attempt to prevent the resident from sustaining further falls

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 3 of 20 residents reviewed for ADLs (Residents #24, Resident #25, and Resident #182).<BR/>The facility failed to ensure Resident #24, and Resident #182 received showers or bed baths as scheduled. <BR/>The facility failed to provide assistance with facial hair removal for Resident #25.<BR/>These failures could place residents at risk of not receiving services and care, and a decreased quality of life.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #24's face sheet dated 02/08/23 revealed an [AGE] year old male initially admitted on [DATE] with diagnoses of pneumonia, unspecified organism (an infection of the lungs), chronic combined systolic (congestive) and diastolic (congestive) heart failure (heart does not pump blood well enough to meet the body's demand for blood and oxygen), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with no behaviors). <BR/>Record review of Resident #24's quarterly MDS assessment with an ARD of 12/30/22 revealed Resident #24 was understood and understood others. The MDS assessment indicated Resident #24 had a BIMS score of 8, indicating cognition was moderately impaired. The MDS assessment indicated Resident #24 required extensive assist for bed mobility, transfer, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence of one person assist for bathing. <BR/>Record review of the care plan last revised on 08/24/22 revealed Resident #24 had a focus of Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner with a goal of resident will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date and resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date and interventions included personal hygiene: extensive assistance, bathing: extensive assistance and provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Resident #24's care plan did not indicate Resident #24 refused ADL care or baths/showers. <BR/>During an observation on 02/06/23 at 12:08 PM, Resident #24 was lying in bed sleeping wearing a hospital gown, hair was messy and disheveled.<BR/>During an observation and interview on 02/07/23 at 9:32 AM, Resident #24 was lying in bed in a hospital gown, hair appeared messy and disheveled. Resident #24 said he had not received a shower or a bed bath since last week. <BR/>During an observation and interview on 02/08/23 at 9:29 AM, Resident #24 was lying in bed wearing a hospital gown, hair appeared messy and disheveled, and he said he still had not received a shower or a bed bath. <BR/>Record review of Resident #24's shower sheets revealed he received showers or bed baths on Tuesday, Thursday, and Saturday. Record review of Resident #24's shower sheets revealed:<BR/>Thursday 01/26/23- shower sheet not signed<BR/>Saturday 01/28/23- no shower sheet was provided by the DON<BR/>Tuesday 01/31/23- no shower sheet was provided by the DON<BR/>Thursday 02/02/23- shower sheet signed refused<BR/>Saturday 02/04/23- no shower sheet was provided by the DON<BR/>Tuesday 02/07/23- shower sheet signed bed bath <BR/>2. <BR/>Record review of a face sheet dated 02/08/23 revealed Resident #182 was a [AGE] year-old male admitted on [DATE] with diagnoses of quadriplegia (paralysis of all four extremities), paroxysmal atrial fibrillation (rapid, erratic heart rate), and neurogenic bladder (bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves).<BR/>Record review of the electronic health record on 02/08/23 revealed Resident #182's MDS assessment was not yet completed. <BR/>Record review of Resident #182's care plan revealed a focus with date initiated of 02/08/23, resident has an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner, goal of resident will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date and resident will participate to the best of their ability and maintain current level of functioning with<BR/>activities of daily living (ADLs) through the next review date, and interventions including dressing: extensive assistance, personal hygiene: extensive assistance, bathing: dependent on staff, and provide shower, shave, oral care, hair care, and nail care per schedule and when needed. <BR/>During an observation and interview on 02/06/23 9:59 AM, Resident #182 said he had not had a shower or a bed bath since he admitted on Friday 02/03/23. Resident #182 was wearing a navy-blue long sleeve shirt. <BR/>During an observation on 02/07/23 at 8:21 AM, Resident #182 was in bed wearing a navy-blue long sleeve shirt. <BR/>During an observation on 02/08/23 at 8:19 AM, Resident #182 was in bed wearing a navy-blue long sleeve shirt crumbs and white particles were all over the shirt. Resident #182 said he still had not received a bed bath or shower. <BR/>Record review of Resident #182's shower sheets revealed only one shower sheet for 02/07/23 and the shower sheet indicated he had a bed bath.<BR/>During an interview on 02/08/23 at 9:45 AM, ADON H said the CNAs do the showers and bed baths. ADON H said there was a shower aide, but if the shower aide was not able to give a shower/bed bath she should let the CNAs on the floor know for them to do it. ADON H said she was responsible for overseeing Resident #24's showers/bed baths. ADON H said she was not aware Resident #24 had not received bed baths/showers. ADON H said she randomly checked with residents and asked them if they were getting their showers/bed baths. ADON H said it was important for the residents to receive showers/bed baths to keep them clean, free of infection, looking good and for overall good health. <BR/>During an interview on 02/08/23 at 10:13 AM, ADON K said the nurses were responsible for making sure the residents received a bed bath/shower. ADON K said she was not aware Resident #182 had not received a shower/bed bath. ADON K said she trusted the CNAs to do the showers/bed baths, and that CNA O had told her she had given Resident #182 a bed bath on Tuesday (02/07/23). ADON K said it was important for the residents to have their clothes changed daily and to receive their showers/bed baths for hygiene, and not receiving showers/bed baths could cause skin breakdown and infections from not being clean. <BR/>During an interview on 02/08/23 at 11:08 AM, CNA O said she had not given Resident #182 a bed bath on Tuesday (02/07/23). CNA O said she was not able to go back and change her charting on the shower sheet to reflect she did not give Resident #182 a bed bath. CNA O said the residents' clothes should be changed every day and the residents should get there baths as scheduled. <BR/>During an interview on 02/08/23 at 12:01 PM CNA N said she had not offered Resident #182 a shower or bed bath and she had not changed his clothes on Monday (02/06/23) because she ran out of time and did not get to it. CNA N said it was necessary to change the residents clothes every day and give them showers/bed baths to prevent odor, bacteria and to prevent neglect. <BR/>During an interview on 02/08/23 at 5:31 PM, CNA L said she was the shower aide and gave the showers Monday-Friday and if she was not at the facility the CNAs on the floor were responsible for giving the showers/bed baths. CNA L said she was not responsible for giving Resident #24 and Resident #182 their showers/bed baths because they were not assigned to her. CNA L said the CNAs on the floor should have done them. CNA L said it was important for the residents to receive a shower/bed bath for them to be clean and to make them feel better, and if they did not get a shower/bed bath this could cause residents to get an infection, sores, or yeast. <BR/>During an interview on 02/08/23 at 5:40 PM, LVN D said the residents' clothes should be changed every day, and the aides and the nurses should make sure the residents' clothes were changed every day and showers/bed baths were given as scheduled. LVN D said it was important for the residents' clothes to be changed and for them to receive their bed baths/showers for clean hygiene and for their health and skin. <BR/>During an interview on 02/08/23 at 5:55 PM, RN B said sometimes Resident #24 refused his showers/bed baths and care. RN B said if Resident #24 refused his showers/bed baths staff was supposed to document the refusals, and it should be in his care plan. RN B said it was important for the residents to have showers/bed baths to prevent illness and odor. <BR/>During an interview on 02/08/23 at 6:29 PM, the DON said the nurse aides were responsible for providing showers/bed baths and the nurses should oversee this. The DON said not providing showers/bed baths was a dignity problem. The DON said he was not aware Resident #24 and Resident #182 had not received a shower/bed bath. The DON said he was not aware Resident #24 refused showers/bed baths, and if Resident #24 did refuse, it should be in his care plan. <BR/>During an interview on 02/08/23 at 7:54 PM, the administrator said the nurses were responsible for ensuring ADL care was provided. The administrator said he expected the CNAs to change the residents clothes every day and provide showers/bed baths as scheduled. The administrator said not changing the residents' clothes every day and not providing showers/bed baths as scheduled would affect the residents' dignity.<BR/>3. Record review of consolidated physician orders dated 2/08/23 indicated Resident #25 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, heart failure, lack of coordination, dementia, and hypertension (elevated blood pressure).<BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #25 understood others and was understood by others. The MDS indicated Resident #25 had a BIMS score of 04 indicating she was severely cognitively impaired. The MDS indicated Resident #25 was not resistive to evaluation or care. The MDS indicated Resident #25 required extensive assistance with dressing and personal hygiene. <BR/>Record review of the most recent comprehensive care plan updated 2/06/23 indicated Resident #25 had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner. The care plan indicated interventions for Resident #25 included provide shower, shave, oral care, hair care, and nail care per schedule and when needed.<BR/>Record review of Resident #25's shower schedule indicated she was to be provided showers on Mondays, Wednesdays, and Fridays.<BR/>Record review of Resident #25's showers sheets dated 1/30/22 through 2/06/23 indicated she had received all her schedule showers. <BR/>During an observation on 2/06/23 at 11:54 a.m. Resident #25 was observed with thick silver colored chin hair approximately 0.5cm in length.<BR/>During an observation and interview on 2/07/23 at 9:58 a.m. Resident #25 was observed with thick silver colored chin hair approximately 0.5cm in length. Resident #25 was confused and unable to be interviewed.<BR/>During an observation on 2/08/23 at 8:33 a.m. Resident #25 was observed with thick silver colored chin hair approximately 0.5cm in length.<BR/>During an interview on 2/08/23 at 1:54 p.m. CNA L said she had given Resident #25 her shower on 2/06/23. CNA L said she did not assist Resident #25 with facial hair removal during her shower. CNA L said she did not notice the Resident #25 having facial hair during her shower. CNA L said another CNA later that day told her about Resident #25's facial hair needing removed. CNA L said she did not go back and assist Resident #25 with her facial hair removal after the other CNA informed of the facial hair. CNA L said Resident #25 was not resistive to care. CNA L said the importance of assisting residents with facial hair removal was for their dignity.<BR/>During an interview on 2/08/23 at 2:20 p.m. LVN D said residents were assisted with facial hair removal during showers. LVN D said Resident #25 was not resistive to care including showers and facial hair removal. LVN D said the importance of assisting residents with facial hair removal was the resident's dignity. <BR/>During an interview on 2/08/23 at 6:08 p.m. the DON said he expected facial hair removal to be performed with resident showers. The DON said Resident #25 sometimes refused care but was easily redirected. The DON said assisting resident with facial hair removal was for dignity.<BR/>During an interview on 2/08/23 at 7:10 p.m. the Administrator he expected staff to assist with residents with facial hair removal during showers and as needed. The Administrator said it was the CNAs responsibility to perform grooming including facial hair removal and showering. The Administrator said all staff responsible for reporting issues including facial hair needing groomed to the appropriate staff. The Administrator said facial hair not being removed was a dignity issue.<BR/>Record review the facility's Activities of Daily Living Care Guidelines policy last reviewed, 2/11/21 indicated, Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene Residents participate in and receive the following person-centered care: Bathing includes grooming activities such as shaving, and brushing teeth and hair, Dressing: wearing garments appropriate to season dress and undress .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided with professional standards of practice for 3 of 16 residents (Residents #26, #47, and #61) reviewed for respiratory care and services. <BR/>1. The facility failed to administer oxygen at 2 via nasal cannula as prescribed by the physician for Resident #26. <BR/>2. The facility failed to properly store Resident #26's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask while not in use. <BR/>3. The facility failed to ensure Resident #47's nasal cannula tubing was changed weekly.<BR/>4. The facility failed to ensure Resident #61's oxygen concentrator had a filter in place. <BR/>These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. <BR/>Findings include: <BR/>1. Record review of Resident #26's order summary report, dated 02/08/2023, indicated Resident #26 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and obstructive sleep apnea (intermittent airflow blockage during sleep). <BR/>Record review of Resident #26's order summary report, dated 02/08/2023, indicated Resident #26 received oxygen at 2 liters per minute via nasal cannula every shift for shortness of breath with a start date 02/13/2021. The order summary indicated Resident #26 received Ipratropium-Albuterol solution 0/5-2.5 (3) mg/ml, inhale orally three times a day for SOB related to COPD with a start date 11/11/2022. <BR/>Record review of Resident #26's annual MDS assessment, dated 02/06/2023, indicated Resident #26 understood others and made himself understood. The assessment indicated Resident #26 was cognitively intact with a BIMS score of 15. The assessment indicated Resident #26 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #26 was receiving oxygen therapy. <BR/>Record review of Resident #26's care plan, with a revision date of 06/22/2022, indicated Resident #26 had an impaired respiratory status related to respiratory failure with hypoxia (low level of oxygen in blood tissues), and sleep apnea. The care plan interventions included oxygen at 2 liter per minute via NC at HS related to sleep apnea, provide oxygen therapy as ordered by the physician, and provide nebulizer therapy as ordered. <BR/>During an observation and interview on 02/06/2023 at 10:14 a.m., Resident #26 was lying in bed wearing oxygen via nasal cannula. Resident #26's five-liter oxygen concentrator was set on 3 liters per minute. Resident #26 stated he wore his oxygen all the time for SOB. Resident #26 stated he did not know what rate the oxygen should be on. Resident #26's nebulizer mask was on the bedside dresser not covered. Resident #26 stated he received a breathing treatment daily for SOB. <BR/>During an observation on 02/06/2023 at 2:24 p.m., Resident #26 was lying in bed wearing oxygen via nasal cannula. Resident #26's five-liter oxygen concentrator was set on 3 liters per minute. Resident #26's nebulizer mask was on the bedside dresser not covered.<BR/>During an observation on 02/07/2023 at 1:20 p.m., Resident #26 was lying in bed wearing oxygen via nasal cannula. Resident #26's five-liter oxygen concentrator was set on 3 liters per minute. Resident #26's nebulizer mask was on the bedside dresser not covered.<BR/>2. Record review of Resident #47's order summary report, dated 02/08/2023, indicated Resident #47 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), dependence on supplemental oxygen, and acute respiratory failure with hypercapnia (buildup of carbon dioxide in bloodstream). <BR/>Record review of Resident #47's order summary report, dated 02/08/2023, indicated Resident #47 received oxygen at 3 liters per minute via nasal cannula continuously every shift with start date 11/11/2022. The order summary indicated to change O2 tubing every night, every Sunday with a start date 09/11/2022. <BR/>Record review of Resident #47's significant change status MDS assessment, dated 11/03/2022, indicated Resident #47 understood others and made herself understood. The assessment indicated Resident #47 was cognitively intact with a BIMS score of 14. The assessment indicated Resident #47 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #47 was receiving oxygen therapy. <BR/>Record review of Resident #47's care plan, with a revision date of 04/21/2022, indicated Resident #47 had an impaired respiratory status and was at risk for shortness of breath, respiratory distress, increased anxiety, and hypoxia. The care plan interventions included provide oxygen therapy as ordered by the physician, provide nebulizer therapy as ordered and encouraged resident to take rest as needed. <BR/>Record review of the MAR dated 01/01/2023-01/31/2023, indicated Resident #47's oxygen tubing was changed on 01/15/2023 on the 6p-6a shift. <BR/>Record review of the MAR dated 01/01/2023-01/31/2023, indicated RN B signed off she changed Resident #47's oxygen tubing 01/22/2023 on the 6p-6a shift. <BR/>Record review of the MAR dated 01/01/2023-01/31/2023, indicated LVN H signed off she changed Resident #47's oxygen tubing 01/29/2023 on the 6p-6a shift. <BR/>Record review of the MAR dated 02/01/2023-02/28/2023, indicated RN G signed off she changed Resident #47's oxygen tubing 02/05/2023 on the 6p-6a shift. <BR/>During an observation on 02/06/2023 at 11:42 a.m., Resident #47 was lying in bed and oxygen was in use via nasal cannula. Resident #47's portable oxygen tank attached to her electric wheelchair had a nasal cannula tubing dated 01/15/2023. <BR/>During an observation on 02/07/2023 at 12:10 p.m., Resident #47's portable oxygen tank attached to her electric wheelchair had a nasal cannula tubing dated 01/15/2023. <BR/>During an observation and interview on 02/08/2023 at 1:50 p.m., Resident #47's portable oxygen tank attached to her wheelchair had a nasal cannula dated 01/15/2023. Resident #47 stated she used the nasal cannula tubing on her electric wheelchair daily for SOB. <BR/>During an observation and interview on 02/08/2023 at 2:12 p.m., RN B stated nurse staff on Sunday's night were responsible for changing and labeling tubing. RN B stated she was Resident #47's 6p-6a charge nurse on 01/22/2023. RN B observed with the surveyor Resident #47's portable oxygen tank nasal cannula tubing dated 01/15/2023. RN B stated she checked off on the MAR that she changed Resident #47's oxygen tubing. RN B stated, honestly I usually don't work a lot of night shifts. RN B stated she got busy and forgot to change the tubing. RN B stated this failure could place residents at risk for respiratory infection. <BR/>During an observation and interview on 02/08/2023 at 2:25 p.m., LVN H stated she was Resident #47's 6p-6a charge nurse on 01/29/2023. LVN H stated she was responsible for changing the nasal cannula tubing. LVN H observed with the surveyor Resident #47's portable oxygen tank nasal cannula tubing dated 01/15/2023. LVN H stated she checked off on the MAR that she changed Resident #47's oxygen tubing but was unable to say why she did not physically change the tubing on 01/29/2023. LVN H stated this failure could place residents at risk for respiratory infection. <BR/>During an interview on 02/08/2023 at 3:45 p.m., RN G stated she was Resident #47's 6p-6a charge nurse on 02/05/2023. RN G stated she was unaware that she was responsible for changing nasal cannula tubing on resident's wheelchair. RN G stated after surveyor intervention it did make sense that she would be responsible for changing all tubing whether it was on the concentrator or portable tank. RN G stated this failure could place residents at risk for respiratory infection. <BR/>3. Record review of Resident #61's order summary report, dated 02/08/2023, indicated Resident #61 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), essential hypertension (high blood pressure), and atrial fibrillation (irregular, often rapid heart rate). <BR/>Record review of Resident #61's order summary report, dated 02/08/2023, indicated Resident #61 received oxygen at 4 liters per minute via nasal cannula to maintain O2 sats greater than 92% with start date 03/16/2022. The order summary report did not address oxygen concentrator filters. <BR/>Record review of Resident #61's admission MDS assessment, dated 03/22/2022, indicated Resident #61 understood others and made himself understood. The assessment indicated Resident #61 was moderately cognitive impaired with a BIMS score of 8. The assessment indicated Resident #61 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #61 became short of breath or trouble breathing with exertion. The MDS indicated Resident #61 was receiving oxygen therapy.<BR/>Record review of Resident #61's care plan, with a revision date of 08/04/2022, indicated Resident #61 had an impaired respiratory status related to COPD, asthma (airway in the lungs become narrowed and swollen, making it difficult to breath). The care plan interventions included provide oxygen therapy as ordered by the physician and provide nebulizer therapy as ordered. The care plan did not address oxygen filters.<BR/>During an observation and interview on 02/06/2023 at 10:05 a.m., Resident #61 was sitting in his wheelchair. Resident #61's oxygen concentrator did not have a filter in place. Resident #61 stated he wore his oxygen at night and PRN. <BR/>During an observation on 02/06/2023 at 3:50 p.m., Resident #61 was sitting in his wheelchair. Resident #61's oxygen concentrator did not have a filter in place.<BR/>During an observation on 02/07/2023 at 8:57 a.m., Resident #61 was sitting in his wheelchair. Resident #61's oxygen concentrator did not have a filter in place.<BR/>During an observation, interview, and record review on 02/08/2023 at 2:46 p.m., LVN A stated she was Resident #26 and #61's 6a-6p charge nurse, LVN A stated Resident #26 used O2 continuously for SOB. LVN A observed with the surveyor Resident #26's oxygen concentrator rate at 3 liters per minute and nebulizer mask on the bedside dresser not covered. LVN A stated she was under the impression that Resident #26 oxygen rate should be at 3 liters per minute. After reviewing Resident #26 electronic medical records, LVN A stated the rate should be at 2 liters per minute. LVN A stated the risk associated with not setting the oxygen at prescribed rate could potentially put residents at risk for hypoxia. LVN A stated Resident #26's nebulizer mask should be covered when not in use. LVN A stated she administered Resident #26 a breathing treatment this morning and to her knowledge she placed the mask back in the plastic bag. LVN A stated all nursing staff were responsible for ensuring oxygen concentrators had filters in place. LVN A said she unaware that Resident #61 filter was missing from his concentrator. LVN A stated these failures could potentially put residents at risk for respiratory infection. <BR/>During an interview om 02/08/2023 at 4:36 p.m., the DON stated he expected Resident #26's nebulizer mask be stored in a bag when not in use. The DON stated he expected Resident #26 oxygen to be set at 2 liters per minute per the physician orders. The DON stated he expected the portable nasal tank cannula tubing to changed/dated and filter in place. The DON stated the 6p-6a charge nurses were responsible for changing and labeling tubing. The DON stated the charge nurses were responsible for ensuring the rate was at 2 liters per minute, filters in place and nebulizers stored in bags when not in use. The DON stated LVN H was responsible ensuring nurses are competent enough to read and carry out a MD order. The DON stated LVN H was responsible for monitoring to ensure respiratory equipment was returned to designed bag after each use. The DON stated LVN H was responsible for monitoring every Monday morning that all O2 tubing has been replaced and properly date. The DON stated LVN H was responsible for following up and ensuring equipment was in proper working order. The DON stated ultimately, he was responsible for monitoring the ADON. The DON stated these failures could potentially cause a decrease in respiratory status. <BR/>During an interview on 02/08/2023 at 5:47 p.m., LVN H stated she was responsible for ensuring charge nurses were following the physicians' orders by making multiple rounds throughout the day and spot checking the O2 concentrators. LVN H stated she could not remember the last time rounds were made to ensure Resident #26 oxygen rate was set at 2 liters per minute. LVN H stated rounds were made this week to ensure masks were bagged when not in use. LVN H stated she did not notice any respiratory equipment laying out when not in use. LVN H stated she could not say if she did or not checked to ensure Resident #61's filter was in place. LVN H stated if rounds were made it was not missed on purposely. <BR/>During an interview on 02/08/2023 at 6:13 p.m., the Administrator stated he expected physician's orders to be followed, nebulizers stored in bags when not in use, tubing to be changed and dated per orders and filters to be placed on O2 concentrators. The Administrator stated this was monitored by the DON or designee. The DON stated these failures put residents at risk for respiratory infection. <BR/>Record review of the facility's Oxygen Administration policy, revised 10/24/2022, indicated, .to describe methods for delivering oxygen to improve tissue oxygenation . Procedure (1) Verify physician order .Simple face mask (3) Set flow rate Completion of Procedure (2) When oxygen not in use, store oxygen tubing and nasal cannula or mask in small plastic bag Concentrator (2) Remove filter from back of concentrator . (3) Rinse filter with water (4) Shake off excess water. Replace filter .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 5 residents (Resident #68) reviewed for (DRR) Drug Regimen Review.<BR/>The facility failed to implement Resident #68's signed Note to Attending Physician/Prescriber which agreed with pharmacist recommendation for a gradual dose reduction for an antidepressant medication. <BR/>This failure could place residents at risk for receiving unnecessary medications at the most effective dosage. <BR/>The findings included:<BR/>Record review of Resident #68's face sheet (undated) revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of peripheral vascular disease (condition or disease affecting the blood vessels), hemiplegia and hemiparesis following a stroke affecting right dominant side (conditions that cause weakness on one side of the body), and type 2 diabetes mellitus with diabetic neuropathy (high blood sugar with nerve damage to hands and feet). <BR/>Record review of the order summary report, dated 02/08/2023, revealed an order that started on 02/08/2023 for trazadone 25mg by mouth every night at bedtime (given at night to help with sleep). <BR/>Record review of the MDS assessment, dated 12/14/2022, revealed Resident #68 had clear speech and was usually understood by others. The MDS revealed Resident #68 was usually able to understand others. The MDS revealed Resident #68 had a BIMS score of 11 which indicated moderately impaired cognition. The MDS revealed Resident #68 had no symptoms of depression. The MDS revealed Resident #68 had no behaviors or refusal of cares. The MDS revealed Resident #68 received and anti-depressant medication 7 out of 7 days during the look-back period. <BR/>Record review of the comprehensive care plan, last revised on 10/18/2022, revealed Resident #68 used antidepressant medications related to depression and insomnia. The interventions included: Review GDR as needed, Medication regimen to be routinely reviewed by the pharmacist with all recommendations, included suggested reduction, to be forwarded on the physician, and monitor pharmacist's drug regime review for identification of potential drug interaction.<BR/>Record review of the Note to Attending Physician/Prescriber, dated 11/14/2022, revealed the primary care physician agreed with the pharmacy consultant recommendation of a GDR for trazadone from 50 mg to 25 mg every night at bedtime. The primary care physician signed the agreement on 12/06/2022. A physician order dated 02/08/2023 revealed a new order for trazadone 25mg by mouth every night at bedtime. <BR/>During an interview on 02/08/2023 at 5:13 PM, ADON H stated the ADONs were responsible for ensuring pharmacy recommendations were completed and placed in the electronic charting system. ADON H stated she was unsure why Resident #68's pharmacy recommendation agreed and signed by the physician and was not implemented until surveyor intervention. ADON H stated the pharmacy recommendations were normally printed off and placed in the doctor's book to sign off on. ADON H stated after the doctor signed off the nurses would place the recommendation under her door. ADON H stated the importance of ensuring pharmacy recommendation were implemented in a timely manner was to ensure the residents did not receive unnecessary medications. <BR/>During an interview on 02/08/2023 at 7:09 PM, the DON stated the ADON was responsible for ensuring pharmacy recommendations were implemented. The DON stated he was responsible for monitoring the ADON and ensuring GDRs were done in a timely manner. The DON stated the GDR for Resident #68 was probably overlooked. The DON stated the importance of implementing GDRs in a timely manner was providing the most effective dose of medication for the resident. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated he expected nursing staff to implement pharmacy recommendations in a timely manner. The ADM stated GDRs were important to implement so the resident gets the appropriate care and changes that were needed. <BR/>Record review of the Documentation and Communication of Consultant Pharmacist Recommendation policy, implemented in August of 2022, revealed 2. Comments and recommendation concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards and to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 20 residents (Resident #47) reviewed for medication storage and 1 of 8 medication carts (Hall 200) reviewed for drugs and biologicals. <BR/>1. The facility did not keep medication being administered under the direct observation of the person administering medications. Resident #47 had 1 bottle of Fluticasone Propionate nasal spray (allergies) and 1 bottle of Azelastine nasal spray (allergies) on her bedside table. <BR/>2. The facility failed to date insulin pens and vials on the hall 200 medication cart. <BR/>These failures could place residents at risk for health complications and not receiving the intended therapeutic benefit of their medication.<BR/>Findings included:<BR/>1. Record review of Resident #47's order summary report, dated 02/08/2023, indicated Resident #47 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included essential hypertension (high blood pressure), COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and acute respiratory failure with hypercapnia (buildup of carbon dioxide in bloodstream). <BR/>Record review of the order summary report dated 02/08/2023 indicated Resident #47 was ordered to receive Azelastine HCL Solution 0.1% (two sprays in both nostrils two times a day) for allergies with a start date 11/01/2022 and Fluticasone Propionate 50 MCG/ACT (two sprays in both nostrils in the morning) for allergies with a start date 11/01/2022. <BR/>Record review of Resident #47's significant change status MDS assessment, dated 11/03/2022, indicated Resident #47 understood others and made herself understood. The assessment indicated Resident #47 was cognitively intact with a BIMS score of 14. The assessment indicated Resident #47 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #47 required supervision with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The assessment indicated Resident #47 required total dependence with bathing. <BR/>Record review of Resident #47's care plan did not address allergies or medications left at bedside. <BR/>During an observation on 02/06/2023 at 11:42 a.m., Resident #47 was lying in bed watching tv. There was 1 brown bottle with a white lid labeled Fluticasone Propionate lying on the floor next to Resident #47's bed. <BR/>During an observation on 02/06/2023 at 12:10 p.m., Resident #47 was lying in bed. There was 1 brown bottle with a white lid labeled Fluticasone Propionate and 1 white bottle labeled Azelastine HCL Solution sitting on Resident #47's bedside table. <BR/>During an interview and observation on 02/07/2023 at 1:50 p.m., Resident #47 was lying in bed. There was 1 brown bottle with a white lid labeled Fluticasone Propionate and 1 white bottle labeled Azelastine HCL Solution sitting on Resident #47's bedside table. Resident #47 stated she used both medications on a daily basis due to allergies. <BR/>During an interview on 02/08/2023 at 2:12 p.m., RN B stated she was Resident #47 6a-6p charge nurse. RN B stated Resident #47 was allowed to have medications at bedside. RN B stated she did not know if Resident #47 had a physician's orders to self-administer medications. After reviewing Resident #47 electronic medical records, RN B stated Resident #47 did not have a physician's order to self-administer medications. RN B stated Resident #47 needed to be educated, assessed, and able to demonstrate she can safely administer her medications by the interdisciplinary team before medications were left at bedside to administer. RN B stated this could potentially cause an overdose and not using medication correctly. <BR/>2. During an observation of the hall 200 medication cart with LVN D starting at 02/08/2023 at 9:25 a.m., the following insulins were observed with no open date:<BR/>* Resident #187's Levemir Flex Touch (diabetic medication), no open date, instructions to discard after 30 days of the open date.<BR/>* Resident #187's Insulin Detemir Solution (diabetic medication), no open date, instructions to discard after 30 days of the open date.<BR/>* Resident #73's Humulin R (diabetic medication), no open date, instructions to discard after 30 days of the open date.<BR/>During an interview on 02/08/2023 at 3:15 p.m., LVN D stated insulins should have been dated upon opening, LVN D stated charge nurses were responsible for ensuring the medication was labeled and dated before administering the first dose. LVN D stated the person opening the medication should date it. LVN D stated this failure could potentially cause the medication to not work properly. <BR/>During an interview on 02/08/2023 at 4:36 p.m., the DON stated Resident #47 was able to keep her medication at bedside if she had a physician's order and had been educated, assessed, and able to demonstrate she could safely administer her medications by the Interdisciplinary Team to allow medications at bedside. The DON stated the Maintenance Manager was responsible for monitoring to ensure medications were not left at bedside by conducting daily rounds. The DON stated this failure could potentially put residents at risk for safety, potential overdose and not taking the medication at the correct time. The DON stated he expected the nurse to date the insulin when first opened. The DON stated carts were checked once a month by RN K. The DON stated there had been times nurses had to be reminded to date a recent opened medication. The DON stated this failure could potentially give a resident an outdated medication. <BR/>During an attempted interview on 02/08/2023 at 5:27 p.m., the Maintenance Manager refused to be interviewed about monitoring to ensure medications were not left at bedside. <BR/>During an interview on 02/08/2023 at 5:39 p.m., RN K stated she was responsible for checking the cart for expiration dates, insulin vials/pen dated when opened. RN K stated rounds are done at least once a month. RN stated the last round was done at the end of January 2023. RN K stated charge nurses are responsible for dating insulins when the medication was first opened. RN K stated she did not look at Resident #187's insulin (diabetic medication) in the past week. RN K stated she did not look at Resident #73's insulin (diabetic medication) since the last round was done in January. RN K stated these failures could potentially cause a medication not to be as effective. <BR/>During an interview on 02/08/2023 at 6:13 p.m., the Administrator stated unless Resident #47 had an order and had been educated, assessed, able to demonstrate they can safely administer their medications, and a locked box to keep medications stored safely, medications should be kept in the med cart. The Administrator stated ultimately the DON or designee was responsible for ensuring residents had an order for medications at bedside. The Administrator stated he knew there was a potential failure but due to him not having a clinical background he was unable to say. The Administrator stated he expected the insulin to be dated when first opened. The Administrator stated this failure could potentially cause a medication not to be as effective. <BR/>Record review of the facility's Bedside Medication Storage policy, revised 08/2020, indicated, .bedside medication storage is permitted for residents who wish to self-administer medications, upon written order of the prescriber and once self -administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team 1. A written order for the bedside storage of medication is present in the resident's medical record 2. Bedside storage of medications is indicated on the resident MAR and in the care plan for the appropriate medications. 4. The resident is instructed in the proper use of bedside medications . the completion of this instructions is documented in the resident's medical record 6. All nurses and aides are required to report to the charge nurse on duty any medications found at bedside not authorized for bedside storage . 8. Bedside medication storage is routinely monitored during medication storage review <BR/>During an interview and record review on 02/08/2023 at 3:31 p.m., the Regional Nurse Consultant stated there was not a policy regarding labeling and dating medication. The Regional Consultant stated the facility used a guidance that indicated . (1) Insulin and removed in 28 or 42 days . (7) Unopened insulin stored without refrigeration remove after 30 days .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.<BR/>The facility failed to ensure:<BR/>1. An open bag of dinner rolls and cookie dough, in a box dated 1/30/23, was stored properly.<BR/>2. A container cooked of ham, dated 1/23/2023, was discarded after 7 days.<BR/>3. A container of cheese, dated 1/4/23, was discarded after 7 days.<BR/>4. An expired container of chocolate pudding, good by date of 1/25/2023, was discarded. <BR/>5. A container of pears was labeled and dated. <BR/>6. The deep fryer was clean and had clear grease. <BR/>7. The ice scoop was stored appropriately when not in use. <BR/>These failures could place residents at risk for food-borne illness. <BR/>The findings included:<BR/>Observation and interview during the brief initial kitchen tour on 02/06/2023 at 9:22 AM, the following was revealed:<BR/>1. An open bag of dinner rolls in a box dated 1/30/2023 was observed in the freezer.<BR/>2. Two open bags of cookie dough in a box dated 1/30/2023 was observed in the freezer.<BR/>3. A container of cooked ham dated 1/23/2023 was observed in the refrigerator. The FSS stated the container of ham was good for 7 days.<BR/>4. A container of cheese dated 1/4/2023 was observed in the refrigerator. The FSS stated she was unsure how long it was good for.<BR/>5. A container of chocolate pudding dated 1/18/2023 was observed in the refrigerator. The good by date was 1/25/2023.<BR/>6. A container of pears had no label or date. The FSS stated she was unsure how long they had been in the refrigerator. <BR/>7. A container of jelly dated 1/18/2023 was observed in the refrigerator. The FSS stated she was unsure how long it was good for. <BR/>8. The deep fryer had multiple white streaks and oil spots on the outside. The grease observed in the deep fryer was a solid dark brown and had numerous food crumbs observed on the inside surfaces. The FSS stated the deep fryer, and the grease was supposed to have been changed weekly. The FSS stated it was supposed to have been cleaned last week. The FSS was unable to provide the date of the last cleaning. The FSS stated the cooks were responsible for ensuring the deep fryer was cleaned. The FSS stated had no log. The FSS stated it was important to keep the deep fryer and grease clean to prevent food-borne illness.<BR/>During an observation and interview on 02/06/2023 at 12:19 PM, the ice scoop was observed in the ice cooler used to pass ice to the residents. The Staffing Coordinator stated it was not supposed to have been left in the ice cooler. The Staffing Coordinator stated it was supposed to be in a bag located on the side. The Staffing Coordinator stated the importance for ensuring the ice scoop was not left inside the cooler was to prevent cross-contamination.<BR/>During an observation and interview on 02/07/2023 at 11:15 AM, the deep fryer had multiple white streaks and oil spots on the outside. The grease observed in the deep fryer was a solid dark brown and had numerous food crumbs observed on the inside surfaces. [NAME] S stated the cooks were responsible for ensuring the deep fryer and the grease was cleaned. [NAME] S stated this was supposed to be completed every other week and as needed. [NAME] S stated she was unsure when the last time it was completed. [NAME] S stated the importance of keeping the deep fryer and grease cleaned was to prevent bacterial growth that would make the residents sick.<BR/>During an interview on 02/08/2023 at 4:46 PM, NA R stated the ice scoop should not have been left in the ice cooler. NA R stated the ice scoop should have been stored in a bag on the side of the cooler. NA R stated it was important to ensure the ice scoop was not left in the ice cooler to prevent cross-contamination. <BR/>During an interview on 02/08/2023 at 5:58 PM, [NAME] S stated all dietary staff were responsible for ensuring everything in the refrigerator, freezer, and dry storage area was labeled, dated, not expired, and stored appropriately. [NAME] S stated food was checked for proper storage and expiration dates every 2 days. [NAME] S stated food should be labeled and dated when supplies were delivered and when placed into a container. [NAME] S stated the importance of labeling, dating, and proper storage was to prevent food-borne illness. <BR/>During an interview on 02/08/2023 at 6:15 PM, the FSS stated the dietary staff was responsible for ensuring all food items were labeled, dated, and stored appropriately. The FSS stated she expected the dietary staff to check this daily. The FSS stated this was monitored by performing spot checks. The FSS stated she was unsure why this was not completed. The FSS stated labeling, dating, and storing food was important to prevent food-borne illness. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated he expected the dietary staff to ensure food items were labeled, dated, and stored appropriately. The ADM stated he expected the FSS to monitor the dietary staff. The ADM stated the importance of labeling, dating, and storing food appropriately was to prevent cross contamination and food-borne illness. <BR/>Record review of the Safe Ice Handling policy, last revised in March of 2012, revealed Scoops must be stored outside of the ice in a manner which protects them from contamination.<BR/>Record review of the Frozen and Refrigerated Food Storage policy, last revised on 12/5/2017, revealed 7. Proper labeling of cooked foods includes the date placed in the refrigerator, and an expiration or use by date. Refrigerated products that are opened must be labeled with an opened on date. The use by date is 7 days from when the product was opened, unless there is a manufacturer's use by, expiration or sell by date. The policy further revealed 10. Packaged frozen items that are opened and not used in their entirety must be properly sealed, labeled and dated for continued storage. <BR/>Record review of the Food Safety and Sanitation Plan policy, last revised on 10/24/2022, did not address cleaning kitchen equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 20 residents (Resident #187) reviewed for resident records. <BR/>The facility failed to ensure Resident #187 had a physician order for contact precautions. <BR/>This failure could place residents at risk of infections and not receiving individualized care and services to meet their needs. <BR/>Findings included:<BR/>Record review of a face sheet dated 02/08/23, revealed Resident #187 was a [AGE] year-old male initially admitted [DATE] with diagnoses of metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), type 2 diabetes mellitus with diabetic neuropathy (high blood sugars with nerve damage), and chronic kidney disease stage 4 (severe kidney damage).<BR/>Record review of Resident #187's Care Plan date initiated 02/03/23 did not indicate Resident #187 was on contact precautions. <BR/>Record review of Resident #187's Comprehensive MDS Assessment with an assessment reference date of 01/27/23 revealed Resident #187 was understood and understood others. Resident #187 had a BIMs score of 9, indicating cognition was moderately impaired. The MDS assessment indicated Resident #187 required extensive assistance for bed mobility, dressing, eating, personal hygiene, and total dependence for transfers, toilet use and bathing. The MDS assessment indicated Resident #187 was on isolation or quarantine for active infections disease (does not include standard body/fluid precautions) while a resident at the facility during the last 14 days. <BR/>Record review of Resident #187's Order Summary report dated 02/08/23 revealed, Resident #187 had an order for Bactrim DS Oral Tablet 800-160 milligrams (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for UTI (urinary tract infection) for 14 Days with a start date of 02/04/23. Record review of the order summary report did not indicate Resident #187 has a physician order for contact precautions. <BR/>During an observation on 02/06/23 at 10:26 AM, personal protective equipment was observed hanging from Resident #187's door and there was a sign posted to see the nurse prior to entering the room. <BR/>During an observation on 02/06/23 at 11:47 AM, CNA N was observed putting on a gown and gloves prior to entering Resident #187 room to provide care. <BR/>During an interview on 02/06/23 at 3:04 PM, Nurse M said Resident #187 was not on any type of isolation. <BR/>During an interview on 02/08/23 at 4:50 PM, ADON H, also the Infection Preventionist, said Resident #187 was supposed to be on contact precautions due to VRE (Vancomycin-resistant Enterococci bacteria) or ESBL (Extended spectrum beta-lactamase bacteria) in the urine. ADON H said the charge nurse was supposed to put a physician order in for contact precautions. ADON H said ADON K was responsible for overlooking Resident #187 physician orders. ADON H said Resident #187 not having a physician order for contact precautions could result in a spread of infection if the staff was not putting on the proper personal protection equipment while providing personal care. <BR/>During an interview on 02/08/23 at 4:55 PM, ADON K said Resident #187 should have a physician order for contact precautions. ADON K said the nurse who received the order should have put it in the electronic health record. ADON K said she did not know why Resident #187 did not have a physician order for contact precautions. ADON K said Resident #187 not having a physician order for contact precautions placed the other residents at risk of getting the infection. <BR/>During an interview on 02/08/23 at 6:49 PM, the DON said Resident #187 was on contact precautions and he should have a physician order for contact precautions. The DON said the nurse who received the physician order should have put it in the electronic health record, and the ADONs were responsible for overseeing this was done. The DON said he did not know why the physician order was not put in the electronic health record for Resident #187. The DON said Resident #187 not having a physician order for contact precautions was a lack of communication and could cause infection issues. <BR/>During an interview on 02/08/23 at 8:08 PM, the administrator said the nurses were responsible for putting in the order for contact precautions in the electronic health record. The administrator said he expected the nurses to place all physician orders in the electronic health record and the DON or designee to oversee this. The administrator said not putting physician orders in the electronic health record placed residents at risk for not getting what they needed. <BR/>Record review of the facility's policy titles, Following Physician Orders, date implemented 09/28/2021, revealed, Policy: The policy provide guidance on receiving and following physician orders . 2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Document the order by entering the order and the time, date, and signature on the physician order sheet. b. follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. 3. For consulting physician/practitioner orders received via telephone, the nurse will: a. Document the order on the physician order form, notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order. b. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. c. Carry out and implement physician order d. Document resident response to physician order in the medical record as indicated .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 staff (RN M, CNA N, and Treatment Nurse) viewed for infection control.<BR/>1. The facility failed to ensure RN M performed hand hygiene after removing his gloves and before putting on clean gloves during tracheostomy care for Resident #62<BR/>2. The facility failed to ensure RN M changed gloves and performed hand hygiene after picking up a nebulizer machine off the ground and before performing oral care and washing Resident #62's face.<BR/>3. The facility failed to ensure the treatment nurse and CNA N changed gloves when providing incontinent care for Resident #182. <BR/>4. The facility failed to ensure the treatment nurse performed hand hygiene between glove changes. <BR/>These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. <BR/>Findings Include:<BR/>1. During an observation on 2/07/23 at 9:16 p.m. RN M performed tracheostomy care on Resident #62. RN M removed his sterile gloves after removing Resident #62's inner cannula, took his cell phone out of his pocket, and then put another pair of sterile gloves. RN M did not perform hand hygiene after removing his sterile gloves and before putting on a clean pair of sterile gloves to complete Resident #62's tracheostomy care. <BR/>During an observation on 2/07/23 at 9:21 a.m. RN M performed suctioning on Resident #62. RN M removed his sterile gloves after he completed suctioning on Resident #62 and put another pair of sterile gloves. RN M did not perform hand hygiene after removing his sterile gloves and before putting on a clean pair of sterile gloves to replace Resident #62's inner cannula (a tube inside the outer tube of a tracheostomy that can be easily removed and cleaned) .<BR/>2. During an observation on 2/07/23 at 9:38 a.m. RN M knocked Resident #62's nebulizer onto the floor. RN M picked the nebulizer up off the floor with his gloved hands and then performed oral care and cleaned Resident #62's face. RN M did not remove his gloves or perform hand hygiene after picking up the nebulizer off the floor and before performing oral care and cleaning Resident #62's face.<BR/>During an interview on 1/07/23 at 9:48 a.m. RN M said hand hygiene should be performed after cleaning the inner cannula and before continuing tracheostomy care and when gloves were changed. RN M said proper hand hygiene was important to prevent the spread of bacteria and for infection control. RN M said when the nebulizer fell into the floor it would have been contaminated. RN M said picking up an item off the floor and then providing care to a resident without changing gloves or performing hand hygiene could introduce bacteria to the resident and cause an infection. RN M said he did not perform hand hygiene between glove changes or change gloves and perform hand hygiene after picking the nebulizer up out of the floor was because it slipped his mind. <BR/>During an interview on 2/08/23 at 2:29 p.m. the Infection Preventionist said she expected staff to perform hand hygiene after providing care, between residents, when hands were visibly soiled, and when gloves were changed. The Infection Preventionist said it was important to perform hand hygiene to keep infections down and to prevent the spread of infections. <BR/>During an interview on 2/08/23 at 6:08 p.m. the DON said he expected the staff to perform hand hygiene before and after entering a resident room and between glove changes. The DON said when staff removed a pair of gloves they did not know what they might accidentally touch when removing the gloves. The DON said the importance of proper hand hygiene was for infection control.<BR/>During an interview on 2/08/23 at 7:10 p.m. the Administrator said he expected staff to perform hand hygiene anytime hands were visibly soiled, before handling food, before and after providing care, and between glove changes. The Administrator said the DON and nursing management were responsible for ensuring staff were trained and performing appropriate hand hygiene. The Administrator said hand hygiene decreased the risk of infection.<BR/>3 and 4. During an observation on 02/06/23 starting at 11:00 AM, CNA N and the treatment nurse were providing incontinent care to Resident #182. During the incontinent care the treatment nurse was holding Resident #182 by buttocks with her two hands and had feces on her gloves. The treatment nurse wiped off the feces from her gloves and removed one glove. The treatment nurse put on a new glove. The treatment nurse did not change both gloves and she did not perform hand hygiene after removal of the one glove. CNA N continued to provide care and removed the dirty brief and applied a clean brief and finished the incontinent care. CNA N did not change her gloves and did not perform hand hygiene after removing the dirty brief. <BR/>During an interview on 02/06/23 at 11:31 AM, the treatment nurse said while providing incontinent care to Resident #182 she did not perform hand hygiene after removing one glove and putting on a new glove. The treatment nurse said she should have changed both gloves and performed hand hygiene. The treatment nurse said it was important to perform hand hygiene and change gloves when they were soiled to prevent cross contamination and so you do not accidentally spread germs. <BR/>During an interview on 02/06/23 at 11:39 AM, CNA N said she should have changed gloves when she took off Resident #182 dirty brief. CNA N said not changing gloves when going from dirty to clean and not performing hand hygiene placed the residents at risk for cross contamination.<BR/>During an interview on 02/08/23 at 5:05 PM, ADON K said there was currently no monitoring in place for incontinent care. ADON K said the DON did skill check offs for the staff, but she did not know how often. ADON said the charge nurses and nurse management were responsible for ensuring the facility staff performed hand hygiene and proper incontinent care. ADON K said not performing proper incontinent care and not performing hand hygiene could cause the residents to get urinary tract infections, skin breakdown, and placed the residents at risk of infection.<BR/>During an interview on 02/08/23 at 6:53 PM, the DON said the treatment nurse and CNA N should have changed gloves and performed hand hygiene when going from dirty to clean. The DON said the nurse overseeing the CNAs was responsible for making sure the CNAs performed hand hygiene and proper incontinent care. The DON said not performing hand hygiene and improper incontinent care placed the residents at risk for infection and skin breakdown.<BR/>During an interview on 02/08/23 at 8:13 PM, the administrator said the treatment nurse and CNA N should have changed gloves and performed hand hygiene while providing incontinent care. The administrator said nursing was responsible for ensuring proper incontinent care was provided and staff were performing hand hygiene. The administrator said improper incontinent care and not performing hand hygiene could cause the residents to have an infection.<BR/>Record review of the facility's policy titled, Incontinence Care, last reviewed 02/14/20, revealed, .8. If feces present, remove with toilet paper or disposable wipe by wiping from front perineum toward rectum. Discard soiled materials and gloves. Wash hands. 9. Put on non-sterile latex-free gloves .14. Remove linen/under pad and discard 15. Remove and discard gloves 16. Wash hands 17. Apply clean linen/underpad, briefs or other incontinent products as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 1 resident (Resident #188) reviewed for smoking.<BR/>The facility failed to ensure Resident #188's smoking evaluation tool was completed upon admission. <BR/>This failure could place residents at risk of an unsafe smoking environment. <BR/>Finding included:<BR/>Record review of a Face Sheet dated 02/08/23 revealed Resident #188 was a [AGE] year-old male admitted on [DATE] with diagnoses of neoplasm of uncertain behavior of bladder (bladder cancer), essential (primary) hypertension (high blood pressure), nicotine dependence, unspecified, uncomplicated (dependence on nicotine a substance found in tobacco products), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Review of the electronic health record on 02/07/23 revealed no care plan, and MDS assessment was not yet completed. <BR/>Review of the electronic health record on 02/07/23 did not reflect Resident #188 had a smoking evaluation tool completed. <BR/>During an interview on 02/06/23 starting at 10:31 AM, Resident #188 stated he smoked. <BR/>During an observation on 02/07/23 starting at 11:03 AM, the Health Information Coordinator was supervising smoking in the facility's smoking area. Resident #188 was observed smoking.<BR/>During an interview on 02/08/23 at 4:15 PM, the social worker said she was responsible for completing the smoking evaluation tool. The social worker said she was aware Resident #188 smoked. The social worker said she did not know why the smoking evaluation tool was not in the electronic health record. The social worker said she thought she had put in the smoking evaluation tool yesterday. The social worker said she tried to complete the smoking evaluation tool within two days of admission. The social worker said it was important to complete the smoking evaluation tool to make sure the residents were safe while smoking.<BR/>During an interview on 02/8/23 at 5:03 PM, ADON H said she was aware Resident #188 smoked. ADON H said a smoking evaluation tool should have been completed on admission and the social worker was responsible for completing the smoking evaluation tool. ADON H said it was important to complete the smoking evaluation tool to know if a resident was safe while smoking. <BR/>During an interview on 02/08/23 at 5:50 PM, Nurse D said a smoking evaluation tool should be completed on admission, and sometimes she completed the smoking evaluation tool. Nurse D said she was aware Resident #188 smoked. Nurse D said she did not do Resident #188's smoking evaluation tool because she ran out of time the day she admitted him. Nurse D said Resident #188 not having a smoking evaluation tool could result in him catching himself on fire.<BR/>During an interview on 02/08/23 at 6:53 PM, the DON said he was aware Resident #188 smoked. The DON said Resident #188 should have had a smoking evaluation tool completed on admission. The DON said if the social worker was not in the building on admission the admitting nurse was responsible for completing the smoking evaluation tool. The DON said he overlooked the completion of the smoking evaluation tool at the interdisciplinary meetings on Monday mornings. The DON said he was not able to do this on Monday because state came in the building. The DON said smoking evaluation tool were completed for the residents' safety, and not completing the smoking evaluation tool placed the residents at risk for possible burn and injury. <BR/>During an interview on 02/08/23 at 8:12 PM, the administrator said the social worker was responsible for completing the smoking evaluation tool. The administrator said he expected the social worker to complete the smoking evaluation tool. The administrator said not completing the smoking evaluation tool placed the residents at risk for injury. <BR/>Record review of the facility's policy titled, Smoking Policy, last revised 4/24/18, revealed, Policy to evaluate a patient's ability to participate and exercise the privilege to smoke while residing within the facility. Fundamental information to establish smoking guidelines for patients that desire to smoke in the center to allocate a nonsmoking area for the residents/staff/visitors Procedure evaluate patients that smoke utilizing the smoking evaluation tool: (a) upon admission; (b) when a previous non-smoking patient takes up smoking; (c) if unsafe smoking practices are observed in a current smoker .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 20 residents (Resident #73) reviewed for self-determination.<BR/>The facility failed to ensure RN M and CNA N assisted Resident #73 to the toilet when she requested to be put on the toilet. <BR/>This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that are import in their life and decrease their quality of life.<BR/>Findings included:<BR/>Record review of Resident #73's face sheet, dated 02/08/23, revealed a [AGE] year-old female initially admitted on [DATE] with diagnoses of metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and chronic obstructive pulmonary disease, unspecified (chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Record review of the MDS assessment, dated 01/30/23, revealed Resident #73 was usually understood and usually understood others. Resident #73's BIMS score was a 00, indicating severe mental impairment. Resident #73's MDS assessment indicated she required extensive assist for bed mobility, transfers, dressing, eating, and personal hygiene and total dependence for toilet use. Resident #73's MDS assessment indicated she was always incontinent of bowel and bladder. <BR/>Record review of Resident #73's care plan, last revised 11/16/22, indicated Resident #73 had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner with the goal of resident will participate to the best of their ability and maintain current level of functioning with ADLs through the next review date. Resident #73's care plan indicated she required extensive assistance with bed mobility, transfers, and toileting. Resident #73's care plan indicated the resident is incontinent of bowel/bladder related to active infections with symptoms of UTI (urinary tract infection), history of UTI, impaired mobility, physical limitations, recent surgery, CVA (stroke), with an intervention to assist to the toilet as needed. <BR/>Record review of Resident #73's order summary report did not reveal any physician's orders restricting Resident #73's activities. <BR/>During an observation and interview on 02/06/23 starting at 10:09 AM, Resident #73 was observed laying in the bed she said she needed to use the bathroom and they would not allow her to get up and go to the bathroom. Resident #73 said she had asked the aides for assistance to the bathroom, and they told her they could not get her up. Resident #73 was not able to give specific names of staff. Resident #73 said it was the nurses and CNAs. This surveyor informed CNA N Resident #73 had requested assistance to go to the bathroom. CNA N replied ok. After this, RN M approached this surveyor and said Resident #73 was incontinent and she was not supposed to get out of bed because her blood pressure would drop, therefore she had to stay in bed and the CNAs would provide incontinent care. Resident #73 remained in the bed and was not assisted to the bathroom. <BR/>During an observation and interview on 02/07/23 at 1:37 PM Resident #73 was observed laying in the bed and said she would like to get out of bed more and be assisted to the toilet instead of having to use her brief because she was trying to be more continent. Resident #73 said she had told the staff but was unable to provide names. <BR/>During an interview on 02/08/23 at 12:01 PM, CNA N said she did not assist Resident #73 to the toilet because RN M told her not to assist her to the toilet because she was incontinent. CNA N said if any resident asked her for assistance, she should assist the resident. <BR/>During an interview on 02/08/23 at 4:25 PM, LVN P said he was one of the nurses that provided care to Resident #73. LVN P said Resident #73 could get out of the bed and should be assisted to the toilet when she requested it. LVN P said Resident #73 had not complained of any dizziness or light headedness when placed on the toilet or in the wheelchair. LVN P said Resident #73 did not have any low blood pressures. <BR/>During an interview on 02/08/23 at 5:21 PM, ADON K said Resident #73 could get up and she should have been assisted to the toilet when she requested it. ADON K said there was no reason why Resident #73 could not have been assisted to the toilet. ADON K said it was Resident #73's right to get up when she chose to. ADON K said Resident #73 should have the choice of when to get out of bed and when to go to the toilet. ADON K said not providing Resident #73 the choice to get up and to go to the toilet could cause her to be depressed, could lead to falls and injuries. ADON K said the nurses and CNAs should be making sure the residents; choices were being respected. <BR/>During an interview on 02/08/23 at 5:25 PM LVN D said she was one of the nurses who provided care for Resident #73. LVN D said Resident #73 did not have low blood pressures. LVN D said Resident #73 had the right to make choices and to be placed on the toilet when she requested it. LVN D said not assisting Resident #73 to the toilet could make her more of a fall risk and if her choices were not respected it could make her angry and upset. <BR/>During an interview on 02/08/23 at 6:43 PM, the DON said Resident #73 should have been put on the toilet. The DON said Resident #73 should have a choice as to her daily activities. The DON said he made sure staff was respecting the residents' rights by doing in-services. The DON said Resident #73 not being assisted to the toilet could decrease her quality of life. <BR/>During an interview on 02/08/23 at 8:02 PM, the administrator said Resident #73 should be able to get up and go. The administrator said Resident #73 should have the choice to be put on the toilet and to get out of bed. The administrator said he did an in-service last week with all the staff on resident rights dignity and respect. The administrator said not assisting Resident #73 to the toilet could affect her dignity, self-esteem, and could make her feel like she did not have a voice, or a choice and it was not letting her keep her independence. <BR/>Phone call interview attempted with RN M on 02/08/23 at 8:27 PM and was unsuccessful. <BR/>Record review of the facility's policy titled Activities of Daily Living Care Guidelines, last reviewed 02/11/21, revealed, . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Residents participate in and receive the following person centered care . mobility: walking or receiving assistance with ambulation, transfer oneself or receiving assistance or use of wheelchair, moving oneself or receiving assistance with bed mobility, toileting/continence: toileting or receiving assistance with toileting . <BR/>Record review of the facility's policy titled Resident Rights, last reviewed 02/20/21, revealed, . The facility will ensure that all staff members are educated on the rights of the residents and the responsibility of the facility to properly care of its residents . Resident Rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility . Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: a. The resident has a right to choose activities, schedules (including sleeping and waking times), health care providers of health care services consistent with his or her interests, assessments ad plan of care and other applicable provisions of this part, b. the resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible to prevent accidents for 2 of 20 (Resident #4 and Resident #59) residents reviewed for accidents and hazards. <BR/>The facility failed to ensure the Maintenance Supervisor fixed the exposed wires on Resident #4 and Resident #59's bed remotes. <BR/>These failures could place residents at an increased risk for injury, electrocution, or fire. <BR/>The findings included:<BR/>1. Record review of Resident #4's face sheet (undated) revealed she was [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset (type of brain disorder that causes problems with memory, thinking and behavior and is a gradually progressive condition), type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar with damaged nerves to hands and feet), and bradycardia (slow heartbeat). <BR/>Record review of the MDS assessment, dated 05/17/2023, revealed Resident #4 had clear speech and was understood by staff. The MDS revealed Resident #4 was able to understand others. The MDS revealed Resident #4 had a BIMS score of 04 which indicated severe cognitive impairment. The MDS revealed Resident #4 required limited assistance with bed mobility and transfers. <BR/>Record review of the comprehensive care plan, last revised on 4/26/2021, revealed Resident #4 had an ADL self-care performance deficit and required limited - extensive assistance with ADLs. <BR/>During an observation and resident interview on 02/06/2023 at 10:19 AM, Resident #4 had exposed wires on her bed remote attached to her bed. Resident #4 was non-interviewable related to severe cognitive impairment as evidenced by confused conversation. <BR/>During a confidential interview on 02/06/2023 at 10:50 AM, a staff member stated exposed wires on residents' bed had been reported to the Maintenance Supervisor verbally on multiple occasions. The staff member stated the exposed wires had caused the bed to short out and not work correctly at times. The staff member stated the problem had not been resolved or fixed. The staff member stated it was important for beds to work properly to prevent an accident or injury to residents. <BR/>During an observation on 02/06/2023 at 3:40 PM, Resident #4 had exposed wires on her bed remote attached to her bed. <BR/>During an observation on 02/07/2023 at 8:27 AM, Resident #4 had exposed wires on her bed remote attached to her bed. <BR/>2. Record review of Resident #59's face sheet (undated) revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), combined systolic and diastolic congestive heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and anxiety disorder (severe, ongoing anxiety that interferes with daily activities). <BR/>Record review of the MDS assessment, dated 11/19/2022, revealed Resident #59 had clear speech and was usually understood by staff. The MDS revealed Resident #59 was usually able to understand others. The MDS revealed Resident #59 had a BIMS score of 8 which indicated moderately impaired cognition. The MDS revealed Resident #59 required extensive assistance with bed mobility and transfers. <BR/>Record review of the comprehensive care plan, last revised on 05/02/2022, revealed Resident #59 had an ADL self-care deficit and required extensive assistance with most ADLs. <BR/>During an observation and resident interview on 02/06/2023 at 10:50 AM, Resident #59 had exposed wires on her bed remote attached to her bed. Resident #59 was non-interviewable related to cognitive status as evidenced by confused conversation. <BR/>During an observation on 02/06/2023 at 2:53 PM, Resident #59 had exposed wires on her bed remote attached to her bed. <BR/>During an observation on 02/07/2023 at 8:23 AM, Resident #59 had exposed wires on her bed remote attached to her bed. <BR/>During an interview on 02/08/2023 at 4:35 PM, CNA Q stated she had noticed exposed wires on Resident #4 and Resident #59's bed remotes attached to their bed. CNA Q stated she reported verbally and showed the exposed wires to the Maintenance Supervisor approximately the week prior. CNA Q stated exposed wires to the bed remotes would cause the bed to not work at times. CNA Q stated the harm to Resident #4 and Resident #59 for exposed wires was risk for electrocution. <BR/>During an interview on 02/08/2023 at 4:46 PM, NA R stated he had noticed exposed wires on some of the residents' beds. NA R stated he had reported the exposed bed wires to the Maintenance Supervisor verbally. NA R stated the Maintenance Supervisor usually resolved the issues reported. NA R stated the failure to Resident #4 and Resident #59 for exposed wires on the bed remote attached to their bed was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 5:13 PM, LVN (ADON) H stated issues identified with beds or exposed wires would be reported to the Maintenance Supervisor via communication book, verbally, or via text message. LVN (ADON) H stated she was unaware of the exposed wires to Resident #4 and Resident #59's bed because it was not reported to her. LVN (ADON) H stated the harm to Resident #4 and Resident #59 for having exposed wires on their bed was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 5:27 PM, RN B stated issues with the residents' beds have been identified and reported to the Maintenance Supervisor. RN B stated the issues identified with the beds included beds not working correctly. RN B stated she was unaware Resident #4 or Resident #59 had exposed bed wires to their beds. RN B stated the harm to Resident #4 and Resident #59 for having exposed wires to the bed remote attached to the bed was an increased risk for electrocution and could have been a fire hazard. <BR/>During an interview on 02/08/2023 at 6:43 PM, the Maintenance Supervisor stated issues identified with beds were reported via the maintenance communication book or verbally by staff or residents. The Maintenance Supervisor stated he addressed issues reported him as quick as he was able. The Maintenance Supervisor stated the exposed wires on Resident #4 and Resident #59's beds were not reported to him. The Maintenance Supervisor stated the harm to Resident #4 and Resident #59 for having exposed wires to bed remotes attached to their beds was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated the Maintenance Supervisor was responsible for fixing and monitoring exposed wires to beds and bed remotes. The ADM stated he expected all staff to report issues identified with exposed wires or beds in the maintenance communication book. The ADM stated reporting issues verbally could have caused issues to have been missed or forgotten. The ADM stated the importance of reporting exposed wires to bed remotes attached to residents' beds was to protect resident safety. The ADM stated exposed bed wires could have caused an increased risk for harm by electrocution or fire. <BR/>Record review of the Maintenance Inspection policy, implemented on 4/11/2022, revealed It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The policy further revealed 3. All opportunities will be corrected immediately by the maintenance personnel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of 20 residents (Residents #26, #14 and #1) reviewed for resident rights.<BR/>1. The facility failed to ensure RN F and CNA Z treated residents with dignity and respect by referring to them as feeders. <BR/>2. The facility failed to ensure the Environmental Service Manager knocked prior to entering Resident #26 room. <BR/>3. The facility failed to ensure LVN E provided privacy for Resident #14 while administering his insulin injection. <BR/>4. The facility failed to ensure Resident #1 had a privacy bag for his catheter drainage bag. <BR/>These failures could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.<BR/>The findings included: <BR/>1. During an observation on 02/06/2023 at 11:52 a.m., RN F stated where's the feeders in the dining hall while passing out food trays to the residents who required assistance with eating. <BR/>During an interview on 02/08/2023 at 1:58 p.m., RN F stated she did not know the word feeder was inappropriate until she was told by the DON. RN F stated the DON told her she should use the word assistance. RN F stated she had used the word feeder several times, but it was not set in her vocabulary. RN F stated the failure to residents for being referred to as a feeder was a dignity issue. <BR/>During an observation and interview on 02/06/2023 at 1:33 PM, CNA Z said, that's for my feeder. CNA Z was approximately 3 feet from several resident doors. CNA Z stated it was not appropriate to refer to a resident as a feeder. CNA Z stated she was trying to explain that was why she had one tray left on the cart. CNA Z stated referring to residents' as feeder could have made residents' feel disrespected.<BR/>2. During an observation on 02/06/2023 at 10:14 a.m., the Environmental Service Manager entered Resident #26 room without knocking. <BR/>During an interview on 02/06/2023 at 10:20 a.m., Resident #26 stated he did not feel he, and his wife had any privacy. Resident #26 stated the housekeepers never knocked prior to entering. <BR/>During an interview on 02/08/2023 at 1:52 p.m., the Environmental Service Manager stated she should have knocked prior to entering Resident #26 room. The Environmental Service Manager stated she was moving too fast and forgot to knock. The Environmental Service Manger stated she had never been told that some of her staff did not knock prior to entering resident's room. The Environmental Service Manager stated this failure was not providing privacy to residents. <BR/>3. During an observation and interview on 02/07/2023 at 11:20 a.m., LVN E administered Resident #14 insulin with the door open. Resident #14 did not have a roommate. LVN E stated it was not okay to administer medication to residents without providing privacy. LVN E was unable to say why she did not close the door prior to administering Resident #14 medication. LVN E stated this failure was a lack of dignity and respect.<BR/>During an interview on 02/08/2023 at 4:36 p.m., the DON stated he expected staff to knock prior to entering resident's room. The DON stated he expected staff to provide privacy when administering medications. The DON stated he expected staff to say assisted dining room instead of saying the word feeder. The DON stated this was monitored by weekly rounds and visiting with residents/family to ensure privacy has been provided. The DON stated staff were in serviced at least once a month. The DON stated he was unaware of any issues. The DON stated there was not a system in place for staff at nurse level to monitor for that specific dignity infarction related to administering medications without privacy. <BR/>During an interview on 02/08/2023 at 6:13 p.m., the Administrator stated he expected staff to knock prior to entering resident's room. The Administrator stated he expected staff to provide privacy when administering medications and expected staff to say assisted dining room instead of the word feeder. The Administrator stated this failure was an embarrassment to the residents and a dignity issue. <BR/>4. Record review of Resident #1's face sheet (undated) revealed he was a [AGE] year-old-male who admitted to the facility on [DATE] with diagnoses of senile degeneration of the brain (mental condition where your brain cells begin to degenerate), unspecified dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and benign prostatic hyperplasia with lower unitary tract symptoms, BPH (overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine). <BR/>Record review of Resident #1's order summary report, dated 02/08/2023, revealed an order which started on 10/31/2022 for May have suprapubic catheter for dx: Obstructive uropathy. The order summary report further revealed an order which started on 10/31/2022 for Suprapubic care q shift and prn. Check privacy bag every shift.<BR/>Record review of the MDS assessment, dated 11/08/2022, revealed Resident #1 had clear speech and was understood by staff. The MDS revealed Resident #1 was able to understand others. The MDS revealed Resident #1 had a BIMS score of 07 which indicated severe cognitive impairment. The MDS revealed Resident #1 had no behaviors or refusal of care. The MDS revealed Resident #1 had an indwelling catheter. <BR/>Record review of the comprehensive care plan, last revised on 01/03/2023, revealed Resident #1 had a suprapubic catheter. The interventions included: Privacy bag over the drainage bag. <BR/>During an observation and resident interview on 02/06/2023 at 10:25 AM, the catheter bag, with approximately 100 mL of clear, yellow urine, was hanging on Resident #1's wheelchair with no privacy bag noted. Resident #1 was non-interviewable related to severe cognitive impairment as evidenced by confused conversation. <BR/>During an observation on 02/06/2023 at 3:35 PM, catheter bag, with approximately 200 mL of clear, yellow urine, was hanging on Resident #1's wheelchair with no privacy bag noted.<BR/>During an observation on 02/07/2023 at 8:17 AM, Resident #1 was self-propelling his wheelchair down the hallway from the dining room, the catheter bag, with the tubing full of clear, yellow, urine, was hanging from wheelchair with no privacy bag noted.<BR/>During an interview on 02/08/2023 at 4:35 PM, CNA Q stated Resident #1 was supposed to have a privacy bag for his catheter drainage bag. CNA Q stated she had no clue why Resident #1 had no privacy bag for his catheter drainage bag. CNA Q stated CNAs were unable to provide the type of privacy bags the facility used. CNA Q stated CNAs were able to alert the nurse that one was needed. CNA Q stated the nurse was not notified that Resident #1 needed a privacy bag. CNA Q stated privacy bags were important so Resident #1 could have privacy and dignity. <BR/>During an interview on 02/08/2023 at 4:46 PM, NA R stated Resident #1 was supposed to have a privacy bag for his catheter drainage bag. NA R stated he was unsure why Resident #1 had no privacy bag on his catheter drainage bag. NA R stated the nurse was responsible for placing privacy bags. NA R stated he was unsure if the nurse was notified of the need for a privacy bag. NA R stated privacy bags were important so Resident #1 could have privacy and dignity. <BR/>During an interview on 02/08/2023 at 5:13 PM, LVN (ADON) H stated the nurses and ADONs were responsible for ensuring privacy bags were applied to catheter drainage bags. LVN (ADON) H stated nurses were responsible for monitoring to ensure privacy bags were applied to catheter drainage bags. LVN (ADON) H stated she was unsure why Resident #1 had no privacy bag. LVN (ADON) H stated privacy bags were important to maintain Resident #1's dignity. <BR/>During an interview on 02/08/2023 at 7:09 PM, the DON stated CNAs should have been aware when residents need a privacy bag to catheter drainage bags. The DON stated Resident #1 should not have been provided with a catheter drainage bag with no privacy ability. The DON stated this was monitored by looking at invoices for resident care equipment ordered by the facility. The DON stated ultimately the nurses were responsible for ensuring privacy bags were provided for catheter drainage bags. The DON stated the importance of privacy bags was to ensure dignity. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated he expected nursing staff to ensure Resident #1 had a privacy bag for his catheter drainage bag. The ADM stated privacy bags were important to ensure Resident #1's dignity and privacy. <BR/>Record review of the Urinary Catheter Management policy, last reviewed on 08/20/2021, revealed Fundamental Information 3.Provide privacy and dignity by covering urinary bag with a bag cover. <BR/>Record review of the Resident Rights policy, last reviewed on 02/20/2021, revealed 4. Respect and Dignity. The resident has a right to be treated with respect and dignity. The policy further revealed 7. Privacy and confidentiality. a. personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible to prevent accidents for 2 of 20 (Resident #4 and Resident #59) residents reviewed for accidents and hazards. <BR/>The facility failed to ensure the Maintenance Supervisor fixed the exposed wires on Resident #4 and Resident #59's bed remotes. <BR/>These failures could place residents at an increased risk for injury, electrocution, or fire. <BR/>The findings included:<BR/>1. Record review of Resident #4's face sheet (undated) revealed she was [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset (type of brain disorder that causes problems with memory, thinking and behavior and is a gradually progressive condition), type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar with damaged nerves to hands and feet), and bradycardia (slow heartbeat). <BR/>Record review of the MDS assessment, dated 05/17/2023, revealed Resident #4 had clear speech and was understood by staff. The MDS revealed Resident #4 was able to understand others. The MDS revealed Resident #4 had a BIMS score of 04 which indicated severe cognitive impairment. The MDS revealed Resident #4 required limited assistance with bed mobility and transfers. <BR/>Record review of the comprehensive care plan, last revised on 4/26/2021, revealed Resident #4 had an ADL self-care performance deficit and required limited - extensive assistance with ADLs. <BR/>During an observation and resident interview on 02/06/2023 at 10:19 AM, Resident #4 had exposed wires on her bed remote attached to her bed. Resident #4 was non-interviewable related to severe cognitive impairment as evidenced by confused conversation. <BR/>During a confidential interview on 02/06/2023 at 10:50 AM, a staff member stated exposed wires on residents' bed had been reported to the Maintenance Supervisor verbally on multiple occasions. The staff member stated the exposed wires had caused the bed to short out and not work correctly at times. The staff member stated the problem had not been resolved or fixed. The staff member stated it was important for beds to work properly to prevent an accident or injury to residents. <BR/>During an observation on 02/06/2023 at 3:40 PM, Resident #4 had exposed wires on her bed remote attached to her bed. <BR/>During an observation on 02/07/2023 at 8:27 AM, Resident #4 had exposed wires on her bed remote attached to her bed. <BR/>2. Record review of Resident #59's face sheet (undated) revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), combined systolic and diastolic congestive heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and anxiety disorder (severe, ongoing anxiety that interferes with daily activities). <BR/>Record review of the MDS assessment, dated 11/19/2022, revealed Resident #59 had clear speech and was usually understood by staff. The MDS revealed Resident #59 was usually able to understand others. The MDS revealed Resident #59 had a BIMS score of 8 which indicated moderately impaired cognition. The MDS revealed Resident #59 required extensive assistance with bed mobility and transfers. <BR/>Record review of the comprehensive care plan, last revised on 05/02/2022, revealed Resident #59 had an ADL self-care deficit and required extensive assistance with most ADLs. <BR/>During an observation and resident interview on 02/06/2023 at 10:50 AM, Resident #59 had exposed wires on her bed remote attached to her bed. Resident #59 was non-interviewable related to cognitive status as evidenced by confused conversation. <BR/>During an observation on 02/06/2023 at 2:53 PM, Resident #59 had exposed wires on her bed remote attached to her bed. <BR/>During an observation on 02/07/2023 at 8:23 AM, Resident #59 had exposed wires on her bed remote attached to her bed. <BR/>During an interview on 02/08/2023 at 4:35 PM, CNA Q stated she had noticed exposed wires on Resident #4 and Resident #59's bed remotes attached to their bed. CNA Q stated she reported verbally and showed the exposed wires to the Maintenance Supervisor approximately the week prior. CNA Q stated exposed wires to the bed remotes would cause the bed to not work at times. CNA Q stated the harm to Resident #4 and Resident #59 for exposed wires was risk for electrocution. <BR/>During an interview on 02/08/2023 at 4:46 PM, NA R stated he had noticed exposed wires on some of the residents' beds. NA R stated he had reported the exposed bed wires to the Maintenance Supervisor verbally. NA R stated the Maintenance Supervisor usually resolved the issues reported. NA R stated the failure to Resident #4 and Resident #59 for exposed wires on the bed remote attached to their bed was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 5:13 PM, LVN (ADON) H stated issues identified with beds or exposed wires would be reported to the Maintenance Supervisor via communication book, verbally, or via text message. LVN (ADON) H stated she was unaware of the exposed wires to Resident #4 and Resident #59's bed because it was not reported to her. LVN (ADON) H stated the harm to Resident #4 and Resident #59 for having exposed wires on their bed was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 5:27 PM, RN B stated issues with the residents' beds have been identified and reported to the Maintenance Supervisor. RN B stated the issues identified with the beds included beds not working correctly. RN B stated she was unaware Resident #4 or Resident #59 had exposed bed wires to their beds. RN B stated the harm to Resident #4 and Resident #59 for having exposed wires to the bed remote attached to the bed was an increased risk for electrocution and could have been a fire hazard. <BR/>During an interview on 02/08/2023 at 6:43 PM, the Maintenance Supervisor stated issues identified with beds were reported via the maintenance communication book or verbally by staff or residents. The Maintenance Supervisor stated he addressed issues reported him as quick as he was able. The Maintenance Supervisor stated the exposed wires on Resident #4 and Resident #59's beds were not reported to him. The Maintenance Supervisor stated the harm to Resident #4 and Resident #59 for having exposed wires to bed remotes attached to their beds was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated the Maintenance Supervisor was responsible for fixing and monitoring exposed wires to beds and bed remotes. The ADM stated he expected all staff to report issues identified with exposed wires or beds in the maintenance communication book. The ADM stated reporting issues verbally could have caused issues to have been missed or forgotten. The ADM stated the importance of reporting exposed wires to bed remotes attached to residents' beds was to protect resident safety. The ADM stated exposed bed wires could have caused an increased risk for harm by electrocution or fire. <BR/>Record review of the Maintenance Inspection policy, implemented on 4/11/2022, revealed It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The policy further revealed 3. All opportunities will be corrected immediately by the maintenance personnel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 4 of 13 (Residents #3, #4, #5, and #6) residents reviewed for reporting.<BR/>1. The facility did not report the resident-to-resident altercation between Resident #3 and Resident #4 to the State Survey Agency within 2 hours of been notified. <BR/>2. The facility did not report the resident-to-resident altercation between Resident #5 and Resident #6 to the State Survey Agency within 2 hours of been notified. <BR/>These failures to report could place the residents at risk for abuse. <BR/>Findings included:<BR/>1. Resident #3<BR/>Record review of Resident #3's face sheet, dated 02/27/25, reflected Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included supraventricular tachycardia (abnormal fast heartbeat). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 02/04/25, reflected Resident #3 usually made himself understood and understood others. Resident #3's BIMS score was 9, which indicated his cognition was moderately impaired. The MDS reflected Resident #3 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #3's comprehensive care plan revised 06/20/24 reflected Resident #3 had a behavior problem as evidenced by: verbal/physical behaviors, and rejection of care. The care plan interventions included: administer medications as ordered, monitor behavior episodes, and attempt to determine underlying cause and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet, dated 02/27/25, reflected Resident #4 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #4's annual MDS assessment, dated 01/02/25, reflected Resident #4 made himself understood and usually understood others. Resident #4's BIMS score was 5, which indicated his cognition was severely impaired. The MDS reflected Resident #4 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #4's comprehensive care plan revised 04/05/24 reflected Resident #4 had a behavior problem as evidence by resident with physical aggression toward another resident when verbally antagonized. The care plan interventions included: administer medication as ordered and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Record review of the PIR dated 10/22/24 reflected an allegation of resident-to-resident incident on Resident #3 and #4 that occurred on 10/17/24 at 10:50 a.m. The PIR reflected both residents were sitting in the sitting area and Resident #4 asked Resident #3 if he would move his chair into his spot. Resident #4 then pushed Resident #3's wheelchair forward from behind. Resident #3 became upset because Resident #4 moved his chair. Resident #3 then went back into Resident #4 with his wheelchair because he moved him. Resident #4 hit Resident #3 on the back of the head due to him hitting his wheelchair. The PIR reflected staff witnessed the incident. The incident was reported to the state agency on 10/17/24 at 1:20 p.m. <BR/>2. Resident #5<BR/>Record review of Resident #5's face sheet, dated 02/27/25, reflected Resident #5 was a [AGE] year-old female, originally admitted to the facility 12/14/23 with a diagnosis which included heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). <BR/>Record review of Resident #5's annual MDS assessment, dated 01/10/25, reflected Resident #5 made herself understood and understood others. Resident #5's BIMS score was 5, which indicated her cognition was severely impaired. The MDS reflected Resident #5 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #5's comprehensive care plan revised on 09/06/24 reflected Resident #5 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to paranoid personality disorder, and depression adult failure to thrive. The care plan interventions included: monitor/document/report to physician any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes and reduce any distractions<BR/>. <BR/>Resident #6<BR/>Record review of Resident #6's face sheet, dated 02/27/25, reflected Resident #6 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #6's quarterly MDS assessment, dated 02/01/25, reflected Resident #6 made herself understood and understood others. Resident #6's BIMS score was 15, which indicated her cognition was intact. The MDS reflected Resident #6 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #6's comprehensive care plan revised on 08/21/23 reflected Resident #6 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to dementia. The care plan interventions included: identify yourself at each interaction, reduce any distractions and provide instructions to resident using clear voice and simple sentences. <BR/>Record review of the undated PIR reflected an allegation of resident-to-resident incident on Resident #5 and Resident #6 that occurred 8/28/24 around 7:30 a.m. per the witnessed statement written by LVN B. The PIR reflected Resident #5 hit Resident #6 with her silverware packet at the breakfast table. The PIR reflected the incident was witnessed. The incident was reported to the state agency on 8/28/24 at 10:00 a.m. The PIR stated the facility substantiate the allegation of abuse. <BR/>During a telephone interview on 02/26/25 at 2:25 p.m., LVN B stated on the morning of 8/28/24 at approximately 7:30 a.m., she was in the dining room with another resident when she heard a noise and then heard Resident #6 state, she hit me referring to Resident #5. Resident #5 was sitting in the chair where Resident #6 normally sits. Resident #6 stated she asked Resident #5 to move, and Resident #5 picked up her silverware packet and hit her on her left arm. Resident #5 was questioned as to why she hit Resident #6 and she stated, she tried to take my silverware. LVN B stated she notified the DON, and the resident was assigned someone to stay with her while investigation was ongoing. LVN B stated the abuse coordinator was the Administrator and she knew the Administrator was on her way to the facility that morning, so she was going to tell her when she got there. <BR/>During an interview on 02/27/25 at 3:10 p.m., the Administrator stated she was the abuse coordinator for the facility. The Administrator stated the incident between Resident #3 and Resident #4 was witnessed by several staff members including herself. The Administrator stated the incident took longer to diffuse that required multiple staff member including herself to calm both residents down. The Administrator stated Resident #3 did not respond well to other staff members, but she was one that he did respond well too. The Administrator stated she was aware of the incident on 8/28/24 due to Resident #6 been at her office door upon her arrival. The Administrator stated after Resident #6 made the allegation, she went down to talk to LVN B and she informed her of the allegation, but she expected LVN B to contact her immediately regarding the incident. The Administrator stated she did agree that the allegations should always be reported within 2 hours unless there are extenuating circumstances. The Administrator stated she was responsible for overseeing by frequent rounding of the halls and dining room and trying to deescalate any agitation by residents as it arises. The Administrator stated she was the only one in the facility who could report abuse allegations to HHSC. The Administrator stated it was important to report an allegation of abuse and neglect for safety and protection of the residents and try to circumvent other incidents of abuse.<BR/>Record review of the facility policy for Policy and Procedures: Abuse, Neglect and Exploitation revised 09/06/24, reflected . it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect . 1. The facility provides resident protection that included: (a) prevention/prohibit resident abuse, neglect . 2. The facility's abuse prevention coordinator is responsible for reporting allegations or suspected abuse, neglect . to the state survey agency and other official in accordance with state law .III. Prevention of Abuse, Neglect and Exploitation . A. (2.) Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: 2(a). Immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involves abuse (with or without bodily injury) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible to prevent accidents for 2 of 20 (Resident #4 and Resident #59) residents reviewed for accidents and hazards. <BR/>The facility failed to ensure the Maintenance Supervisor fixed the exposed wires on Resident #4 and Resident #59's bed remotes. <BR/>These failures could place residents at an increased risk for injury, electrocution, or fire. <BR/>The findings included:<BR/>1. Record review of Resident #4's face sheet (undated) revealed she was [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset (type of brain disorder that causes problems with memory, thinking and behavior and is a gradually progressive condition), type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar with damaged nerves to hands and feet), and bradycardia (slow heartbeat). <BR/>Record review of the MDS assessment, dated 05/17/2023, revealed Resident #4 had clear speech and was understood by staff. The MDS revealed Resident #4 was able to understand others. The MDS revealed Resident #4 had a BIMS score of 04 which indicated severe cognitive impairment. The MDS revealed Resident #4 required limited assistance with bed mobility and transfers. <BR/>Record review of the comprehensive care plan, last revised on 4/26/2021, revealed Resident #4 had an ADL self-care performance deficit and required limited - extensive assistance with ADLs. <BR/>During an observation and resident interview on 02/06/2023 at 10:19 AM, Resident #4 had exposed wires on her bed remote attached to her bed. Resident #4 was non-interviewable related to severe cognitive impairment as evidenced by confused conversation. <BR/>During a confidential interview on 02/06/2023 at 10:50 AM, a staff member stated exposed wires on residents' bed had been reported to the Maintenance Supervisor verbally on multiple occasions. The staff member stated the exposed wires had caused the bed to short out and not work correctly at times. The staff member stated the problem had not been resolved or fixed. The staff member stated it was important for beds to work properly to prevent an accident or injury to residents. <BR/>During an observation on 02/06/2023 at 3:40 PM, Resident #4 had exposed wires on her bed remote attached to her bed. <BR/>During an observation on 02/07/2023 at 8:27 AM, Resident #4 had exposed wires on her bed remote attached to her bed. <BR/>2. Record review of Resident #59's face sheet (undated) revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), combined systolic and diastolic congestive heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and anxiety disorder (severe, ongoing anxiety that interferes with daily activities). <BR/>Record review of the MDS assessment, dated 11/19/2022, revealed Resident #59 had clear speech and was usually understood by staff. The MDS revealed Resident #59 was usually able to understand others. The MDS revealed Resident #59 had a BIMS score of 8 which indicated moderately impaired cognition. The MDS revealed Resident #59 required extensive assistance with bed mobility and transfers. <BR/>Record review of the comprehensive care plan, last revised on 05/02/2022, revealed Resident #59 had an ADL self-care deficit and required extensive assistance with most ADLs. <BR/>During an observation and resident interview on 02/06/2023 at 10:50 AM, Resident #59 had exposed wires on her bed remote attached to her bed. Resident #59 was non-interviewable related to cognitive status as evidenced by confused conversation. <BR/>During an observation on 02/06/2023 at 2:53 PM, Resident #59 had exposed wires on her bed remote attached to her bed. <BR/>During an observation on 02/07/2023 at 8:23 AM, Resident #59 had exposed wires on her bed remote attached to her bed. <BR/>During an interview on 02/08/2023 at 4:35 PM, CNA Q stated she had noticed exposed wires on Resident #4 and Resident #59's bed remotes attached to their bed. CNA Q stated she reported verbally and showed the exposed wires to the Maintenance Supervisor approximately the week prior. CNA Q stated exposed wires to the bed remotes would cause the bed to not work at times. CNA Q stated the harm to Resident #4 and Resident #59 for exposed wires was risk for electrocution. <BR/>During an interview on 02/08/2023 at 4:46 PM, NA R stated he had noticed exposed wires on some of the residents' beds. NA R stated he had reported the exposed bed wires to the Maintenance Supervisor verbally. NA R stated the Maintenance Supervisor usually resolved the issues reported. NA R stated the failure to Resident #4 and Resident #59 for exposed wires on the bed remote attached to their bed was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 5:13 PM, LVN (ADON) H stated issues identified with beds or exposed wires would be reported to the Maintenance Supervisor via communication book, verbally, or via text message. LVN (ADON) H stated she was unaware of the exposed wires to Resident #4 and Resident #59's bed because it was not reported to her. LVN (ADON) H stated the harm to Resident #4 and Resident #59 for having exposed wires on their bed was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 5:27 PM, RN B stated issues with the residents' beds have been identified and reported to the Maintenance Supervisor. RN B stated the issues identified with the beds included beds not working correctly. RN B stated she was unaware Resident #4 or Resident #59 had exposed bed wires to their beds. RN B stated the harm to Resident #4 and Resident #59 for having exposed wires to the bed remote attached to the bed was an increased risk for electrocution and could have been a fire hazard. <BR/>During an interview on 02/08/2023 at 6:43 PM, the Maintenance Supervisor stated issues identified with beds were reported via the maintenance communication book or verbally by staff or residents. The Maintenance Supervisor stated he addressed issues reported him as quick as he was able. The Maintenance Supervisor stated the exposed wires on Resident #4 and Resident #59's beds were not reported to him. The Maintenance Supervisor stated the harm to Resident #4 and Resident #59 for having exposed wires to bed remotes attached to their beds was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated the Maintenance Supervisor was responsible for fixing and monitoring exposed wires to beds and bed remotes. The ADM stated he expected all staff to report issues identified with exposed wires or beds in the maintenance communication book. The ADM stated reporting issues verbally could have caused issues to have been missed or forgotten. The ADM stated the importance of reporting exposed wires to bed remotes attached to residents' beds was to protect resident safety. The ADM stated exposed bed wires could have caused an increased risk for harm by electrocution or fire. <BR/>Record review of the Maintenance Inspection policy, implemented on 4/11/2022, revealed It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The policy further revealed 3. All opportunities will be corrected immediately by the maintenance personnel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to ensure residents were free from abuse for 7 of 13 residents (Residents #3, #4, #5, #6, #7, #8 and #9) reviewed for resident abuse. <BR/>1. The facility did not ensure Resident #3 was free from abuse when Resident #9 shoved Resident #3 on 8/19/24. <BR/>2. The facility did not ensure Resident #6 was free from abuse when Resident #5 hit Resident #6 with her silverware packet on 8/28/24. <BR/>3. The facility did not ensure Resident #3 was free from abuse when Resident #4 hit Resident #3 on the back of the head 10/17/24. <BR/>4. The facility did not ensure Resident #7 was from abuse when Resident #8 hit Resident #7 on the head 12/20/24. <BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings included: <BR/>1. Resident #3<BR/>Record review of Resident #3's face sheet, dated 02/27/25, reflected Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included supraventricular tachycardia (abnormal fast heartbeat) and mild intellectual disabilities (developmental disability that affects a person's ability to think abstractly and learn new information). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 02/04/25, reflected Resident #3 usually made himself understood and understood others. Resident #3's BIMS score was 9, which indicated his cognition was moderately impaired. The MDS reflected Resident #3 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #3's comprehensive care plan revised 06/20/24 reflected Resident #3 had a behavior problem as evidenced by: verbal/physical behaviors, and rejection of care. The care plan interventions included: administer medications as ordered, monitor behavior episodes, and attempt to determine underlying cause and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Resident #9 <BR/>Record review of Resident #9's face sheet, dated 02/27/25, reflected Resident #9 an [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life).<BR/>Record review of the quarterly MDS assessment, dated 02/13/25, reflected Resident #9 made himself understood and understood others. Resident #9 BIMS score was 8, which indicated his cognition was moderately impaired. The MDS reflected Resident #9 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #9's comprehensive care plan revised 09/23/24 reflected Resident #9 had a behavior problem as evidence by noncompliance to policies despite numerous educational conversations, resident continues to go to Walmart and buy batteries, tools and OTC inhalers and constantly states people are getting handsy with women when they are just talking. The care plan interventions included: monitor behavior episodes and attempt to determine underlying cause and minimize potential for disruptive behaviors by offering tasks or activities which divert attention. <BR/>Record review of the facility's undated PIR with an incident category of abuse was signed by the Administrator on 08/23/24. The PIR reflected RN F witnessed Resident #9 shoved Resident #3 in the dining room. The PIR included a skin assessment completed 08/19/24, incident report for both residents completed 08/19/24, psychiatric assessment for Resident #9 completed on 08/19/24, psychiatric assessment for Resident #3 completed on 08/21/24, social services note for Resident #9 completed 8/19/24, safe surveys with no areas of concerns dated for 08/19/24 and a 1:1 schedule for Resident #9 completed 08/19/24. The PIR reflected staff was in-serviced promptly on abuse and neglect dated 08/19/24. <BR/>Record review of the physical aggression report dated 08/19/24 written by RN F indicated Resident #9 became verbally aggressive with Resident #3 in the dining room prior to breakfast. Resident #9 was cussing and insulating Resident #3. RN F instructed Resident #9, that if his behavior continued, he would have to leave the dining room. Resident #9 continued to cuss and insult Resident #3. RN F told the resident that he would have to leave the dining room and return to his room for breakfast due to his behavior. As Resident #9 was leaving the dining room he shoved Resident #3 the back and again insulted him. RN F immediately assisted Resident #9 back to his room and he was placed on 1:1 observation. <BR/>Record review of a statement dated 08/19/24 written by RN F stated she was in the dining room helping prepare breakfast. RN F stated Resident #3 was sitting at his usual table in his wheelchair. Resident #9 usually sat at another table, but that morning Resident #9 pulled his wheelchair up to the table and began trying to move an empty chair away from the table. Resident #3 became upset and told Resident #9 the chair he was trying to move belonged to another resident and she was coming back to sit in it in a few minutes after smoke break. Resident #9 became agitated and started cussing at Resident #3. Resident #9 called Resident #3 several names and told Resident #3 to shut the hell up. RN F stated she intervened and told Resident #9 that if he continued with this behavior, he would be asked to leave the dining room. Resident #9's foul language continued, and RN F asked him to return to his room for breakfast. On his way out of the dining room, as Resident #9 passed Resident #3 he shoved Resident #3 in the back. Another resident seated at another table told Resident #9 you can not put your hands on people like that, Resident #9 told her to shut her damn mouth as he exited the dining room. His agitation and foul language continued as he went down the hall to his room. RN F stated at no time did Resident #3 ever make any physical contact with Resident #9 or even attempt to. <BR/>An attempted telephone interview on 02/27/25 at 11:10 a.m. with RN F, the RN that witnessed the incident, was unsuccessful. <BR/>During an interview on 02/27/25 at 9:13 a.m., Resident #3 stated Resident #9 hit him on the back his neck when asked about the incident between him and Resident #9. Resident #3 stated He's mean. <BR/>During an interview on 02/27/25 at 9:22 a.m., Resident #9 stated he was trying to hit me when asked about the incident between him and Resident #3. Resident #9 stated Resident #3 was overbearing and if I didn't get up out the chair, he would've kick my ass. <BR/>2. Resident #5<BR/>Record review of Resident #5's face sheet, dated 02/27/25, reflected Resident #5 was a [AGE] year-old female, originally admitted to the facility 12/14/23 with a diagnosis which included heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). <BR/>Record review of Resident #5's annual MDS assessment, dated 01/10/25, reflected Resident #5 made herself understood and understood others. Resident #5's BIMS score was 5, which indicated her cognition was severely impaired. The MDS reflected Resident #5 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #5's comprehensive care plan revised on 09/06/24 reflected Resident #5 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to paranoid personality disorder, and depression adult failure to thrive. The care plan interventions included: monitor/document/report to physician any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes and reduce any distractions.<BR/>Resident #6<BR/>Record review of Resident #6's face sheet, dated 02/27/25, reflected Resident #6 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #6's quarterly MDS assessment, dated 02/01/25, reflected Resident #6 made herself understood and understood others. Resident #6's BIMS score was 15, which indicated her cognition was intact. The MDS reflected Resident #6 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #6's comprehensive care plan revised on 08/21/23 reflected Resident #6 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to dementia. The care plan interventions included: identify yourself at each interaction, reduce any distractions and provide instructions to resident using clear voice and simple sentences. <BR/>Record review of the undated PIR with an incident category of abuse was signed by the Administrator on 08/28/24. The PIR reflected LVN B witnessed Resident #5 hit Resident #6 with her silverware at the breakfast table. The PIR included a skin assessment completed 08/28/24, incident report for both residents completed 08/28/24, psychiatric assessment for both residents completed 08/28/24, safe surveys with no areas of concerns dated for 08/28/24, and a 1:1 schedule for Resident #5 completed 08/28/24-08/31/24. The PIR reflected staff was in-serviced promptly on abuse and neglect dated 08/28/24. <BR/>Record review of undated witnessed statement written by Resident #10 stated on 08/28/24 she was in the dining room around 7:30 a.m. Resident #6 came in and sat at the table she always sat at. Resident #10 stated at 7:00 a.m. her and Resident #6 went out to smoke and when they came back in Resident #5 was sitting where Resident #6 was sitting and would not move when asked to. Resident #10 stated Resident #5 suddenly grabbed her silverware and hit Resident #6 on the arm. Resident #5 was then asked to leave the table by an aide, and she refused. <BR/>During a telephone interview on 02/26/25 at 2:25 p.m., LVN B stated on the morning of 8/28/24 at approximately 7:30 a.m., she was in the dining room with another resident when she heard a noise and then heard Resident #6 state, she hit me referring to Resident #5. Resident #5 was sitting in the chair where Resident #6 normally sits. Resident #6 stated she asked Resident #5 to move, and Resident #5 picked up her silverware packet and hit her on her left arm. Resident #5 was questioned as to why she hit Resident #6 and she stated, she tried to take my silverware. LVN B stated she notified the DON, and the resident was assigned someone to stay with her while investigation was ongoing.<BR/>During an interview on 02/27/25 at 9:19 a.m., Resident #10 stated I didn't see it, I heard about it when asked about the incident between Resident #5 and Resident #6. Resident #10 appeared to be agitated when state surveyor introduced herself. <BR/>During an interview on 02/27/25 at 9:27 a.m., Resident #6 stated I can't remember why she hit me on my arm with her silverware when asked about the incident between Resident #5 and Resident #6. <BR/>During an interview on 02/27/25 at 9:30 a.m., Resident #5 stated It didn't happen with me I don't think, somebody would've told me I hit her when asked about the incident between Resident #5 and Resident #6. <BR/>3. Resident #3<BR/>Record review of Resident #3's face sheet, dated 02/27/25, reflected Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included supraventricular tachycardia (abnormal fast heartbeat). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 02/04/25, reflected Resident #3 usually made himself understood and understood others. Resident #3's BIMS score was 9, which indicated his cognition was moderately impaired. The MDS reflected Resident #3 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #3's comprehensive care plan revised 06/20/24 reflected Resident #3 had a behavior problem as evidenced by: verbal/physical behaviors, and rejection of care. The care plan interventions included: administer medications as ordered, monitor behavior episodes, and attempt to determine underlying cause and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Record review of Resident #4's face sheet, dated 02/27/25, reflected Resident #4 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). <BR/>Record review of Resident #4's annual MDS assessment, dated 01/02/25, reflected Resident #4 made himself understood and usually understood others. Resident #4's BIMS score was 5, which indicated his cognition was severely impaired. The MDS reflected Resident #4 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #4's comprehensive care plan revised 04/05/24 reflected Resident #4 had a behavior problem as evidence by resident with physical aggression toward another resident when verbally antagonized. The care plan interventions included: administer medication as ordered and when resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmy in conversation, or attempting to other interventions. <BR/>Record review of the PIR dated 10/22/24 with an incident category of abuse was signed by the Administrator on 10/22/24. The PIR reflected both residents were sitting in the sitting area and Resident #4 asked Resident #3 if he would move his chair into his spot. Resident #4 then pushed Resident #3's wheelchair forward from behind. Resident #3 became upset because Resident #4 moved his chair. Resident #3 then went back into Resident #4 with his wheelchair because he moved him. Resident #4 hit Resident #3 on the back of the head due to him hitting his wheelchair. The PIR included a skin assessment for Resident #3 and Resident #4 completed 10/17/24, social services progress notes for both residents completed 10/18/24, incident report for both residents completed 10/17/24, psychiatric assessment for Resident #4 completed 10/18/24, psychiatric assessment for Resident #3 completed 10/7/24, safe surveys with no areas of concerns dated for 10/17/24, and a 1:1 schedule for Resident #4 completed 10/17/24 and 10/18/24. The PIR reflected staff was in-serviced promptly on abuse and neglect dated 10/17/24. <BR/>During an interview on 02/26/25 at 11:10 a.m., CNA G stated Resident #3 was sitting in the doorway of the TV room and Resident #4 rolled up in his wheelchair and pushed Resident #3 wheelchair and told him to move that was his spot. CNA G stated Resident #3 told him he was not moving that he was there first. CNA G stated Resident #4 stood up and punched Resident #3 in the back of the neck with his fist closed three times. CNA G stated her, and other staff members immediately separated the residents and took Resident #4 to his room. CNA G stated Resident #4 was placed on 1:1. <BR/>During an interview on 02/26/25 at 11:41 a.m., MA E stated Resident #3 was sitting in his wheelchair in the open frame of the tv room. MA E stated Resident #4 was trying to sit where Resident #3 was sitting and he told Resident #3 to move his wheelchair and Resident #3 stated no. MA E stated Resident #4 was trying to push Resident #3 wheelchair and that was when Resident #4 stood up behind Resident #3 and punched him in the back of head/neck three times fast before staff could intervene. MA E stated it happened so fast before staff could intervene. MA E stated Resident #4 had a history of arguing with residents and usually you could verbally intervene, and he would stop. MA E stated residents were separated immediately. <BR/>During a telephone interview on 02/27/25 at 11:11 a.m., LVN A stated she was sitting at the nursing station when the incident occurred. LVN A stated Resident #3 was sitting in his wheelchair right outside the tv room and Resident #4 was coming up behind him telling him to move because he wanted to sit there. LVN A stated Resident #3 did not want to move because he was already sitting there. LVN A stated they went back and forth for a few seconds before Resident #4 hit Resident #3 in the back of the head three times. LVN A stated residents were immediately separated, and Resident #4 placed on 1:1. <BR/>During an interview on 02/27/25 at 9:03 a.m., Resident #4 stated he just moved his wheelchair off his foot. Resident #4 stated He's retarded I just got him off my foot, I didn't put my hands on him when asked about the incident between him and Resident #3.<BR/>During an interview on 02/27/25 at 9:13 a.m., Resident #3 stated two weeks ago Resident #4 hit him on his neck because he would not talk to him. <BR/>4. Resident #7 <BR/>Record review of Resident #7's face sheet, dated 02/27/25, reflected Resident #7 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included senile degeneration of brain (progressive decline in cognitive functions, such as memory, reasoning, and judgement). <BR/>Record review of Resident #7's quarterly MDS assessment, dated 02/29/25, reflected Resident #7 usually made himself understood and usually understood others. Resident #7's BIMS score was 7, which indicated his cognition was severely impaired. The MDS reflected Resident #7 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #7's comprehensive care plan revised on 02/26/25 reflected Resident #7 had impaired cognition and is at risk for further decline in cognitive and functional abilities related to dementia. The care plan interventions included: monitor/document/report to physician any changes in cognitive function, identify yourself at each interaction, stop and return if the resident becomes agitated. <BR/>Resident #8 <BR/>Record review of Resident #8's face sheet, dated 02/27/25, reflected Resident #8 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life).<BR/>Record review of Resident #8's annual MDS assessment, dated 01/31/25, reflected Resident #8 made himself understood and understood others. Resident #8's BIMS score was 5, which indicated his cognition was severely impaired. The MDS reflected Resident #8 had no behaviors or refusal of care during the look-back period.<BR/>Record review of Resident #8's comprehensive care plan initiated on 10/18/24 reflected Resident #8 had a behavior problem as evidenced by aggressive behaviors. The care plan interventions included: assist resident to a calm quiet area if starts becoming agitated, consult psych services if needed concerning behaviors and monitor resident for increased agitation. Resident #8 exhibits verbally abusive behavior at times and is at risk for harm and not having their needs met in a timely manner. The care plan interventions included: administer medications as ordered by the physician and monitor for effectiveness/potential adverse side effects, monitor behavior episodes, and attempt to determine underlying cause. <BR/>Record review of the undated PIR with an incident category of abuse. The PIR reflected Resident #8 asked Resident #7 to stop going in his Christmas bag. Resident #7 went into Resident #8 bag again and Resident #8 asked him again to stop. Resident #8 asked staff for help but before the staff could move Resident #7 did it again and Resident #8 popped him on the head. The PIR included a skin assessment for Resident #7 completed 12/20/24, incident report for both residents completed 12/20/24, psychiatric assessment for Resident #8 completed 12/31/24, safe surveys with no areas of concerns dated for 12/20/24, and a 1:1 schedule for Resident #8 completed 12/20/24 and 12/21/24. The PIR reflected staff was in-serviced promptly on abuse and neglect dated 12/20/24. <BR/>During an interview on 022/26/25 at 11:36 a.m., Rehab Tech H stated as she was passing by the media room, she observed Resident #7 reaching into a Christmas gift bag that was sitting next to Resident #8's chair. Rehab Tech H stated upon Resident #8 realizing that Resident #7 was reaching into his bag, Resident #8 slapped Resident #7 on top of his head stating, get out of my shit. Rehab Tech H stated her, and other staff members immediately separated the residents, interviewed the residents to see what had happened and reported the incident to the Administrator. <BR/>During an interview on 02/26/25 at 11:59 a.m., OTA K stated she was walking with Rehab Tech H from a patient's room headed back to the rehab gym and as she was passing by the media room, she observed Resident #7 reaching into a Christmas gift bag that was sitting next to Resident #8's chair. OTA K stated upon Resident #8 realizing that Resident #7 was reaching into his bag, he slapped Resident #7 on top of his head stating, get out of my shit. OTA K Stated her, and other staff members immediately separated the residents, and asked Resident #8 why he slapped Resident #7 and told him it was not ok to do that. OTA K stated Resident #8 was taking to his room by another staff member. OTA K stated she immediately went to report the incident to the Administrator. <BR/>During an interview on 02/26/25 at 1:23 p.m., the Social Worker stated she had just walked up to the nursing station when she witnessed Resident #7 reaching into Resident #8 Christmas gift bag. The Social Worker stated it appeared Resident #8 had swung his arm at Resident #7, but she did not know if contact was made. The Social Worker stated there was two therapist staff present and they immediately separated the residents. <BR/>During an interview on 02/27/25 at 9:07 a.m., Resident #7 stated I don't recall that at all when asked about the incident between him and Resident #8. <BR/>During an interview on 02/27/25 at 9:24 a.m., Resident #8 stated I hit his stupid ass because he kept going in my bag when I told him not too. <BR/>During an interview on 02/27/25 at 11:25 a.m., the DON stated she was aware of the abuse allegations. The DON stated the victims did not have any changes in behavior or any type of emotional distress since the incident. The DON stated Resident #3 and Resident #8 both have behavioral disorders that was been monitored by psych services and PCP. The DON stated the social worker has tried to find Resident #8 alternate placement but at this time there was no other facility willing to accommodate him with his behaviors. The DON stated the facility tried to find alternate placement for Resident #3, but the family was against it due to location. The DON stated staff were provided education on abuse and neglect related to all allegations of abuse of neglect. The DON stated the last in-service on abuse and neglect was 2/24/25. <BR/>During an interview on 02/27/25 at 3:10 p.m., the Administrator stated she was the abuse coordinator for the facility. The Administrator stated she was responsible for overseeing by frequent rounding of the halls and dining room and trying to deescalate any agitation by residents as it arises. The Administrator stated when a resident-resident altercation occurred the residents were immediately separated, and aggressor kept on 1:1 monitoring until a psychiatric evaluation was completed or PCP did an evaluation. The Administrator stated Resident #3 had a dx of mild ID and intermittent explosive disorder that could causes him to be disruptive or have impulse control issues. The Administrator stated once the facility learned of any allegation, they acted appropriately to protect all the residents.<BR/>Record review of the facility's policy titled Policy and Procedures: Abuse, Neglect and Exploitation revised 09/06/24 indicated . 1. The facility provides resident protection that included: (a) prevention/prohibit resident abuse, neglect . 2. The facility's abuse prevention coordinator is responsible for reporting allegations or suspected abuse, neglect . to the state survey agency and other official in accordance with state law .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible to prevent accidents for 2 of 20 (Resident #4 and Resident #59) residents reviewed for accidents and hazards. <BR/>The facility failed to ensure the Maintenance Supervisor fixed the exposed wires on Resident #4 and Resident #59's bed remotes. <BR/>These failures could place residents at an increased risk for injury, electrocution, or fire. <BR/>The findings included:<BR/>1. Record review of Resident #4's face sheet (undated) revealed she was [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset (type of brain disorder that causes problems with memory, thinking and behavior and is a gradually progressive condition), type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar with damaged nerves to hands and feet), and bradycardia (slow heartbeat). <BR/>Record review of the MDS assessment, dated 05/17/2023, revealed Resident #4 had clear speech and was understood by staff. The MDS revealed Resident #4 was able to understand others. The MDS revealed Resident #4 had a BIMS score of 04 which indicated severe cognitive impairment. The MDS revealed Resident #4 required limited assistance with bed mobility and transfers. <BR/>Record review of the comprehensive care plan, last revised on 4/26/2021, revealed Resident #4 had an ADL self-care performance deficit and required limited - extensive assistance with ADLs. <BR/>During an observation and resident interview on 02/06/2023 at 10:19 AM, Resident #4 had exposed wires on her bed remote attached to her bed. Resident #4 was non-interviewable related to severe cognitive impairment as evidenced by confused conversation. <BR/>During a confidential interview on 02/06/2023 at 10:50 AM, a staff member stated exposed wires on residents' bed had been reported to the Maintenance Supervisor verbally on multiple occasions. The staff member stated the exposed wires had caused the bed to short out and not work correctly at times. The staff member stated the problem had not been resolved or fixed. The staff member stated it was important for beds to work properly to prevent an accident or injury to residents. <BR/>During an observation on 02/06/2023 at 3:40 PM, Resident #4 had exposed wires on her bed remote attached to her bed. <BR/>During an observation on 02/07/2023 at 8:27 AM, Resident #4 had exposed wires on her bed remote attached to her bed. <BR/>2. Record review of Resident #59's face sheet (undated) revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), combined systolic and diastolic congestive heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and anxiety disorder (severe, ongoing anxiety that interferes with daily activities). <BR/>Record review of the MDS assessment, dated 11/19/2022, revealed Resident #59 had clear speech and was usually understood by staff. The MDS revealed Resident #59 was usually able to understand others. The MDS revealed Resident #59 had a BIMS score of 8 which indicated moderately impaired cognition. The MDS revealed Resident #59 required extensive assistance with bed mobility and transfers. <BR/>Record review of the comprehensive care plan, last revised on 05/02/2022, revealed Resident #59 had an ADL self-care deficit and required extensive assistance with most ADLs. <BR/>During an observation and resident interview on 02/06/2023 at 10:50 AM, Resident #59 had exposed wires on her bed remote attached to her bed. Resident #59 was non-interviewable related to cognitive status as evidenced by confused conversation. <BR/>During an observation on 02/06/2023 at 2:53 PM, Resident #59 had exposed wires on her bed remote attached to her bed. <BR/>During an observation on 02/07/2023 at 8:23 AM, Resident #59 had exposed wires on her bed remote attached to her bed. <BR/>During an interview on 02/08/2023 at 4:35 PM, CNA Q stated she had noticed exposed wires on Resident #4 and Resident #59's bed remotes attached to their bed. CNA Q stated she reported verbally and showed the exposed wires to the Maintenance Supervisor approximately the week prior. CNA Q stated exposed wires to the bed remotes would cause the bed to not work at times. CNA Q stated the harm to Resident #4 and Resident #59 for exposed wires was risk for electrocution. <BR/>During an interview on 02/08/2023 at 4:46 PM, NA R stated he had noticed exposed wires on some of the residents' beds. NA R stated he had reported the exposed bed wires to the Maintenance Supervisor verbally. NA R stated the Maintenance Supervisor usually resolved the issues reported. NA R stated the failure to Resident #4 and Resident #59 for exposed wires on the bed remote attached to their bed was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 5:13 PM, LVN (ADON) H stated issues identified with beds or exposed wires would be reported to the Maintenance Supervisor via communication book, verbally, or via text message. LVN (ADON) H stated she was unaware of the exposed wires to Resident #4 and Resident #59's bed because it was not reported to her. LVN (ADON) H stated the harm to Resident #4 and Resident #59 for having exposed wires on their bed was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 5:27 PM, RN B stated issues with the residents' beds have been identified and reported to the Maintenance Supervisor. RN B stated the issues identified with the beds included beds not working correctly. RN B stated she was unaware Resident #4 or Resident #59 had exposed bed wires to their beds. RN B stated the harm to Resident #4 and Resident #59 for having exposed wires to the bed remote attached to the bed was an increased risk for electrocution and could have been a fire hazard. <BR/>During an interview on 02/08/2023 at 6:43 PM, the Maintenance Supervisor stated issues identified with beds were reported via the maintenance communication book or verbally by staff or residents. The Maintenance Supervisor stated he addressed issues reported him as quick as he was able. The Maintenance Supervisor stated the exposed wires on Resident #4 and Resident #59's beds were not reported to him. The Maintenance Supervisor stated the harm to Resident #4 and Resident #59 for having exposed wires to bed remotes attached to their beds was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated the Maintenance Supervisor was responsible for fixing and monitoring exposed wires to beds and bed remotes. The ADM stated he expected all staff to report issues identified with exposed wires or beds in the maintenance communication book. The ADM stated reporting issues verbally could have caused issues to have been missed or forgotten. The ADM stated the importance of reporting exposed wires to bed remotes attached to residents' beds was to protect resident safety. The ADM stated exposed bed wires could have caused an increased risk for harm by electrocution or fire. <BR/>Record review of the Maintenance Inspection policy, implemented on 4/11/2022, revealed It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The policy further revealed 3. All opportunities will be corrected immediately by the maintenance personnel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 1 facility and 3 of 17 Residents (Resident #1, Resident #2, Resident #3) reviewed for environment. <BR/>1. The facility failed to ensure there were no dead trees and bushes in the front parking lot/area.<BR/>2.The facility failed to ensure Resident #1, Resident #2, and Resident #3 had a safe place in the front area of the facility to smoke. There was no designated smoking area in the front of the facility where residents go smoke, and the entrance of the facility's parking lot was near a two-lane street with a posted speed limit of 30 mph.<BR/>3. The facility failed to prevent the littering of a substantial amount discarded cigarettes on the front parking lot.<BR/>4. The facility failed to ensure metal ashtrays, a trash can, and fire extinguisher or fire blanket, in the smoking area in front of the facility. <BR/>These failures placed resident at risk for injury, harm, or exposure to smoke or fire. <BR/>Finding include: <BR/>1. Record review of a face sheet dated 07/08/23 indicated Resident #1 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Parkinson's disease ( a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), heart failure (the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), cerebral infarction (stroke), contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) to right hand, contracture of muscle, right upper arm, neuropathy (develops when nerves in the body's extremities - such as the hands, feet and arms - are damaged) and hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction affecting right dominant side.<BR/>Record review of an annual MDS assessment dated [DATE] indicated Resident #1 was understood and understood others. Resident #1 had minimal difficulty hearing (difficulty in some environment) with no hearing aid, clear speech, and impaired vision (sees large print, but not regular print in newspapers/books) with corrective lenses. Resident #1 had a BIMS score of 13 which indicated intact cognition and required limited assistance for bed mobility, dressing, toilet use, personal hygiene, and bathing but supervision for transfer. Resident #1 had functional limitation in range of motion (interfered with daily functions or placed resident at risk of injury) with impairment on one side, upper and lower extremities. Resident #1 used a walker and manual wheelchair for a mobility device. Resident #1 used tobacco. Resident #1 was administered an opioid (powerful pain-reducing medications). <BR/>Record review of a care plan dated 10/22/2022 indicated Resident #1 was a smoker and was at risk for injury. Resident #1 was a safe smoker and did not require an apron. Intervention included educate resident on smoking policy, explain, and show resident and family where designated smoking areas are and repeat as necessary, and assist resident to and from smoking area as needed.<BR/>Record review of a care plan dated 10/20/22 indicated Resident #1 had impaired visual function and was at risk for falls, injury, and a decline in functional ability. Intervention included involve in activities which do not require vision to participate.<BR/>Record review of a care plan dated 05/25/22 indicated Resident #1 had the potential for falls related to stroke/hemiplegia, meds, weakness, unsteady/poor balance, neuropathy, right ankle pain, contractures, and osteoporosis (is a disease that thins and weakens the bones). Intervention included wheelchair operation. <BR/>Record review of a care plan dated 05/05/23 indicated Resident #1 had communication problems related to stroke, decreased hearing, and does not wear hearing aid. Intervention included anticipate and meet needs.<BR/>Record review of a smoking assessment dated [DATE], completed by RN A, indicated Resident #1 had visual deficit and needed supervision for adaptive equipment. <BR/>Record review of a smoking assessment dated [DATE], completed by RN B, indicated Resident #1 had dexterity (skill and grace in physical movement, especially in the use of the hands) problem and needed supervision for adaptive equipment.<BR/>Record review of a smoking assessment dated [DATE], completed by SW C, indicated Resident #1 had dexterity (skill and grace in physical movement, especially in the use of the hands) problem and needed supervision for adaptive equipment.<BR/>Record review of a fall risk assessment dated [DATE], completed by LVN C, indicated Resident #1 was a moderate risk for falls.<BR/>During an interview and observation on 07/08/23 at 2:45 p.m., Resident #1 was sitting in the front lobby in her wheelchair. Resident #1's right arm was contracted. Resident #1 said she liked to smoke at the end of the parking lot near the entrance and sometimes she went to the store. She said she had to wheel herself in the street because there was no sidewalk.<BR/>2. Record review of a face sheet dated 07/08/23 indicated Resident #2 was a [AGE] year-old female and admitted on [DATE] with diagnoses including dementia (is the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), congestive heart failure (is a serious condition in which the heart doesn't pump blood as efficiently as it should), nicotine dependence (involves physical and psychological factors that make it difficult to stop using tobacco, even if the person wants to quit), cigarettes, long term current use of anticoagulants (are medications that help stop your blood from thickening or clotting.) and chronic obstructive pulmonary disease (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Record review of an admission MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. Resident #2 had minimal difficulty hearing and no hearing aid. Resident #2 had clear speech and moderately impaired vision (limited vision) used corrective lenses. Resident #2 had a BIMS score of 08 which indicated moderate cognition impairment and required limited assistance for toilet use, extensive assistance for bed mobility, transfer, dressing, personal hygiene, and bathing. Resident #2 was not steady, only able to stabilize with staff assistance for walking and turning around and facing the opposite direction while walking. Resident #2 used a walker and wheelchair for mobility devices. The MDS indicated Resident #2 was not a current tobacco use. Resident #2 had a fall in the last 2-6 months prior to admission. <BR/>Record review of a care plan dated 03/24/23 indicated Resident #2 had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to confusion, forgetfulness, and age-related decline. Resident #2 takes an anticoagulant and was at risk for bleeding. Resident #2 had impaired visual function and was at risk for falls, injury, and decline in functional ability. Resident #2 had a communication problem related to impaired hearing/vision/cognition. Intervention ensure/provide a safe environment. Resident #2 had the potential for falls related to status post-surgery, weakness, decreased mobility, pain, meds, impaired cognition/vision, and history of falls. Resident #2 was a smoker and was at risk for injury. Resident is a smoker and does not require an apron. Interventions included educate on smoking policy and explain and show resident and family where designated smoking areas are and repeat as necessary and assist resident to and from smoking area as needed.<BR/>Record review of a smoking assessment dated [DATE], completed by RN B, indicated Resident #2 needed supervision for adaptive equipment and to be supervised with each smoke break. <BR/>Record review of a smoking assessment dated [DATE], completed by LVN D, indicated Resident #2 needed supervision for adaptive equipment. <BR/>During an interview on 07/08/23 at 3:00 p.m., Resident #2 said a couple months ago the facility started letting her check in and out to smoke unsupervised. She said she had to sign out at the nurse's station to get her cigarette and lighter and sign out at the receptionist desk. Resident #2 said she had to smoke 50 feet away from the building but still on the facility's premise. She said when she came back from smoking, she had to turn the cigarettes and lighters back to the nurse. Resident #2 said she put her cigarettes out then rolled it up in napkin or Kleenex in her hand the threw it away in a trash can when she got in the facility. She said she did not throw her cigarettes butts in the ground.<BR/>3. Record review of a face sheet dated 07/08/23 indicated Resident #3 was a [AGE] year-old male and admitted [DATE] with diagnoses including cerebral infarction (stroke), vascular dementia (refers to changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction affecting left non-dominant side, lack of coordinator, seizures (is a medical condition where you have a temporary, unstoppable surge of electrical activity in your brain), contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity), left foot, muscle weakness, Type 2 diabetes mellitus (is a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic neuropathy (is a type of nerve damage that can occur if you have diabetes) and long term current use of anticoagulants (are medications that help stop your blood from thickening or clotting.). <BR/>Record review of an admission MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. Resident #3 had adequate hearing and vision. Resident #3 had a BIMS of 14 which indicated intact cognition and required extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. Resident #3 had functional limitation in range of motion on one side, upper and lower extremities. Resident #3 had one fall with no injury since admission. Resident #3 used tobacco. Resident #3 was administered an opioid (powerful pain-reducing medications).<BR/>Record review of a care plan dated 04/25/23 indicated Resident #3 had potential for falls related to stroke history, hemiplegia/hemiparesis, pain meds, antihypertensive meds, contracture left foot, seizure disorder, restless legs syndrome, diabetes, poor balance, impaired mobility, incontinence, and insomnia. Intervention included educate the resident/family/caregivers about safety reminders. <BR/>Record review of a care plan dated 04/25/23 indicated Resident #3 had a history of seizures and was taking anticonvulsant medication which places the resident at risk for falls and injury. Intervention remove objects that resident may strike during seizure activity. <BR/>Record review of a care plan dated 04/25/23 indicated Resident #3 had alteration in musculoskeletal status related to contracture left foot. Intervention included educate resident, family/caregivers on safety measures that need to be taken in order to reduce risk of falls. <BR/>Record review of care plan dated 07/07/23 indicated Resident #3 was a smoker and at risk for injury. Resident #3 does not require an apron. Intervention included educate resident on smoking policy, explain, and show resident and family where designated smoking areas are and repeat as necessary and assist resident to and from smoking area as needed. Resident was a safe smoker and did not require direct staff supervision during.<BR/>During an observation on 07/08/23 at 8:23 a.m., the facility's front entrance was perpendicular to a two lane, side street with a posted speed limit of 30 mph. On the left side of the street, when facing the main street, the facility was near, a building of medical offices and a convenience store. On the right side of the street, was a local hospital. The side street did not have a sidewalk of either side. The facility's entrance driveway was narrow and was cut off by a metal fence. Near the metal fence, parallel parking spots were noted and regular parking spaces on the other side. The front door entrance was on slight incline with a circular driveway. The maintenance supervisor was picking up trash and used cigarettes. 3 dead trees were noted in front of the nursing facility. Two of the dead trees were in an area where 2 benches and metal patio set were placed. One of the dead trees, near the benches, had a moderate amount of brittle bark at the base. Four dead bushes were scattered in front of the building. Discarded cigarettes were noted throughout the facility grounds near the metal fence, in the area with the two dead trees, and along the driveway headed to the side street. The only one trash can was seen directly at the entrance door which was not 50 feet away from the front entrance.<BR/>During an interview on 07/08/23 at 8:35 a.m., the ADM said Resident #3 was out on pass for the weekend.<BR/>During an interview on 07/08/23 at 9:19 a.m., Receptionist F said she worked the front desk on the weekends, either 8:00 am-5:00 pm or 8:00 am-8:00 pm. She said residents could to the front of the building to smoke. She said residents had to sign in and out in the binder when they went out front. She said Resident #1, Resident #2, and Resident #3 were the main residents who smoked out front. She said residents had to be 50 ft away from the front door to smoke in the front. She said sometimes the resident were not compliant. She said she would instruct the residents to go smoke in the area with the bench behind the therapy building. She said residents who smoked in the front, left cigarettes butts everywhere. She said there was a trash can by the door but not 50 ft away from the entrance door and no ashtrays.<BR/>During an interview on 07/08/23 at 11:00 a.m., the Payroll Coordinator said she had been employed at the facility for 7 years. She said on the weekends she occasionally worked as a CNA. She said since she started 7 years ago, smokers smoked in the back of the facility and at the schedule smoke break times. She said about 90-120 days ago when the new administrator started, smokers were allowed to request their smoking box which held cigarettes and lighter, sign out and in at nurse's station, then sign out and in at the receptionist desk and smoke wherever per the administrator. She said the residents did have to smoke at least 50 ft away from the entrance door. She said the residents were supposed to be cognitive enough to sign out and in and return smoking items to the nurse. She said the nurses were supposed to keep up with which resident was smoking out front and if they had turned in their smoking items or not. She said the problem with that situation was they had to take care of other residents and were not stationed at the nurse's station and different residents were asking for their smoking items at different times. She said she normally arrived to work around 3:00 a.m.- 6:00 a.m., and residents were outside smoking in the dark parking lot. She said the residents in the front smoked at the front door, in between cars near the metal fence, and at the entrance of the facility parking lot near the hospital. She said she did not think any of the residents who were allowed to smoke in the front were cognitive enough to be outside unsupervised. She said all of residents discarded their used cigarettes on the ground. She said staff from the nearby medical buildings had expressed concerns about the residents being in the front alone. She said Resident #3 had almost been hit by a car in the front parking lot because the visitor could not see him. She said the front area where the residents were allowed to smoke, did not have ashtrays or metal receptacles. She said she did not feel like the front parking lot was a safe area to smoke in because it was a high traffic area and tight parking spaces. She said the facility had several dead trees and bushes and there was one in the area behind therapy where benches were. She said the ADM and the corporation who owned the facility were aware of the dead trees and bushes.<BR/>During an interview on 07/08/23 at 11:22 a.m., SW C said she had been employed for the facility for 2 weeks. She said she knew residents could not smoke within 50 feet of the building, in the front. She said if residents were non-compliant with the smoking policy, counseling was provided. She said she had seen ashtrays and metal receptacles in the back smoking area but not the front. She said the facility had dead bushes. She said it depended on the resident cognition and physical ability if it was, they were safe to be unsupervised smoking. She said she did not know the residents well enough to determine would was safe and not safe in the front unsupervised.<BR/>During an interview on 07/08/23 at 11: 30 a.m., the Staffing Coordinator said she had been employed at the facility for 11 years. She said about 3 weeks ago she noticed residents smoking in the front parking lot of the facility. She said the residents who smoked in the front were usually by the metal fence or by the benches behind the therapy office. She said the front area where the residents smoked did not have metal ashtrays or receptacles. She heard about a resident almost getting hit by a car in the front parking lot, but she did not witness the incident. She said she came to work normally at 5 am and would occasionally see Resident #2 out front smoking. She said she did not think the front parking lot was a safe area for residents to smoke because visitors and staff members did not know how to drive, and it was a highly trafficked area.<BR/>During an interview on 07/08/23 at 11:50 a.m., MDS coordinator J said she had been employed at the facility for 6 years. She said the area in front where the residents smoked did not have metal ashtrays or trash cans. She said that the facility had a lot of cigarette butts on the ground since the facility allowed the residents to start smoking in the front. She said she got to the facility around 7 am and residents were already outside smoking. She said the residents were normally at the metal fence in the parking lot and sometimes at the front door smoking. She said she did not think the parking lot was a safe place for the residents to smoke because some of residents were in wheelchairs and may not be seen by drivers. She said the facility had elderly visitors who may not see very well and could hit the residents. She said the facility did have a lot of dead trees and a dead limb had fallen on a staff's vehicle a year ago.<BR/>During an interview on 07/08/23 at 12:08 p.m., the BOM said she had been employed at the facility since November 2022. She said the facility did not provide a safe environment for residents to smoke when they went out front which is what the admission agreement stated. She said that the facility started letting residents smoke out front about 3 to 4 months ago. She said the main residents that smoked out front were Rident #1, Resident #2, and Resident #3. She said Resident #1 and Resident #3 were in wheelchairs and Resident #2 used a rollator. She said the residents had to smoke at least 50 feet from the front door. She said the residents normally smoked at the fence line but Resident #1 liked to smoke at the end of the driveway near the side street. She said the facility had a lot of cigarette butts on the ground since the residents were allowed to smoke in the front. She said there was no fire safety stuff in the front where the residents smoked. She said she did not know where the residents disposed of their cigarettes after they smoked because there was no trash can in the front. She said she did not think the front parking lot was a safe area for the residents to smoke due to the facility having elderly visitors who probably could not see well. She said she had not witnessed Resident #3 almost getting hit by a vehicle but heard a resident's wife almost hit him. She said the facility did have a lot of dead bushes and trees on the premises. She said the trees and bushes were not safe nor looked did they look appealing.<BR/>During an interview on 07/08/23 at 12:06 p.m., the Dietary Manager said she had been employed by the facility for 4 years. She said until about 30 days ago, residents could only smoke in the designated smoking area in the back of the facility. She said she did not know which residents were allowed to smoke out front. She said she routinely saw Resident #1, Resident #2, and Resident #3 out front smoking. She said Resident #2 and Resident #3 were normally by the metal fence in the parking lot, but she had seen Resident #1 at the end of the driveway near the side street. She said there was no fire safety stuff in front in case a fire started, or a resident got burned. She said the front parking lot was not safe because the driveway slopped and people drove too fast, and the residents were not supervised. She said she had not confiscated any resident's smoking items but heard Resident #1 had smoking items after smoke breaks. She said she had noticed the maintenance supervisor picking up discarded cigarettes butts.<BR/>During an interview on 07/08/23 at 12:34 p.m., MDS Coordinator K said she had been employed at the facility for 2 years but worked 2010-2019 as the ADON and treatment nurse. She said her understanding of the smoking policy was only a resident who was able to sign themselves out were allowed to smoke in the front. She said the residents who smoked in the front were normally in gravel area of the parking lot but Resident #1 was by side street and sometimes not smoking. She said the front parking lot was not safe because of the high traffic and hilly, bumpy driveway. She said the front parking lot did not have fire safety equipment. She said she did not know where the residents were discarding their used cigarettes. She said she heard yesterday Resident #3 almost got hit by a visitor in the front parking lot. She said the facility had a lot of dead trees and bushes which were not safe for the staff or residents. <BR/>During an interview on 07/08/23 at 12:43 p.m., the Business Development Specialist said she had worked for the company for 15 years. She said smoking in the front of the facility was not safe, but the residents had been instructed to put on a hat and sunblock plus bring a water bottle outside. She said the residents who smoked out front had been asked to not smoke when it was dark outside. She said there was no fire safety materials where the residents smoked out front. She said she saw cigarettes butts around the facility grounds. She said the front parking lot was not safe due to the high traffic flow. She said Resident #1 sat by the side street. She said people drove higher than the speed limit on the side street. She said the facility had elderly visitors who did not see well but were still driving. She said she saw family members and residents in the area with the benches so smoking could be happening there. She said the facility had a lot of dead trees and bushes, and the area around the benches had some. She said the trees and bushes had been dead for at least a year and it was not safe.<BR/>During an interview on 07/08/23 at 1:04 p.m., LVN M said she had been employed again at the facility since January 2023. She said her understanding of the smoking process was only residents who were physically able to get 50 ft from the building could smoke in the front. She said she preferred not to give residents smoking items outside of designated smoke break times. She said she could not determine if the weather conditions were safe for the residents to go outside. She said as the resident's nurse, she was supposed to ensure their safety and she could not do that with the new smoking policy. She said the front parking did not have a lot of shade for hot days and the residents were not supervised. She did not understand how a resident could sign out and smoke anywhere, unsupervised. She said the front parking lot was unsafe with staff supervision. She said Resident #1, Resident #2, and Resident #3 had either cognitive, vision, hearing, or physical limitation which made them need supervision when outside. She said Resident #3 had left sided weakness and would return from smoke break exhausted from wheeling himself up the inclined driveway to the front door.<BR/>During an interview on 07/08/23 at 1:26 p.m., the maintenance manager said he had been employed at the facility for one year. He said he was responsible for life safety, building maintenance, routine maintenance, and vendors. He said the residents who smoked in the front normally were near the metal fence and under a [NAME] tree. He said the facility did have a lot of cigarettes butts on the ground. He said he had to pick up cigarettes butts 3-4 times a week. He said the front parking lot did not have fire safety equipment where residents smoked. He said fire safety equipment was needed to handle fire hazards. He said he found a few cigarettes butts in the area behind the therapy area with the benches. He said the front area of the facility was not safe for smoking or unsupervised residents. He said the residents should be in a controlled environment not a parking lot with traffic and blind spots. He said he heard about the incident with Resident #3 almost being hit by a visitor but did not witness it. He said the facility had dead trees and bushes since he started. He said a tree company was coming on Monday (07/10/23) to remove one dead tree near the benches behind the therapy office. He said the broken, dead tree limb had been leaning against the gutter for a couple of weeks. He said the trees were not safe because they could break and fall on residents. He said he could not take care of the dead trees and broken limb because he did not have the right equipment. He said two of the dead trees were 15-20 ft from the benches.<BR/>During an interview on 07/08/23 at 1:51 p.m., the ADM said residents who smoked in the front of the building had to be at least 50 feet away from the entrance the building. She said any area 50 feet away from the building was allowed, but the facility did not consider it designated even though the facility had instructed the residents of the guidance. She said the facility did not provide the residents who smoked, in what they considered an undesignated area, metal ashtray and trash cans or fire extinguisher. She said the designated smoking area in the back of the facility had the appropriate fire safety equipment. She said when the residents signed out, they released the facility of the responsibility to provide them fire safety equipment. She said the residents who chose to smoke in the front, were educated on safety measures to take when smoking in the undesignated area. She said the facility provided fire safety equipment in the designated smoke area to prevent the start of fires and to handle a fire if it happened. She said the facility had dead trees and bushes. She said her company required the facility to obtain 3 bids for the removal and they finally had someone coming out to take care of one of the trees. She said she did not how long the trees and bushes had been dead but knew at least for three months when she started. She said the dead trees were not safe because they could fall and cause an accident. She said the Maintenance Supervisor was responsible for the upkeep of the facility including the grounds. The ADM said she the facility did not have a policy regarding maintenance or safe environment. <BR/>Record review of a undated facility's admission Agreement indicated .Smoking policy .the facility shall provide an environment where residents who smoke may do so safely .all residents who smoke will be supervised .Therefore smoking is prohibited in this facility except in designated smoking areas . ashtrays of noncombustible material and safe design shall be provided in the designated smoking area .metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available in the designated smoking area .<BR/>Record review of a facility's Smoking Policy origination dated 02/26/14, revision 04/12/23 indicated, to evaluate a patient's ability to participant and exercise the privilege to smoke .while residing within the facility .to establish guidelines for patients that desire to smoke .in the center .maintain safety equipment such as an A-type fire extinguisher or fire blanket, in an accessible location near the designated smoking area .ashtrays that meet life safety code regulations are available and are to be utilized in the designated smoking area . <BR/> <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 1 resident (Resident #188) reviewed for smoking.<BR/>The facility failed to ensure Resident #188's smoking evaluation tool was completed upon admission. <BR/>This failure could place residents at risk of an unsafe smoking environment. <BR/>Finding included:<BR/>Record review of a Face Sheet dated 02/08/23 revealed Resident #188 was a [AGE] year-old male admitted on [DATE] with diagnoses of neoplasm of uncertain behavior of bladder (bladder cancer), essential (primary) hypertension (high blood pressure), nicotine dependence, unspecified, uncomplicated (dependence on nicotine a substance found in tobacco products), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Review of the electronic health record on 02/07/23 revealed no care plan, and MDS assessment was not yet completed. <BR/>Review of the electronic health record on 02/07/23 did not reflect Resident #188 had a smoking evaluation tool completed. <BR/>During an interview on 02/06/23 starting at 10:31 AM, Resident #188 stated he smoked. <BR/>During an observation on 02/07/23 starting at 11:03 AM, the Health Information Coordinator was supervising smoking in the facility's smoking area. Resident #188 was observed smoking.<BR/>During an interview on 02/08/23 at 4:15 PM, the social worker said she was responsible for completing the smoking evaluation tool. The social worker said she was aware Resident #188 smoked. The social worker said she did not know why the smoking evaluation tool was not in the electronic health record. The social worker said she thought she had put in the smoking evaluation tool yesterday. The social worker said she tried to complete the smoking evaluation tool within two days of admission. The social worker said it was important to complete the smoking evaluation tool to make sure the residents were safe while smoking.<BR/>During an interview on 02/8/23 at 5:03 PM, ADON H said she was aware Resident #188 smoked. ADON H said a smoking evaluation tool should have been completed on admission and the social worker was responsible for completing the smoking evaluation tool. ADON H said it was important to complete the smoking evaluation tool to know if a resident was safe while smoking. <BR/>During an interview on 02/08/23 at 5:50 PM, Nurse D said a smoking evaluation tool should be completed on admission, and sometimes she completed the smoking evaluation tool. Nurse D said she was aware Resident #188 smoked. Nurse D said she did not do Resident #188's smoking evaluation tool because she ran out of time the day she admitted him. Nurse D said Resident #188 not having a smoking evaluation tool could result in him catching himself on fire.<BR/>During an interview on 02/08/23 at 6:53 PM, the DON said he was aware Resident #188 smoked. The DON said Resident #188 should have had a smoking evaluation tool completed on admission. The DON said if the social worker was not in the building on admission the admitting nurse was responsible for completing the smoking evaluation tool. The DON said he overlooked the completion of the smoking evaluation tool at the interdisciplinary meetings on Monday mornings. The DON said he was not able to do this on Monday because state came in the building. The DON said smoking evaluation tool were completed for the residents' safety, and not completing the smoking evaluation tool placed the residents at risk for possible burn and injury. <BR/>During an interview on 02/08/23 at 8:12 PM, the administrator said the social worker was responsible for completing the smoking evaluation tool. The administrator said he expected the social worker to complete the smoking evaluation tool. The administrator said not completing the smoking evaluation tool placed the residents at risk for injury. <BR/>Record review of the facility's policy titled, Smoking Policy, last revised 4/24/18, revealed, Policy to evaluate a patient's ability to participate and exercise the privilege to smoke while residing within the facility. Fundamental information to establish smoking guidelines for patients that desire to smoke in the center to allocate a nonsmoking area for the residents/staff/visitors Procedure evaluate patients that smoke utilizing the smoking evaluation tool: (a) upon admission; (b) when a previous non-smoking patient takes up smoking; (c) if unsafe smoking practices are observed in a current smoker .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible to prevent accidents for 2 of 20 (Resident #4 and Resident #59) residents reviewed for accidents and hazards. <BR/>The facility failed to ensure the Maintenance Supervisor fixed the exposed wires on Resident #4 and Resident #59's bed remotes. <BR/>These failures could place residents at an increased risk for injury, electrocution, or fire. <BR/>The findings included:<BR/>1. Record review of Resident #4's face sheet (undated) revealed she was [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset (type of brain disorder that causes problems with memory, thinking and behavior and is a gradually progressive condition), type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar with damaged nerves to hands and feet), and bradycardia (slow heartbeat). <BR/>Record review of the MDS assessment, dated 05/17/2023, revealed Resident #4 had clear speech and was understood by staff. The MDS revealed Resident #4 was able to understand others. The MDS revealed Resident #4 had a BIMS score of 04 which indicated severe cognitive impairment. The MDS revealed Resident #4 required limited assistance with bed mobility and transfers. <BR/>Record review of the comprehensive care plan, last revised on 4/26/2021, revealed Resident #4 had an ADL self-care performance deficit and required limited - extensive assistance with ADLs. <BR/>During an observation and resident interview on 02/06/2023 at 10:19 AM, Resident #4 had exposed wires on her bed remote attached to her bed. Resident #4 was non-interviewable related to severe cognitive impairment as evidenced by confused conversation. <BR/>During a confidential interview on 02/06/2023 at 10:50 AM, a staff member stated exposed wires on residents' bed had been reported to the Maintenance Supervisor verbally on multiple occasions. The staff member stated the exposed wires had caused the bed to short out and not work correctly at times. The staff member stated the problem had not been resolved or fixed. The staff member stated it was important for beds to work properly to prevent an accident or injury to residents. <BR/>During an observation on 02/06/2023 at 3:40 PM, Resident #4 had exposed wires on her bed remote attached to her bed. <BR/>During an observation on 02/07/2023 at 8:27 AM, Resident #4 had exposed wires on her bed remote attached to her bed. <BR/>2. Record review of Resident #59's face sheet (undated) revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), combined systolic and diastolic congestive heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and anxiety disorder (severe, ongoing anxiety that interferes with daily activities). <BR/>Record review of the MDS assessment, dated 11/19/2022, revealed Resident #59 had clear speech and was usually understood by staff. The MDS revealed Resident #59 was usually able to understand others. The MDS revealed Resident #59 had a BIMS score of 8 which indicated moderately impaired cognition. The MDS revealed Resident #59 required extensive assistance with bed mobility and transfers. <BR/>Record review of the comprehensive care plan, last revised on 05/02/2022, revealed Resident #59 had an ADL self-care deficit and required extensive assistance with most ADLs. <BR/>During an observation and resident interview on 02/06/2023 at 10:50 AM, Resident #59 had exposed wires on her bed remote attached to her bed. Resident #59 was non-interviewable related to cognitive status as evidenced by confused conversation. <BR/>During an observation on 02/06/2023 at 2:53 PM, Resident #59 had exposed wires on her bed remote attached to her bed. <BR/>During an observation on 02/07/2023 at 8:23 AM, Resident #59 had exposed wires on her bed remote attached to her bed. <BR/>During an interview on 02/08/2023 at 4:35 PM, CNA Q stated she had noticed exposed wires on Resident #4 and Resident #59's bed remotes attached to their bed. CNA Q stated she reported verbally and showed the exposed wires to the Maintenance Supervisor approximately the week prior. CNA Q stated exposed wires to the bed remotes would cause the bed to not work at times. CNA Q stated the harm to Resident #4 and Resident #59 for exposed wires was risk for electrocution. <BR/>During an interview on 02/08/2023 at 4:46 PM, NA R stated he had noticed exposed wires on some of the residents' beds. NA R stated he had reported the exposed bed wires to the Maintenance Supervisor verbally. NA R stated the Maintenance Supervisor usually resolved the issues reported. NA R stated the failure to Resident #4 and Resident #59 for exposed wires on the bed remote attached to their bed was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 5:13 PM, LVN (ADON) H stated issues identified with beds or exposed wires would be reported to the Maintenance Supervisor via communication book, verbally, or via text message. LVN (ADON) H stated she was unaware of the exposed wires to Resident #4 and Resident #59's bed because it was not reported to her. LVN (ADON) H stated the harm to Resident #4 and Resident #59 for having exposed wires on their bed was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 5:27 PM, RN B stated issues with the residents' beds have been identified and reported to the Maintenance Supervisor. RN B stated the issues identified with the beds included beds not working correctly. RN B stated she was unaware Resident #4 or Resident #59 had exposed bed wires to their beds. RN B stated the harm to Resident #4 and Resident #59 for having exposed wires to the bed remote attached to the bed was an increased risk for electrocution and could have been a fire hazard. <BR/>During an interview on 02/08/2023 at 6:43 PM, the Maintenance Supervisor stated issues identified with beds were reported via the maintenance communication book or verbally by staff or residents. The Maintenance Supervisor stated he addressed issues reported him as quick as he was able. The Maintenance Supervisor stated the exposed wires on Resident #4 and Resident #59's beds were not reported to him. The Maintenance Supervisor stated the harm to Resident #4 and Resident #59 for having exposed wires to bed remotes attached to their beds was increased risk for electrocution. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated the Maintenance Supervisor was responsible for fixing and monitoring exposed wires to beds and bed remotes. The ADM stated he expected all staff to report issues identified with exposed wires or beds in the maintenance communication book. The ADM stated reporting issues verbally could have caused issues to have been missed or forgotten. The ADM stated the importance of reporting exposed wires to bed remotes attached to residents' beds was to protect resident safety. The ADM stated exposed bed wires could have caused an increased risk for harm by electrocution or fire. <BR/>Record review of the Maintenance Inspection policy, implemented on 4/11/2022, revealed It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The policy further revealed 3. All opportunities will be corrected immediately by the maintenance personnel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a means by which to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 2 of 24 residents reviewed for call system. (Resident #38 and Resident #13)<BR/>The facility did not ensure Resident #38 and Resident #13's emergency call lights were functioning in their rooms. <BR/>These failures could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.<BR/>Findings included:<BR/>1. Record review of the consolidated physician orders dated [DATE] indicated Resident #38 was [AGE] years old, admitted [DATE] with diagnoses including schizophrenia, drug induced tremor, chronic kidney disease, and osteoarthritis. <BR/>Record review of the MDS dated [DATE] indicated Resident #38 made himself understood, understood others, and had moderate cognitive impairment with a BIMS of 10. The MDS indicated Resident #38 required supervision with transferring, bed mobility, personal hygiene, and dressing. <BR/>Record review of the care plan updated on [DATE] indicated Resident #38 had impaired visual function and was at risk for falls, injury, and a decline in functional ability. The care plan indicated Resident #38 had an Activities of Daily Living Self Care Performance Deficit related to decreased mobility, impaired balance, visual impairment, and incontinence. The care plan indicated Resident #38 had the potential for falls related to gait/balance problems, vision problems, and history of falls.<BR/>Record review of Nurse Call System Test dated [DATE] indicated Resident #38's call light was working properly.<BR/>Record review of daily room rounds dated 11/05 (no year) indicated Resident #38's call light was in reach and working.<BR/>Record review of Nurse Call System Test dated [DATE] indicated Resident #38's call light was working properly.<BR/>During an observation and interview on [DATE] at 11:01 a.m., Resident #38 said his emergency call light in in his room next to his bed did not work. Resident #38 said he did not use his call light often. Resident #38 said he would like for his call light to be working in case of an emergency. Resident #38 said his call light had not worked for approximately 14 days and he had reported it to a CNA. Resident #38 could not remember which CNA he reported to the call light was broken. The emergency call light was supposed to have a button for the resident to push to activate the call light in the hallway and at the nurse's station. The call light's button was broken off making Resident #38 unable to use his call light. <BR/>During an observation on [DATE] at 02:50 p.m. Resident #38's call light was not working with the button to activate the call system broken off.<BR/>During an observation on [DATE] at 08:57 a.m. Resident #38's call light was not working with the button to activate the call system broken off.<BR/>During an interview in the Resident Council meeting on [DATE] at 10:45 a.m. Resident #38 said his call light was broken. Resident #38 said he told a nurse aide about 2 weeks ago and it was still not working. Resident #38 said he would use the call light if it worked.<BR/>During an observation on [DATE] at 03:01 p.m. Resident #38's call light was not working with the button to activate the call system broken off.<BR/>During an observation on [DATE] at 10:15 p.m. Resident #38's call light was not working with the button to activate the call system broken off.<BR/>2. Record review of the consolidated physician orders dated [DATE] indicated Resident #13 was [AGE] years old, re-admitted [DATE] with diagnoses including anxiety disorder, dementia, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and chronic pain. <BR/>Record review of the MDS dated [DATE] indicated Resident #13 made herself understood, understood others, and had moderate cognitive impairment with a BIMS of 09. The MDS indicated Resident #38 required supervision with transferring, bed mobility, and dressing. The MDS indicated Resident #38 required limited assistance with personal hygiene. <BR/>Record review of the care plan updated on [DATE] indicated Resident #13 had impaired visual function and was at risk for falls, injury, and a decline in functional ability. The care plan indicated Resident #13 had an Activities of Daily Living Self Care Performance Deficit and was at risk for not having needs met in a timely manner related to dementia, weakness, and decreased mobility. The care plan indicated Resident #13 had the potential for falls related to dementia, weakness, unsteady/poor balance, and poor safety awareness. <BR/>Record review of Nurse Call System Test indicated Resident #13's call light was not tested for proper functioning on the following dates provided by the maintenance supervisor:<BR/>*[DATE]<BR/>*[DATE]<BR/>*[DATE]<BR/>*[DATE]<BR/>Record review of undated daily room rounds indicated Resident #13's call light was in reach and working.<BR/>During an observation on [DATE] at 11:00 a.m. Resident #13's call light was not working with the button to activate the call system broken off.<BR/>During an observation on [DATE] at 02:35 p.m. Resident #13's call light was not working with the button to activate the call system broken off.<BR/>During an observation and interview on [DATE] at 09:37 a.m., Resident #13 said she would like her call light to work so she could use it when she needed. Resident #13 said she had never needed to use her call light. Resident #13 said she wanted her call light working properly in case she needed it for an emergency. The emergency call light was supposed to have a button for the resident to push to activate the call light in the hallway and at the nurse's station. The call light's button was broken off making Resident #13 unable to use her call light. <BR/>During an interview and observation on [DATE] at 10:40 a.m. CNA B said residents notified staff of needing assistance when in their room or in their bathroom by utilizing the call light system. CNA B said residents used the call light in their rooms by pushing a button to activate the call system. CNA B said if the button was broken off the call system residents would not have a way of calling for assistance. CNA B said it was the responsibility of all staff members to monitor call lights functionality. CNA B was shown Resident #38 and Resident #13's broken call lights and said they would not have been able to call for assistance with the broken call light in their rooms. CNA B said she had not been aware of the call lights were broken.<BR/>During an interview and observation on [DATE] at 10:45 a.m. the Maintenance Supervisor said he was responsible for replacing call lights. The Maintenance Supervisor said he checks the call lights for proper functioning weekly. The Maintenance Supervisor said he expected the nurse aides to report call lights that were not working properly. The Maintenance Supervisor was shown by the surveyor Resident #38 and Resident #13's broken call lights and he said they would not be able to use the call system in case of emergency and needing assistance with the broken call lights. <BR/>During an interview on [DATE] at 11:47 a.m. LVN A said residents notified staff of needing assistance when in their room or in their bathroom by utilizing the call light system. LVN A said residents used the call light in their rooms by pushing a button to activate the call system. LVN A said if the button was broken off the call system residents would have to yell for assistance. LVN A said all staff were responsible for ensuring call lights were functional. LVN A said she was unaware the call lights for Resident #38 and Resident #13 were broken.<BR/>During an interview on [DATE] at 10:53 a.m. the ADON said the call lights notified staff of residents needing assistance. The ADON said some of the call lights in the room were touch/pressure activated and some were push button activated. The ADON said if a push button call light had a broken button the only way a resident could notify staff of needing assistance was ask their roommate to push their call light or yell. The ADON said she expected each resident to have their own, personal and functional call light. The ADON said it was the maintenance supervisor's responsibility to monitor call light function. The ADON said she was unaware of Resident #38 and Resident #13's call lights being broken. The ADON said Resident #38 and Resident #13 were independent residents who did not use their call lights regularly. The ADON said broken call lights would not allow the residents to call for assistance in the event of an emergency.<BR/>During an interview on [DATE] at 03:15 p.m. the Administrator said residents notified staff of needing assistance when in their room or in their bathroom by utilizing the call light system. The Administrator said some of the call lights in the room were touch/pressure activated and some were push button activated. The Administrator said if the button was broken off the call system residents would not be able to call for assistance.The Administrator said it was the responsibility of all staff to monitor call light function. The Administrator said he was unaware of Resident #38 and Resident #13's call lights being broken. The Administrator said Resident #38 and Resident #13 were independent residents who did not use their call lights regularly. The Administrator said broken call lights would not allow the residents to call for assistance in the event of an emergency. The Administrator said he expected the staff to report broken call lights to the maintenance supervisor. <BR/>Record Review of Call Light response policy dated [DATE] indicated, The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance .Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied .

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 20 residents (Resident #20, Resident #35, and Resident #69) reviewed for palatable food. <BR/>The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #20, Resident #35, and Resident #69 who complained the food was served cold and did not taste good. <BR/>This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. <BR/>The findings included:<BR/>Record review of the Grievance/Complaint Report, dated 12/30/2022, revealed Resident #36, Resident #47, and Resident #56 complained the food was cold.<BR/>During an interview on 02/06/2023 at 10:02 AM, Resident #69 stated the food was never seasoned. <BR/>During an interview on 02/06/2023 at 10:38 AM, Resident #35 stated the meat was tough and the food was not seasoned. <BR/>During an interview on 02/06/2023 at 11:30 AM, Resident #20 stated the food was bland.<BR/>During and observation and interview on 02/06/2023 at 12:56 PM, a lunch tray was sampled by the FSS and five surveyors. The sample tray consisted of noodles, peas, cubed steak, roll, and a brownie. The FSS stated the noodles were very unseasoned and bland. The FSS stated the noodles were cool not hot. The FSS stated the peas were bland. The FSS stated the cubed steak was cold.<BR/>During an interview on 02/08/2023 at 5:58 PM, [NAME] S stated she was unaware of any food complaints. [NAME] S stated she ensured food was palatable and appetizing by making sure the food looked appetizing to her. [NAME] S stated the importance of ensuring food looked appetizing and tasted well was to ensure residents wanted to eat the food.<BR/>During an interview on 02/08/2023 at 6:15 PM, the FSS stated the cooks were responsible for ensuring food looked appetizing and palatable. The FSS stated she monitored this by performing spot checks. The FSS stated she was aware of complaints by the residents who stated the food was too salty. The FSS stated she was unaware of any food complaints recently. The FSS stated ensuring the food was appetizing and palatable was important so the residents would want to eat the food. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated he expected dietary staff to ensure the food was appetizing and palatable. The ADM stated he expected the FSS to ensure that was completed. The ADM stated ensuring the food was palatable and appetizing was important so residents would find the food enticing. The food palatability policy was requested and not received upon exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 2 of 20 residents (Resident #73 and Resident #183) reviewed for accuracy of assessments.<BR/>The facility failed to complete Resident #73 and Resident #183's admission MDS assessment within 14 days of admission. <BR/>This failure could place residents at risk of not having their needs met.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #73's face sheet, dated 02/08/23, revealed a [AGE] year-old female initially admitted on [DATE] with diagnoses of metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and chronic obstructive pulmonary disease, unspecified (chronic inflammatory lung disease that causes obstructed airflow from the lungs).<BR/>Record review of Resident #73's comprehensive MDS assessment with an ARD (assessment reference date) of 11/08/2022 indicated in Section A0310 it was an admission assessment (required by day 14). The MDS assessment for Resident #73 indicated in Section A1600 an entry date of 11/04/2022. The MDS assessment in Section Z0500B was signed completed on 11/28/2022, indicating the MDS assessment for Resident #73 was completed 11 days late. <BR/>2. <BR/>Record review of Resident #183's face sheet, dated 02/08/23, revealed a [AGE] year old female initially admitted on [DATE] with diagnoses of Wernicke's encephalopathy (a brain disorder caused by thiamine deficiency, typically from chronic alcoholism or persistent vomiting, and marked by mental confusion, abnormal eye movements, and unsteady gait), cerebral infarction due to thrombosis of right middle cerebral artery (a stroke due to interruption of blood flow to areas of the brain resulting in permanent brain damage), and atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). <BR/>Record review of Resident #183's comprehensive MDS assessment with an ARD (assessment reference date) of 02/01/2023 indicated in Section A0310 it was an admission assessment (required by day 14). The MDS assessment for Resident #183 indicated in Section A1600 an entry date of 01/23/2023. The MDS assessment in Section Z0500B was signed completed on 02/08/2023, indicating the MDS assessment for Resident #183 was completed 2 days late. <BR/>During an interview on 02/8/23 at 6:04 PM, the RN case-mix manager said she was responsible for completing Resident #73 and Resident #183's MDS assessments. The RN case-mix manager said Resident #73 and Resident #183's MDS assessments were completed late. The RN case-mix manager said the MDS assessments were completed late because she was behind. The RN case-mix manager said it was important to complete the MDS assessments in a timely manner so that the plan of care could be completed, and continuity of care could be provided for the residents. <BR/>During an interview on 02/08/23 at 8:07 PM, the administrator said he expected the MDS assessments to be completed in a timely manner. The administrator said the MDS nurses were responsible for completing the MDS assessments. The administrator said it was important to complete the MDS assessments in a timely manner because it was an assessment of the resident, and it affected their care and needs. <BR/>Record review of the facility's policy titled, Clinical Practice Guidelines MDS Completion last review date, 2/10/2021, revealed, . b. admission Assessment- completed within 14 days of admission counting the day of admission as day #1 when: i. The resident has no prior admission, or ii. Prior admission was less than 14 days, and no admission assessment was completed during the prior admission, or iii. Prior admission ended with a Discharge Return not Anticipated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have physician orders for the resident's immediate care for 1 of 1 residents (Resident #182) reviewed for admission physician orders.<BR/>The facility failed to ensure Resident #182 had a physician order for dressing change to suprapubic catheter. <BR/>This failure could place residents at risk for not receiving appropriate care, treatment services, and at risk for infection.<BR/>Findings included: <BR/>Record review of a face sheet dated 02/08/23 revealed Resident #182 was a [AGE] year-old male admitted on [DATE] with diagnoses of quadriplegia (paralysis of all four extremities), paroxysmal atrial fibrillation (rapid, erratic heart rate), and neurogenic bladder (bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves).<BR/>Record review of the order summary report dated 02/08/32, revealed Resident #182 had an order to cleanse supra pubic catheter site with normal saline, pat dry, apply T-drain dressing and secure with tape every day and as needed if soiled or dislodged every day shift with start date of 02/06/23. <BR/>Record review of Resident #182's care plan included an intervention to perform suprapubic catheter care and treatment to catheter site as ordered with date initiated 02/08/23.<BR/>During an observation and interview on 02/06/23 at 9:59 AM, Resident #182 had a dressing to his suprapubic catheter dated 02/02/23. Resident #182 said he was admitted Friday 02/03/23 and his suprapubic catheter dressing had not been changed. <BR/>During an interview on 02/06/23 at 11:31 AM after incontinent care was provided for Resident #182 the treatment nurse said she saw Resident #182 had a dressing to his suprapubic catheter that was dated 02/02/23. The treatment nurse said there was no physician order for the dressing change, but she would fix it. The treatment nurse said any of the admission nurses should have put in the physician order to change the dressing on the suprapubic catheter. The treatment nurse said not changing the dressing placed Resident #182 at risk for infection. <BR/>During an interview on 02/08/23 at 4:22 PM, LVN P said he was the nurse that admitted Resident #182, and he was aware that Resident #182 had a suprapubic catheter. LVN P said he should have obtained a physician order for the dressing change for Resident #182, and he should have changed the dressing. LVN P said not changing the dressing to Resident #182 suprapubic catheter placed him at risk for infection. <BR/>During an interview on 02/08/23 at 5:16 PM, ADON K said she overlooked the physician orders for Resident #182. ADON K said the admitting nurse should have put in the physician order for the dressing change to the suprapubic catheter. ADON K said the nurses should have done the dressing change, and not providing the dressing changes placed Resident #182 at risk for infection. <BR/>During an interview on 02/08/23 at 6:41 PM, the DON said the admitting nurse on admission should have put the physician order in for the dressing change to the suprapubic catheter for Resident #182. The DON said the ADONs were responsible for ensuring that the admitting physician orders were put in. The DON said Resident #182's dressing to suprapubic catheter not being changed could lead to a possible infection. <BR/>During an interview on 02/08/23 at 8:00 PM, the administrator said the charge nurse was responsible for changing the dressing to Resident #182's suprapubic catheter. The administrator said the charge nurse should have put the physician order in. The administrator said nurse management was responsible for ensuring the admitting physician orders were put in. The administrator said Resident #182 not getting his suprapubic dressing changed could cause an infection. <BR/>Record review of the facility's policy titled, Following Physician Orders, date implemented 9/28/2021, did not address admission physician orders.

Based on observation, interviews, and record review, the facility failed to ensure the meals served to residents met the nutritional needs of residents for 1 of 1 meal (the lunch meal), as evidenced by: <BR/>The facility failed to ensure [NAME] S followed the recipe for pureeing the honey glazed ham and cabbage during the lunch meal. <BR/>These failures could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life.<BR/>The findings included:<BR/>During an observation and interview on 02/07/2023 at 10:25 AM, [NAME] S was preparing to puree the residents' meals. [NAME] S stated she normally followed a recipe while pureeing the food. [NAME] S had a prefilled metal measuring container filled with cabbage. [NAME] S stated she guessed on how much food was needed for the 6 pureed residents. [NAME] S placed the pre-measured, cooked cabbage into the blender and proceeded to puree. [NAME] S took the empty measuring container and placed a small amount of water into the blender. [NAME] S stated she used water to blend her pureed meals daily. [NAME] S stated if the food became too runny, she used a small amount of thickener. [NAME] S stated she was unaware the recipe had instructions on mixing the pureed meals. [NAME] S stated she eye-balled the consistency until it was the consistency of baby food. [NAME] S continued to puree the other items on the menu without using a recipe. [NAME] S also used water to puree the honey glazed ham. [NAME] S stated following the menu was important to maintain the nutrient value of food and residents' weights. <BR/>During an interview on 02/07/2023 at 10:34 AM, the FSS stated she normally printed off the pureed recipe for the cooks to use. The FSS stated she had not printed them off for the lunch menu because she had not had time. The pureed menus and policy for following the menus was requested to the FSS. <BR/>During an interview on 02/08/2023 at 6:15 PM, the FSS stated she had no time to print off the recipes for the cook, during the observed lunch meal. The FSS stated she was taught approximately a week ago how to pull up and print off the pureed recipes. The FSS stated it was important to follow the recipes, so residents receive the correct amount of food, and the nutrient value of the food did not decrease. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated he expected dietary staff to follow the menu and the recipes for pureed food. The ADM stated he expected the FSS to ensure recipes were printed for each meal. The ADM stated the importance of following the recipe was to ensure residents had the appropriate nutrients. <BR/>Record review of the Menus and Nutritional Adequacy policy, last revised on 02/20/2018, did not address following pureed recipes or preparing pureed meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 20 residents (Resident #44) reviewed for care plans. <BR/>The facility did not implement Resident #44's fall management care plan to ensure she always wore non-skid footwear and have a fall mat at bedside. <BR/>This failure could place residents at risk of not having their individual needs met. <BR/>Findings include:<BR/>Record review of Resident #44's order summary report, dated 02/08/2023, indicated Resident #44 was a [AGE] year-old female, originally admitted on [DATE] with a diagnosis which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (high blood pressure), and history of falling. <BR/>Record review of Resident #44's significant change in status MDS assessment, dated 10/07/2022, indicated Resident #44 rarely/never understood others and rarely/never made herself understood. The assessment did not address Resident #44 cognitive status. The assessment indicated Resident #44 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #44 had a fall in the last month, last 2-6 months, and obtained a fracture related to a fall in the 6 months prior to admission/entry or reentry. <BR/>Record review of Resident #44's care plan, with an initiated date of 08/05/2022, indicated Resident #44 had a history of falls related to dementia with behaviors, pain, medications, immobility, unsteady/poor balance, and recent fall with injuries. The care plan interventions included, always ensure non-skid footwear, fall mat at bedside and increase staff rounding. <BR/>Record review of the fall risk assessment tool dated 11/24/2022 indicated Resident #44 had multiple falls within the previous six months, on three high risk drugs, unable to independently come to a standing position, required hands-on assistance to move from place to place, use an assistive device and decrease in muscle coordination. The fall risk assessment indicated Resident #44 was a high risk for falls. <BR/>During observations of Resident #44's room the following was noted: <BR/>02/06/2023 at 10:00 a.m. Resident lying in bed with no fall mat at bedside. <BR/>02/06/2023 at 3:34 p.m. Resident lying in bed with no fall mat at bedside. <BR/>02/07/2023 at 2:37 a.m. Resident lying in bed with no fall mat at bedside. <BR/>During an observation on 02/07/2023 at 9:08 a.m., Resident #44 was sitting in her wheelchair in the tv room wearing a pair of off-white socks with no grip on the bottom. <BR/>During an observation, interview, and record review on 02/08/2023 at 2:46 p.m., LVN A stated she was Resident #44's 6a-6p charge nurse. LVN A stated she was unaware that Resident #44 should have a fall mat at bedside. After reviewing Resident #44 electronic medical records, LVN A stated she should have a fall mat at bedside and always wore nonskid socks. LVN A observed with the surveyor Resident #44's fall mat was not at bedside. LVN A stated nursing staff were responsible for ensuring a fall mat was at Resident #44 bedside and ensure Resident #44 always wear non-skid footwear. LVN A stated there was not a system at this time that staff could review what devices were needed for residents. LVN A stated this failure could potentially put Resident #44 at risk for a serious injury. <BR/>During an interview on 02/08/2023 at 4:14 p.m., NA C stated she was Resident #44's 2p-10p aide. NA C stated she unaware that Resident #44 was a high risk for falls. NA C stated she did not know that Resident #44 needed a fall mat at bedside and should always wear non-skid socks. NA C stated there was times Resident #44 did not have on non-skid socks. NA C stated she did not have access to resident's care plan. NA C stated this failure could potentially cause an injury (concussion) to Resident #44. <BR/>During an interview on 02/08/2023 at 4:36 p.m., the DON stated he expected Resident #44 to have a fall mat at bedside and always wear non-skid socks. The DON stated the aides and nurses were responsible for ensuring care plan items were in place. The DON stated daily rounds were made by LVN H to ensure safety measures are in place. The DON stated currently there was a system being put in place to inform staff of care plan needs. The DON stated this failure could potentially put Resident #44 at risk for injury. <BR/>During an interview on 02/08/2023 at 5:47 p.m., LVN H stated herself and the department heads were responsible for daily rounds. LVN H stated she could not say the last time rounds were done on Resident #44 due to frequent room changes. LVN H stated she expected the nursing staff to ensure fall preventions measure are in place. LVN H stated this failure could potentially put Resident #44 at risk for injury. <BR/>During an interview on 02/08/2023 at 6:13 p.m., the Administrator stated he expected the care plan to be followed. The Administrator stated ultimately the DON or designee was responsible for ensuring safety measures were in place. The Administrator stated this failure could potentially put Resident #44 at risk for injury. <BR/>Record review of the facility's Fall Management System policy, revised 01/03/2017, indicated, . it is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan implemented based on the resident's assessed needs Procedure (3) A care plan is implemented for residents at risk for falls . Investigation and follow up of accidents involving falls (2) Interventions will be implemented in an attempt to prevent the resident from sustaining further falls

Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 1 of 20 employees (Dietician) reviewed for required annual trainings.<BR/>The facility failed to ensure the Dietician received required dementia training upon hire 07/17/23. <BR/>These failures placed residents at risk for unmet needs due to untrained staff.<BR/>Findings included:<BR/>Record review of Personnel Files on 03/27/24 indicated the dietician was hired on 07/17/23 and had no dementia training upon hire. <BR/>During an interview on 03/27/24 at 06:17 PM the Human Resources Manager said the corporate office was responsible for the training required upon hire for the dietician. She said she had reached out to the corporate office by email, and they refused to send the information needed. The Human Resources Manager said the failure placed staff at risk for not knowing how to correctly care for a resident with dementia. <BR/>During an interview on 03/27/24 at 06:27 PM the Administrator said the corporate office had access to the dietician hire records and it should have been sent to the facility for the Human Resources Manager to file. The Administrator said the failure of not having training placed the employee ineligible to work and usure if she had the knowledge required. <BR/>Record review of the facility policy Training Requirements dated 11/29/2022 indicated:<BR/>Policy: <BR/>It is the policy of this facility 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. <BR/>Policy Explanation and Compliance Guidelines .<BR/> 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. <BR/>6. Training content includes, at a minimum: a. Effective communication for direct care staff. <BR/>b. Resident rights and facility responsibilities for caring of residents. <BR/>c. Elements and goals of the facility's QAPI program. <BR/>d. Written standards, policies, and procedures for the facility's infection prevention and control program. <BR/>e. Written standards, policies, and procedures for the facility's compliance and ethics program. <BR/>f. Behavioral health including informed trauma care <BR/>g. Restraints <BR/>h. HIV <BR/>i. Dementia management and care of the cognitively impaired. <BR/>j. Abuse, neglect, and exploitation prevention. <BR/>k. Safety and emergency procedures. <BR/>7. It is the responsibility of each employee, volunteer, or contract staff to complete required training. <BR/>a. The facility offers a variety of training methods and times to accommodate individuals. <BR/>b. An individual's failure to complete required training in a timely manner will result in termination of employment or contractual/volunteer status .10. Documentation of required training may be forwarded to the HR Department to be placed into the individual's personnel file or in accordance with facility policy for retention of training records.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 20 residents (Resident #20, Resident #35, and Resident #69) reviewed for palatable food. <BR/>The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #20, Resident #35, and Resident #69 who complained the food was served cold and did not taste good. <BR/>This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. <BR/>The findings included:<BR/>Record review of the Grievance/Complaint Report, dated 12/30/2022, revealed Resident #36, Resident #47, and Resident #56 complained the food was cold.<BR/>During an interview on 02/06/2023 at 10:02 AM, Resident #69 stated the food was never seasoned. <BR/>During an interview on 02/06/2023 at 10:38 AM, Resident #35 stated the meat was tough and the food was not seasoned. <BR/>During an interview on 02/06/2023 at 11:30 AM, Resident #20 stated the food was bland.<BR/>During and observation and interview on 02/06/2023 at 12:56 PM, a lunch tray was sampled by the FSS and five surveyors. The sample tray consisted of noodles, peas, cubed steak, roll, and a brownie. The FSS stated the noodles were very unseasoned and bland. The FSS stated the noodles were cool not hot. The FSS stated the peas were bland. The FSS stated the cubed steak was cold.<BR/>During an interview on 02/08/2023 at 5:58 PM, [NAME] S stated she was unaware of any food complaints. [NAME] S stated she ensured food was palatable and appetizing by making sure the food looked appetizing to her. [NAME] S stated the importance of ensuring food looked appetizing and tasted well was to ensure residents wanted to eat the food.<BR/>During an interview on 02/08/2023 at 6:15 PM, the FSS stated the cooks were responsible for ensuring food looked appetizing and palatable. The FSS stated she monitored this by performing spot checks. The FSS stated she was aware of complaints by the residents who stated the food was too salty. The FSS stated she was unaware of any food complaints recently. The FSS stated ensuring the food was appetizing and palatable was important so the residents would want to eat the food. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated he expected dietary staff to ensure the food was appetizing and palatable. The ADM stated he expected the FSS to ensure that was completed. The ADM stated ensuring the food was palatable and appetizing was important so residents would find the food enticing. The food palatability policy was requested and not received upon exit.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 20 residents (Resident #20, Resident #35, and Resident #69) reviewed for palatable food. <BR/>The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #20, Resident #35, and Resident #69 who complained the food was served cold and did not taste good. <BR/>This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. <BR/>The findings included:<BR/>Record review of the Grievance/Complaint Report, dated 12/30/2022, revealed Resident #36, Resident #47, and Resident #56 complained the food was cold.<BR/>During an interview on 02/06/2023 at 10:02 AM, Resident #69 stated the food was never seasoned. <BR/>During an interview on 02/06/2023 at 10:38 AM, Resident #35 stated the meat was tough and the food was not seasoned. <BR/>During an interview on 02/06/2023 at 11:30 AM, Resident #20 stated the food was bland.<BR/>During and observation and interview on 02/06/2023 at 12:56 PM, a lunch tray was sampled by the FSS and five surveyors. The sample tray consisted of noodles, peas, cubed steak, roll, and a brownie. The FSS stated the noodles were very unseasoned and bland. The FSS stated the noodles were cool not hot. The FSS stated the peas were bland. The FSS stated the cubed steak was cold.<BR/>During an interview on 02/08/2023 at 5:58 PM, [NAME] S stated she was unaware of any food complaints. [NAME] S stated she ensured food was palatable and appetizing by making sure the food looked appetizing to her. [NAME] S stated the importance of ensuring food looked appetizing and tasted well was to ensure residents wanted to eat the food.<BR/>During an interview on 02/08/2023 at 6:15 PM, the FSS stated the cooks were responsible for ensuring food looked appetizing and palatable. The FSS stated she monitored this by performing spot checks. The FSS stated she was aware of complaints by the residents who stated the food was too salty. The FSS stated she was unaware of any food complaints recently. The FSS stated ensuring the food was appetizing and palatable was important so the residents would want to eat the food. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated he expected dietary staff to ensure the food was appetizing and palatable. The ADM stated he expected the FSS to ensure that was completed. The ADM stated ensuring the food was palatable and appetizing was important so residents would find the food enticing. The food palatability policy was requested and not received upon exit.

Based on observation, interviews, and record reviews, the facility failed provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 6 out of 10 dietary staff. (Cook T, DW U, [NAME] V, DA W, [NAME] S, and DW X)<BR/>The facility failed to ensure [NAME] T, DW U, [NAME] V, DA W, [NAME] S, and DW X had appropriate food handlers permit by the 60th day from hire. <BR/>This failure could place residents at risks who consume food prepared in the kitchen at risk of foodborne illness.<BR/>The findings included:<BR/>Review of the food handler's certificates of completion provided by the facility on 02/07/2023 at 10:45 AM, revealed the following:<BR/>1. [NAME] T had a food handler certificate that expired on 01/29/2023. <BR/>2. DW U, hired on 08/30/2021, had no food handler certificate. <BR/>3. [NAME] V, hired on 06/28/2022, had no food handler certificate.<BR/>4. DA W, hired on 08/03/2022, had no food handler certificate. <BR/>5. [NAME] S, hired on 08/09/2021, had no food handler certificate.<BR/>6. DW X, hired on 03/21/2022, had no food handler certificate.<BR/>During an interview on 02/08/2023 at 6:15 PM, the FSS stated the dietary staff should have kept track of their food handler certificate expiration date. The FSS stated ultimately, she was responsible for ensuring staff completed their food handler certificate training upon hire and every 2 years. The FSS was unsure why the dietary staff had not completed their food handler certificate training. The FSS stated the importance of obtaining and maintaining the food handler certificate training was to teach staff how to prevent food-borne illness and cross contamination. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated he expected the FSS to ensure the dietary staff had their food handler certificates within 60 days of hire and before they expired. The ADM stated the importance of obtaining and maintaining the food handler certificate training was to teach staff how to prevent food-borne illness and cross contamination. <BR/>Record review of the Certified Food Protection Professional and Food Safety Training, last revised on 11/14/2017, revealed 5. All food employees except for the certified food manager shall successfully completed an accredited food handler training course, within 60 days of employment. <BR/>Record review of The Texas Department of State Health Services (TXDSHS), under Texas Food Establishment Rules (TFER) &sect;228.33, requires that ' .all food employees shall successfully complete an accredited food handler training course, within 60 days of employment.'

Based on observation, interviews, and record review, the facility failed to ensure the meals served to residents met the nutritional needs of residents for 1 of 1 meal (the lunch meal), as evidenced by: <BR/>The facility failed to ensure [NAME] S followed the recipe for pureeing the honey glazed ham and cabbage during the lunch meal. <BR/>These failures could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life.<BR/>The findings included:<BR/>During an observation and interview on 02/07/2023 at 10:25 AM, [NAME] S was preparing to puree the residents' meals. [NAME] S stated she normally followed a recipe while pureeing the food. [NAME] S had a prefilled metal measuring container filled with cabbage. [NAME] S stated she guessed on how much food was needed for the 6 pureed residents. [NAME] S placed the pre-measured, cooked cabbage into the blender and proceeded to puree. [NAME] S took the empty measuring container and placed a small amount of water into the blender. [NAME] S stated she used water to blend her pureed meals daily. [NAME] S stated if the food became too runny, she used a small amount of thickener. [NAME] S stated she was unaware the recipe had instructions on mixing the pureed meals. [NAME] S stated she eye-balled the consistency until it was the consistency of baby food. [NAME] S continued to puree the other items on the menu without using a recipe. [NAME] S also used water to puree the honey glazed ham. [NAME] S stated following the menu was important to maintain the nutrient value of food and residents' weights. <BR/>During an interview on 02/07/2023 at 10:34 AM, the FSS stated she normally printed off the pureed recipe for the cooks to use. The FSS stated she had not printed them off for the lunch menu because she had not had time. The pureed menus and policy for following the menus was requested to the FSS. <BR/>During an interview on 02/08/2023 at 6:15 PM, the FSS stated she had no time to print off the recipes for the cook, during the observed lunch meal. The FSS stated she was taught approximately a week ago how to pull up and print off the pureed recipes. The FSS stated it was important to follow the recipes, so residents receive the correct amount of food, and the nutrient value of the food did not decrease. <BR/>During an interview on 02/08/2023 at 7:25 PM, the ADM stated he expected dietary staff to follow the menu and the recipes for pureed food. The ADM stated he expected the FSS to ensure recipes were printed for each meal. The ADM stated the importance of following the recipe was to ensure residents had the appropriate nutrients. <BR/>Record review of the Menus and Nutritional Adequacy policy, last revised on 02/20/2018, did not address following pureed recipes or preparing pureed meals.