Avir at Converse

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments for 1 of 24 (Resident #35) residents reviewed for care plan revisions.<BR/>The facility failed to ensure Resident #35's care plan was updated to reflect the resident was on oxygen therapy.<BR/>This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. <BR/>The findings included:<BR/>Record review of Resident #35's electronic face sheet dated 02/21/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks), bacteremia (viable bacteria in the blood), pressure ulcer of right hip, stage IV (may look like a reddish crater in the skin. Muscles, bones, and/or tendons may also be visible at the bottom of the stage IV), dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), dysphagia (difficulty swallowing) and contracture of muscle multiple sites (muscles, tendons, joints, or other tissues tighten or shorten causing a deformity).<BR/>Record review of Resident #35's quarterly MDS assessment with an ARD of 01/09/2024 reflected she was not a candidate for a BIMS which signified she was severely cognitively impaired. She could usually understand and usually be understood. She was not coded to have oxygen therapy while a resident. She required total assistance with her ADL's.<BR/>Record review of Resident #35's comprehensive person-centered care plan revised date 01/19/2024, Focus, has an ADL, self-care performance deficit, mobility, transfers, eating, bathing, dressing and personal hygiene. Resident #35's comprehensive care plan did not address oxygen therapy.<BR/>Record review of Resident #35's Active Orders as of: 02/02/2024 reflected 02 at 2-5L per NC to maintain sp02 &gt;90% every shift .for dyspnea (difficulty breathing) .Active 01/02/2024.<BR/>Record review of Resident #35's progress notes for the week of 01/02/2024 to 01/09/2024 reflected she was on Oxygen therapy at 2L/NC.<BR/>Observation on 02/20/2024 at 10:23 AM of Resident #35 revealed she was lying in bed and had oxygen infusing at 2.5 L/min via NC.<BR/>Observation on 02/22/2024 at 09:30 AM of Resident #35 revealed she was lying in bed and had oxygen infusing at 2.5 L/min via NC.<BR/>Observation on 02/22/2024 at 11:50 AM of RN F provide G-tube medication to Resident #35 revealed Resident #69 was on oxygen therapy.<BR/>Interview on 02/22/2024 at 11:55 AM with RN F who was Resident #35's nurse, she stated the resident was on continuous oxygen therapy for at least a month.<BR/>Interview on 02/24/2024 at 2:00 PM with the MDS nurse, she stated Resident #35 was on oxygen therapy and it was within the look back time and it should have been coded and the care plan revised. She did not know why they were not. She stated it was important for the resident's care plan to be revised as changes in care occur to keep nursing staff informed.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON, she stated Resident #35's care plan was not revised as required and it was important to be correct to communicate to nursing staff the care required for the resident. She stated she was accountable for overseeing the care plans.<BR/>Record review of the facility's undated Comprehensive Care Planning policy, from the Nursing Policy & Procedure Manual, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the 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 comprehensive assessment .Each resident will have a person-centered comprehensive care plan developed and implement to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs . The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 4 of 8 residents (Residents #37, #49, #31, and #54) reviewed for storage.<BR/>1. Resident #37's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened.<BR/>2. Resident #49's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened. <BR/>3. Resident #31's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened.<BR/>4. Resident #54's insulin (Novolog) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened.<BR/>These failures could place residents at risk of having not therapeutic effects by using old insulins. <BR/>The findings were:<BR/>1. Record review of Resident #37's face sheet, dated [DATE], revealed Resident #37 was a [AGE] year-old male and admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses of paraplegia (inability to voluntarily move the lower parts of the body), radiculopathy (injury or damage to nerve roots in the area where they leave the spine), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and muscle weakness. <BR/>Record review of Resident #37's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognition was intact, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #37's physician's order, dated [DATE], revealed the resident had the order of Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 50 unit subcutaneously two times a day for type 2 diabetes mellitus. <BR/>Record review of Resident #37's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 50 unit subcutaneously two times a day for type 2 diabetes mellitus at 8:00 am and 8:00 pm. <BR/>Observation on [DATE] at 2:47 p.m. revealed Resident #37's insulin Glargine (Lantus) for diabetes with no open date inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #37's insulin Glargine (Lantus) for diabetes with no open date was inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #37's insulin Glargine (Lantus) for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #37's insulin pen.<BR/>2. Record review of Resident #49's face sheet, dated [DATE], revealed Resident #49 was a [AGE] year-old male and admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses of atherosclerosis of coronary artery bypass graft (over time arteries can become narrowed and hardened by the build-up of fatty called plaques), hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and hypertension (high blood pressure). <BR/>Record review of Resident #49's Annual MDS, dated [DATE], revealed the resident's BIMS score was 13 out of 15, which indicated the resident's cognition was intact, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #49's physician's order, dated [DATE], revealed the resident had the order of Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 15 unit subcutaneously at bedtime for type 2 diabetes mellitus. <BR/>Record review of Resident #49's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 15 unit subcutaneously at bedtime for type 2 diabetes mellitus at 8:00 pm. <BR/>Observation on [DATE] at 2:47 p.m. revealed Resident #49's insulin Glargine (Lantus) for diabetes with no open date inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #49's insulin Glargine (Lantus) for diabetes with no open date was inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #49's insulin Glargine (Lantus) for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #49's insulin pen.<BR/>3. Record review of Resident #31's face sheet, dated [DATE], revealed Resident #31 was a [AGE] year-old female and admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses of type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), and muscle weakness. <BR/>Record review of Resident #31's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 1 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #31's physician's order, dated [DATE], revealed the resident had the order of Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 10 unit subcutaneously two times a day for type 2 diabetes mellitus. <BR/>Record review of Resident #31's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 10 unit subcutaneously two times a day for type 2 diabetes mellitus at 10:00 am and 4:00 pm. <BR/>Observation on [DATE] at 2:47 p.m. revealed Resident #31's insulin Glargine (Lantus) for diabetes with no open date inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #31's insulin Glargine (Lantus) for diabetes with no open date was inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #31's insulin Glargine (Lantus) for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #31's insulin pen.<BR/>4. Record review of Resident #54's face sheet, dated [DATE], revealed Resident #54 was a [AGE] year-old female and admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses of senile degeneration of brain (progressive decline in cognitive function, impacting memory, and reasoning), pneumonia (infection to the lung), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and muscle weakness. <BR/>Record review of Resident #54's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 4 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #54's physician's order, dated [DATE], revealed the resident had the order of Novolog injection solution 100 unit/ml - inject per sliding scale subcutaneously before meals for type 2 diabetes mellitus. <BR/>Record review of Resident #54's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Novolog injection solution 100 unit/ml - inject per sliding scale subcutaneously before meals for type 2 diabetes mellitus at 7:00 am, 11:00 am, and 4:00 pm. <BR/>Observation on [DATE] at 2:47 p.m. revealed Resident #54's insulin Novolog for diabetes with no open date inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #54's insulin Novolog for diabetes with no open date was inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #54's insulin Novolog for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #54's insulin pen.<BR/>Interview on [DATE] at 2:57 p.m. the DON said the facility nurses should have written open dates on insulins when they opened them to discard them 28 days after opened. Nurses would not know when they have to discard insulins if insulins did not have open dates, and it might cause improper use, and residents might not have therapeutic effects. DON said that it was nurse' responsibility, and DON and ADON sometimes reviewed nursing carts, but they did not know what reason nurses did not write the open dates. <BR/>Record review of the facility's policy, titled Insulin Expiration, undated, revealed . 2. All insulin, once opened or removed from the refrigerator must be dated. 3. All insulin, once or removed from refrigerator expired in 28 days and must be taken out of use and be replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain medical records on each resident that are-accurately documented for 1 (Resident #44) of 24 residents reviewed for accurate medical records in that:<BR/>LVN F initialed off on Resident #44's MAR that the resident's compression stockings were applied on 02/22/2024, when they were not.<BR/>This deficient practice could affect residents who have medical records and could result in misinformation about professional care provided.<BR/>The findings included:<BR/>Record review of Resident #44's electronic face sheet, dated 02/20/2024, revealed the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: diabetes mellitus (a disease of inadequate control of blood levels of glucose), atherosclerotic heart disease (a common condition that develops when plaque builds up inside the arteries), obstructive sleep apnea (when the throat muscles relax and block the airway), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should).<BR/>Record review of Resident #44's quarterly MDS assessment with an ARD of 12/22/2023 revealed the resident scored a 15/15 on his BIMS which signified he was cognitively intact, and required moderate assistance with his ADL's. Further review revealed the resident was coded to have an active diagnosis of congestive heart failure (CHF) (a long-term condition that happens when the heart cannot pump blood well enough to give a body a normal supply, blood and fluid can collect in the lungs and legs).<BR/>Record review of Resident #44's comprehensive care plan, revised date 10/01/2020, revealed, Focus, at risk for breakdown r/t decreased mobility, occasional incontinence, edema and CHF (Congestive Heart Failure). Further review revealed the resident's need for compression stockings were not reflected as an intervention for the resident's edema.<BR/>Record review of Resident #44's Active Orders as of: 02/20/2024 reflected Check edema every shift every shift Active 12/28/2022 .Compression stockings to BLE. Apply in AM and remove at HS one time a day for edema Active 12/05/2023.<BR/>Record review of Resident #44's MAR for February 2024 revealed the resident was being checked for edema each shift and his compression stockings were applied in the morning and taken off in the evening to include 02/22/2024 being initialed off as having been applied.<BR/>Observation on 02/22/2024 at 09:30 AM of Resident #44 revealed he was sitting in his room in a wheelchair. Further observation revealed the resident had [NAME] stockings on. <BR/>In an interview on 02/22/2024 at 09:40 AM with Resident #44, he stated he did not always get his special stockings applied.<BR/>Interview with LVN F on 02/23/2024 at 1:00 PM, LVN F stated she relied on the aides to put on Resident #44's compression stockings. LVN F stated the resident was supposed to get them put on in the morning and taken off at bedtime. LVN F stated she had not checked and initialed off that the resident had them put on. LVN F stated she should have checked, but she relied on the aides to tell her if they were not applied.<BR/>Interview with the DON on 02/24/2024 at 2:10 PM, the DON stated LVN F should not have initialed off on Resident #44's MAR that the resident's compression stockings were applied because they were not, and that would be false documentation. The DON stated she was accountable for the nursing staff and needed to remind them to check the residents prior to initialing off in the MAR.<BR/>Review of the facility policy and procedure titled Documentation-Nursing (undated) reflected Nursing documentation will be concise, clear, pertinent, accurate and evidence based .medication administration records and treatment administration records are completed with each medication or treatment completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 (Residents #35, #36, #44 and #56) of 16 residents reviewed for care plans.<BR/>1. Resident #35's comprehensive care plan did not address she was contracted in her hands.<BR/>2. Resident #36's comprehensive care plan did not address all areas affected by the resident's hemiplegia.<BR/>3. Resident #44's compression stockings were not reflected in the resident's care plan.<BR/>4. Resident #56's Renal Diet was not reflected in his care plan.<BR/>These failures placed residents at risk of not receiving needed care and services in accordance with their individually assessed needs which could result in not having their needs met and a decreased quality of life and quality of care.<BR/>The findings included:<BR/>1. Record review of Resident #35's electronic face sheet dated 02/21/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks), bacteremia (viable bacteria in the blood), pressure ulcer of right hip, stage IV (may look like a reddish crater in the skin. Muscles, bones, and/or tendons may also be visible at the bottom of the stage IV), dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), dysphagia (difficulty swallowing) and contracture of muscle multiple sites (muscles, tendons, joints, or other tissues tighten or shorten causing a deformity).<BR/>Record review of Resident #35's quarterly MDS assessment with an ARD of 01/09/2024 revealed the resident was not a candidate for a BIMS which signified she was severely cognitively impaired. Further review revealed the resident could usually understand and usually be understood, was noted to have No impairment of her Upper extremities (shoulder, elbow, wrist, and hand), and required total assistance with her ADL's.<BR/>Record review of Resident #35's comprehensive person-centered care plan revised date 01/19/2024, Focus, has an ADL, self-care performance deficit, mobility, transfers, eating, bathing, dressing and personal hygiene. Further review revealed Resident #35's comprehensive care plan did not address her contractures.<BR/>Observation on 02/20/2024 at 10:23 AM of Resident #35 revealed she was lying in bed and had a rolled-up washcloth in her right hand which appeared contracted. Further observation revealed the resident's left had was contracted.<BR/>Observation on 02/22/2024 at 11:50 AM of RN F provided G-tube medication to Resident #69 and the resident had contracted hands.<BR/>Interview on 02/22/2024 at 11:55 AM with RN F who was Resident #69's nurse, she stated Resident #69's hands were contracted.<BR/>Interview on 02/24/2024 at 2:00 PM with the MDS Nurse, she stated Resident #69's comprehensive care plan did not reflect the resident's hand contractions. The MDS Nurse stated it was important for the care plan to be accurate because it provides information for the resident's care, she could miss needed care without it being addressed.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON, she stated Resident #69's care plan did not reflect her contractions and it was important to be in the care plan to communicate to nursing staff the care required for the resident. She stated she was accountable for overseeing the care plans.<BR/>2. Review of Resident #36's face sheet, dated 2/24/24, revealed the resident was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis (paralysis on one side) following Cerebral Infarction (stroke) affecting non-dominant side and memory deficit following Cerebral Infarction.<BR/>Review of Resident #36's MDS assessment, dated 1/25/24, revealed her BIMS was 3 reflecting severe cognitive impairment and she was dependent for eating, toileting hygiene, shower, upper and lower body dressing, putting and taking off footwear and personal hygiene.<BR/>Review of Resident #36's Care Plan, revised 2/2/24 revealed, The resident requires assistance with ADLs. bed mobility, transfers, locomotion, dressing, toilet use, eating, personal hygiene and bathing. The interventions only addressed Resident #36 was totally dependent for bed mobility and transfers. It did not reflect the level of assistance Resident #36 required for the other ADLs. Further review revealed the Care Plan identified Resident #36 was hemiplegic but there were no interventions included on how staff would assist Resident #36 related to being hemiplegic.<BR/>Interview on 02/23/24 at 11:26 AM with MDS Coordinator revealed Resident #36's Care Plan's interventions only addressed bed mobility and transfer and there were no interventions for hermiparesis. The MDS Coordinator stated the Care Plan was started but never completed. MDS Coordinator stated it was important to ensure the Care Plan accurately reflected the care and services Resident #36 needed because the information transferred to Resident #36's [NAME]. The MDS Coordinator further stated the CNA's relied on this information to determine the level of care Resident #36 required.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON revealed it was important for it to be her care plan to communicate to nursing staff the care required for the resident. The DON stated she was accountable for overseeing the care plans.<BR/>3. Record review of Resident #44's electronic face sheet, dated 02/20/2024, revealed the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: diabetes mellitus (a disease of inadequate control of blood levels of glucose), atherosclerotic heart disease (a common condition that develops when plaque builds up inside the arteries), obstructive sleep apnea (when the throat muscles relax and block the airway), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should).<BR/>Record review of Resident #44's quarterly MDS assessment with an ARD of 12/22/2023 revealed the resident scored a 15/15 on his BIMS which signified he was cognitively intact, and required moderate assistance with his ADL's. Further review revealed the resident was was coded to have an active diagnosis of congestive heart failure (CHF) (a long-term condition that happens when the heart cannot pump blood well enough to give a body a normal supply, blood and fluid can collect in the lungs and legs).<BR/>Record review of Resident #44's comprehensive care plan revised date 10/01/2020 reflected Focus, at risk for breakdown r/t decreased mobility, occasional incontinence, edema and CHF (Congestive Heart Failure). Further review revealed the resident's need for compression stockings was not reflected as an intervention for his edema.<BR/>Record review of Resident #44's Active Orders as of: 02/20/2024 reflected Check edema every shift every shift Active 12/28/2022 .Compression stockings to BLE. Apply in AM and remove at HS one time a day for edema Active 12/05/2023.<BR/>Record review of Resident #44's MAR for February 2024 reflected he was being checked for edema each shift and his compression stockings were applied in the morning and taken off in the evening.<BR/>Observation on 02/22/2024 at 09:30 AM of Resident #44 revealed he was sitting in his room in a wheelchair and the resident had [NAME] (a pattern used on items of clothing such as socks or sweaters, consisting of diamond shapes of various colors) socks on. <BR/>In an interview on 02/22/2024 at 09:40 AM with Resident #44, he stated he does not always get his special stockings applied.<BR/>Observation on 02/23/2024 at 10:00 AM of Resident #44 revealed he was sitting in his room in a wheelchair. Further observation revealed the resident had black compression stockings on his BLE's. <BR/>Interview on 02/23/2024 at 10:05 AM with Resident #44, he stated he wore the special stockings to keep his lower legs from swelling. <BR/>Interview on 02/23/2024 at 1:00 PM with LVN F, she stated she relied on the aides to put on Resident #44's compression stockings. LVN F stated he was supposed to get them put on in the morning and taken off at bedtime. LVN F stated the resident's compression stockings should be in his care plan because he needed them.<BR/>Interview on 02/24/2024 at 2:00 PM with the MDS Nurse, she stated Resident #44's comprehensive care plan did not reflect the resident's compression stockings. The MDS Nurse stated it was important for the care plan to be accurate because it provides information for the resident's care, the resident could miss needed care without it being addressed.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON, she stated Resident #44's care plan did not reflect the resident's compression stockings, she stated it was important for it to be in his care plan to communicate to nursing staff the care required for the resident. The DON stated she was accountable for overseeing the care plans.<BR/>4. Record review of Resident #56's electronic face sheet, dated 02/20/2024, revealed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included: hypertension (when the pressure in the blood vessels is too high), diabetes mellitus (a disease of inadequate control of blood levels of glucose), chronic atrial fibrillation (an irregular heart rhythm), renal disease (when chronic kidney disease causes loss of kidney function) and unspecified protein-calorie malnutrition (the lack of sufficient energy or protein to meet the body's metabolic demands).<BR/>Record review of Resident #56's quarterly MDS assessment with an ARD of 11/17/2023 reflected he scored a 14/15 on his BIMS which signified he was cognitively intact, and required extensive assistance with his ADL's. Further review revealed the resident was on a therapeutic diet and had an active diagnosis of renal disease.<BR/>Record review of Resident #56's comprehensive care plan revised 02/28/2022 reflected, Focus, has DX/HX Renal Disease, Interventions/Tasks, ensure resident is ready for dialysis, remind dietary of need for to go meal to take with them. Further review revealed the resident's therapeutic diet, a renal diet was not addressed in his care plan.<BR/>Record review of Resident #56's Active Orders as of: 02/20/2024 reflected, Renal diet Regular texture, Regular/Thin consistency Active 05/04/2023.<BR/>Observation on 02/20/2024 at 12:30 PM of Resident #56 in the dining room and record review of his meal ticket reflected, Renal Diet.<BR/>In an interview on 02/20/2024 at 12:35 PM with Resident #56, he stated he received extra protein servings, and was on a special diet.<BR/>Interview on 02/24/2024 at 2:00 PM with the MDS Nurse, she stated Resident #56's comprehensive care plan did not reflect his renal diet. The MDS Nurse stated it was important for the care plan to be accurate because it provides information for the resident's care, she could miss needed care without it being addressed.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON, she stated Resident #56's care plan did not reflect the resident's renal diet, she stated it was important for it to be in his care plan to communicate to nursing staff the care required for the resident. The DON stated she was accountable for overseeing the care plans.<BR/>Record review of the facilities policy and procedure titled Comprehensive Care Plans (undated) reflected, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 8 residents (Resident #18) who were observed for call light placement. <BR/>The facility failed to ensure the call light was within reach for Resident #18.<BR/>This failure could affect any resident and keep them from calling for help as needed.<BR/>The findings were:<BR/>Record review of Resident #18's face sheet, dated 04/02/2025, revealed he was admitted to the facility on [DATE] with diagnoses which included: epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), unspecified, not intractable, with status epilepticus (a seizure that lasts longer than 5 minutes or when seizures occur in rapid succession without the person regaining consciousness between them), essential hypertension (high blood pressure), muscle weakness generalized, and unspecified dementia (a group of symptoms affecting memory, thinking and social abilities, unspecified severity, without behavioral disturbance, psychotic disturbance and anxiety. <BR/>Record review of Resident #18's Quarterly MDS assessment, dated 02/21/2025, revealed the resident's BIMS score was 00, which indicated severe cognitive impairment. The Quarterly MDS assessment further revealed Resident #18 was dependent (helper does all of the effort) for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, personal hygiene, putting on/taking off footwear, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, tub/shower transfer, and roll left and right. <BR/>Record review of Resident #18's care plan, last care plan review completed date of 03/31/2025, revealed Resident #18 had a focus of [resident's name] is at risk for fall due to periods of unsteady gait, resident also noncompliant with staff assistance. and interventions read Call light in reach in room and answered promptly. Encourage and remind him to use call light to ask for assistance.<BR/>Observation on 04/01/2025 at 10:50 a.m. revealed Resident #18 sleeping in his bed, bed in the lowest position to the floor with call light clipped to privacy curtain. <BR/>Observation on 04/02/2025 at 9:36 a.m. revealed Resident #18 sleeping in his bed, bed in the lowest position to the floor, lying on his side with the call light clipped to the privacy curtain. <BR/>Observation and interview on 04/02/2025 at 9:57 a.m. CNA E stated Resident #18 would scream a lot at times and would yell for things. CNA E further stated normally he does not use his call light, but she goes in there to check on him during her rounds. CNA E revealed Resident #18 would not have been able to reach the call light if he needed it. CNA E then removed the call light from the curtain and clipped to his blanket and explained to him what she was doing when he began yelling as he was resting in the bed. CNA E stated to Resident #18 I'm giving you your call light, and Resident #18 responded okay as he went back to sleep. CNA E stated the call light was used for residents to ask for help if they needed her and it was her responsibility to place it where he could reach it. <BR/>During interview on 04/04/2025 at 2:17 p.m. the DON stated the call light should be near the resident where they can grab it. The DON further stated when in the bed it should be always accessible. The DON stated the CNA and the nurse on the floor were responsible for placing it within reach and when they went in the room, they should have seen it and corrected it. The DON stated by being out of reach the resident would not be able to press it if they needed assistances. <BR/>During an interview on 04/04/2025 at 2:21 p.m. the administrator stated staff in general were responsible for call light placement, but usually the CNA. The administrator further stated when anyone went in or during rounds anyone can place within reach. The administrator stated by not having the call light a resident might not get their needs met. The administrator stated he believed Resident #18 did not use it and the staff rounded on him frequently. <BR/>Record review of facility's Call Lights policy, no date, read The purpose of this procedure is to respond to the resident's requests and needs., General Guidelines .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 resident (Resident #35) of 24 residents reviewed for MDS assessments.<BR/>Resident #35's MDS assessment did not accurately reflect she had limitations on her upper extremities and she was on continuous oxygen therapy.<BR/>This deficient practice could result in missed or inaccurate care.<BR/>The findings included:<BR/>Record review of Resident #35's electronic face sheet dated 02/21/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks), bacteremia (viable bacteria in the blood), pressure ulcer of right hip, stage IV (may look like a reddish crater in the skin. Muscles, bones, and/or tendons may also be visible at the bottom of the stage IV), dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), dysphagia (difficulty swallowing) and contracture of muscle multiple sites (muscles, tendons, joints, or other tissues tighten or shorten causing a deformity).<BR/>Record review of Resident #35's quarterly MDS assessment with an ARD of 01/09/2024 reflected she was not a candidate for a BIMS which signified she was severely cognitively impaired. She could usually understand and usually be understood. She was noted to have No impairment of her Upper extremities (shoulder, elbow, wrist, and hand). She was not coded to have oxygen therapy while a resident. She required total assistance with her ADL's.<BR/>Record review of Resident #35's comprehensive person-centered care plan revised date 01/19/2024, Focus, has an ADL, self-care performance deficit, mobility, transfers, eating, bathing, dressing and personal hygiene. Resident #35's comprehensive care plan did not address her contractures or oxygen therapy.<BR/>Record review of Resident #35's Active Orders as of: 02/02/2024 reflected 02 at 2-5L per NC to maintain sp02 &gt;90% every shift .for dyspnea .Active 01/02/2024.<BR/>Record review of Resident #35's progress notes for the week of 01/02/2024 to 01/09/2024 reflected she was on Oxygen therapy at 2L/NC.<BR/>Observation on 02/22/2024 at 09:30 AM of Resident #35 revealed she was lying in bed and had oxygen infusing at 2.5 L/min via NC.<BR/>Observation on 02/20/2024 at 10:23 AM of Resident #35 revealed she was lying in bed and had oxygen infusing at 2.5 L/min via NC, and she had a rolled-up washcloth in her right hand which appeared contracted. Her left hand was contracted.<BR/>Observation and interview on 02/22/2024 at 11:50 AM, RN F provided G-tube (is a tube inserted through the belly that brings nutrition directly to the stomach) medication to Resident #69, she was in bed on oxygen therapy and her bilateral hands contracted. RN F stated Resident #69's hands wasere contracted and was on continuous oxygen therapy for at least a month.<BR/>Interview on 02/24/2024 at 2:00 PM with the MDS nurse, she stated Resident #69's quarterly MDS with an ARD of 01/09/2024 was inaccurate. She stated the resident was on oxygen therapy and it was within the look back time and it should have been coded. She stated Resident #69's upper limitations should have been coded. She did not know why they were not. She stated it was important for the MDS to be accurate because it provides information for the resident's care plan and she could miss needed care without it being addressed.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON, she stated Resident #69's MDS was inaccuratei, and it was important to be correct to communicate to nursing staff the care required for the resident. She stated she was accountable for overseeing the MDS's.<BR/>Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 (Residents #35, #36, #44 and #56) of 16 residents reviewed for care plans.<BR/>1. Resident #35's comprehensive care plan did not address she was contracted in her hands.<BR/>2. Resident #36's comprehensive care plan did not address all areas affected by the resident's hemiplegia.<BR/>3. Resident #44's compression stockings were not reflected in the resident's care plan.<BR/>4. Resident #56's Renal Diet was not reflected in his care plan.<BR/>These failures placed residents at risk of not receiving needed care and services in accordance with their individually assessed needs which could result in not having their needs met and a decreased quality of life and quality of care.<BR/>The findings included:<BR/>1. Record review of Resident #35's electronic face sheet dated 02/21/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks), bacteremia (viable bacteria in the blood), pressure ulcer of right hip, stage IV (may look like a reddish crater in the skin. Muscles, bones, and/or tendons may also be visible at the bottom of the stage IV), dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), dysphagia (difficulty swallowing) and contracture of muscle multiple sites (muscles, tendons, joints, or other tissues tighten or shorten causing a deformity).<BR/>Record review of Resident #35's quarterly MDS assessment with an ARD of 01/09/2024 revealed the resident was not a candidate for a BIMS which signified she was severely cognitively impaired. Further review revealed the resident could usually understand and usually be understood, was noted to have No impairment of her Upper extremities (shoulder, elbow, wrist, and hand), and required total assistance with her ADL's.<BR/>Record review of Resident #35's comprehensive person-centered care plan revised date 01/19/2024, Focus, has an ADL, self-care performance deficit, mobility, transfers, eating, bathing, dressing and personal hygiene. Further review revealed Resident #35's comprehensive care plan did not address her contractures.<BR/>Observation on 02/20/2024 at 10:23 AM of Resident #35 revealed she was lying in bed and had a rolled-up washcloth in her right hand which appeared contracted. Further observation revealed the resident's left had was contracted.<BR/>Observation on 02/22/2024 at 11:50 AM of RN F provided G-tube medication to Resident #69 and the resident had contracted hands.<BR/>Interview on 02/22/2024 at 11:55 AM with RN F who was Resident #69's nurse, she stated Resident #69's hands were contracted.<BR/>Interview on 02/24/2024 at 2:00 PM with the MDS Nurse, she stated Resident #69's comprehensive care plan did not reflect the resident's hand contractions. The MDS Nurse stated it was important for the care plan to be accurate because it provides information for the resident's care, she could miss needed care without it being addressed.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON, she stated Resident #69's care plan did not reflect her contractions and it was important to be in the care plan to communicate to nursing staff the care required for the resident. She stated she was accountable for overseeing the care plans.<BR/>2. Review of Resident #36's face sheet, dated 2/24/24, revealed the resident was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis (paralysis on one side) following Cerebral Infarction (stroke) affecting non-dominant side and memory deficit following Cerebral Infarction.<BR/>Review of Resident #36's MDS assessment, dated 1/25/24, revealed her BIMS was 3 reflecting severe cognitive impairment and she was dependent for eating, toileting hygiene, shower, upper and lower body dressing, putting and taking off footwear and personal hygiene.<BR/>Review of Resident #36's Care Plan, revised 2/2/24 revealed, The resident requires assistance with ADLs. bed mobility, transfers, locomotion, dressing, toilet use, eating, personal hygiene and bathing. The interventions only addressed Resident #36 was totally dependent for bed mobility and transfers. It did not reflect the level of assistance Resident #36 required for the other ADLs. Further review revealed the Care Plan identified Resident #36 was hemiplegic but there were no interventions included on how staff would assist Resident #36 related to being hemiplegic.<BR/>Interview on 02/23/24 at 11:26 AM with MDS Coordinator revealed Resident #36's Care Plan's interventions only addressed bed mobility and transfer and there were no interventions for hermiparesis. The MDS Coordinator stated the Care Plan was started but never completed. MDS Coordinator stated it was important to ensure the Care Plan accurately reflected the care and services Resident #36 needed because the information transferred to Resident #36's [NAME]. The MDS Coordinator further stated the CNA's relied on this information to determine the level of care Resident #36 required.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON revealed it was important for it to be her care plan to communicate to nursing staff the care required for the resident. The DON stated she was accountable for overseeing the care plans.<BR/>3. Record review of Resident #44's electronic face sheet, dated 02/20/2024, revealed the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: diabetes mellitus (a disease of inadequate control of blood levels of glucose), atherosclerotic heart disease (a common condition that develops when plaque builds up inside the arteries), obstructive sleep apnea (when the throat muscles relax and block the airway), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should).<BR/>Record review of Resident #44's quarterly MDS assessment with an ARD of 12/22/2023 revealed the resident scored a 15/15 on his BIMS which signified he was cognitively intact, and required moderate assistance with his ADL's. Further review revealed the resident was was coded to have an active diagnosis of congestive heart failure (CHF) (a long-term condition that happens when the heart cannot pump blood well enough to give a body a normal supply, blood and fluid can collect in the lungs and legs).<BR/>Record review of Resident #44's comprehensive care plan revised date 10/01/2020 reflected Focus, at risk for breakdown r/t decreased mobility, occasional incontinence, edema and CHF (Congestive Heart Failure). Further review revealed the resident's need for compression stockings was not reflected as an intervention for his edema.<BR/>Record review of Resident #44's Active Orders as of: 02/20/2024 reflected Check edema every shift every shift Active 12/28/2022 .Compression stockings to BLE. Apply in AM and remove at HS one time a day for edema Active 12/05/2023.<BR/>Record review of Resident #44's MAR for February 2024 reflected he was being checked for edema each shift and his compression stockings were applied in the morning and taken off in the evening.<BR/>Observation on 02/22/2024 at 09:30 AM of Resident #44 revealed he was sitting in his room in a wheelchair and the resident had [NAME] (a pattern used on items of clothing such as socks or sweaters, consisting of diamond shapes of various colors) socks on. <BR/>In an interview on 02/22/2024 at 09:40 AM with Resident #44, he stated he does not always get his special stockings applied.<BR/>Observation on 02/23/2024 at 10:00 AM of Resident #44 revealed he was sitting in his room in a wheelchair. Further observation revealed the resident had black compression stockings on his BLE's. <BR/>Interview on 02/23/2024 at 10:05 AM with Resident #44, he stated he wore the special stockings to keep his lower legs from swelling. <BR/>Interview on 02/23/2024 at 1:00 PM with LVN F, she stated she relied on the aides to put on Resident #44's compression stockings. LVN F stated he was supposed to get them put on in the morning and taken off at bedtime. LVN F stated the resident's compression stockings should be in his care plan because he needed them.<BR/>Interview on 02/24/2024 at 2:00 PM with the MDS Nurse, she stated Resident #44's comprehensive care plan did not reflect the resident's compression stockings. The MDS Nurse stated it was important for the care plan to be accurate because it provides information for the resident's care, the resident could miss needed care without it being addressed.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON, she stated Resident #44's care plan did not reflect the resident's compression stockings, she stated it was important for it to be in his care plan to communicate to nursing staff the care required for the resident. The DON stated she was accountable for overseeing the care plans.<BR/>4. Record review of Resident #56's electronic face sheet, dated 02/20/2024, revealed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included: hypertension (when the pressure in the blood vessels is too high), diabetes mellitus (a disease of inadequate control of blood levels of glucose), chronic atrial fibrillation (an irregular heart rhythm), renal disease (when chronic kidney disease causes loss of kidney function) and unspecified protein-calorie malnutrition (the lack of sufficient energy or protein to meet the body's metabolic demands).<BR/>Record review of Resident #56's quarterly MDS assessment with an ARD of 11/17/2023 reflected he scored a 14/15 on his BIMS which signified he was cognitively intact, and required extensive assistance with his ADL's. Further review revealed the resident was on a therapeutic diet and had an active diagnosis of renal disease.<BR/>Record review of Resident #56's comprehensive care plan revised 02/28/2022 reflected, Focus, has DX/HX Renal Disease, Interventions/Tasks, ensure resident is ready for dialysis, remind dietary of need for to go meal to take with them. Further review revealed the resident's therapeutic diet, a renal diet was not addressed in his care plan.<BR/>Record review of Resident #56's Active Orders as of: 02/20/2024 reflected, Renal diet Regular texture, Regular/Thin consistency Active 05/04/2023.<BR/>Observation on 02/20/2024 at 12:30 PM of Resident #56 in the dining room and record review of his meal ticket reflected, Renal Diet.<BR/>In an interview on 02/20/2024 at 12:35 PM with Resident #56, he stated he received extra protein servings, and was on a special diet.<BR/>Interview on 02/24/2024 at 2:00 PM with the MDS Nurse, she stated Resident #56's comprehensive care plan did not reflect his renal diet. The MDS Nurse stated it was important for the care plan to be accurate because it provides information for the resident's care, she could miss needed care without it being addressed.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON, she stated Resident #56's care plan did not reflect the resident's renal diet, she stated it was important for it to be in his care plan to communicate to nursing staff the care required for the resident. The DON stated she was accountable for overseeing the care plans.<BR/>Record review of the facilities policy and procedure titled Comprehensive Care Plans (undated) reflected, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 Resident (Resident #38) whose records were reviewed for oxygen care.<BR/>The facility failed to ensure Resident #38's oxygen concentrator was cleaned and the filter was not covered in lint. <BR/>This deficient practice could affect residents residents on oxygen at risk of decreased efficiency of the concentrator and infection.<BR/>The findings were:<BR/>Review of Resident #38's face sheet, dated 2/21/24, revealed she was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (lungs are susceptible to infections) and Chronic Systolic (Congestive) Heart Failure. <BR/>Review of Resident #38's quarterly MDS assessment, dated 1/28/23, revealed her BIMS was a 15 reflective of no cognitive impairment and she was receiving Hospice care and on oxygen therapy.<BR/>Review of Resident #38's Care Plan, revised on 1/24/24, revealed Resident #38 had oxygen therapy related to Congestive Heart Failure.<BR/>Review of Resident #38's consolidated physician orders revealed an order for oxygen, 2l-5l via n/c continuous. Further review did not reveal instructions for the maintenance of the filter, oxygen tubing or humidifier.<BR/>Observation on 02/20/24 at 11:14 AM revealed there was an oxygen sign on Resident #38's door. Resident #38 was sitting on the side of the bed, in lower position, with oxygen infusing via a nasal cannula at 3 liters per hour. Further observation revealed the oxygen concentrator's filter had built up lint on the filter that was white in color. <BR/>Observation on 02/21/24 at 9:21 AM revealed Resident #38 was lying in bed with oxygen infusing via nasal cannula at 3 liters per hour. Further observation revealed the oxygen concentrator's filter had built up lint on the filter that was white in color. <BR/>Interview with MA V and LVN H on 02/21/24 at 9:21 AM, at the same time as the observation, revealed MA V and LVN H stated Resident #38's oxygen concentrator's filter was white because of the built up lint. LVN H stated she was new and did not know the process of cleaning the filters but would find out. MA V stated the oxygen concentrator filter was, really dirty. <BR/>Interview on 02/23/24 at 4:00 PM with the DON revealed the nursing staff should clean the oxygen filters every Sunday. The DON further stated if it was a hospice oxygen concentrator then nursing staff should call hospice and they would provide clean filters. The DON stated either way nursing staff should ensure the filter was cleaned to ensure it provided a clean air path because residents using oxygen were susceptible to upper respiratory infections. The DON stated it was her responsibility to ensure this was done. The DON stated the Administrator had audited all oxygen concentrators last week and Resident #38's filter was probably skipped over because she was receiving hospice services.<BR/>Review of facility policy, Oxygen Administration undated, read: Purpose: To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. Procedures 9. Check and clean oxygen equipment (including filter), masks, tubing and cannula. If visibly soiled, or otherwise known to be contaminated, replace masks, tubing and/or cannula. Regular replacement intervals are not required, but not otherwise prohibited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 5 of 8 residents (Residents ##28, #25, #37, #31. and #38) reviewed for pharmacy services.<BR/>1. Resident #28's insulin flex pen (Humalog) for diabetes had an open date of [DATE] found inside the 100/200-hall nursing cart on [DATE]. It should have been discarded 28 days after opening.<BR/>2. Resident #25's insulin (Lispro) for diabetes had an open date of [DATE] found inside the 100/200-hall nursing cart on [DATE]. It should have been discarded 28 days after opening. <BR/>3. Resident #37's insulin (Novolog) for diabetes had an open date of [DATE] found inside the 100/200-hall nursing cart on [DATE]. It should have been discarded 28 days after opening.<BR/>4. Resident #31's insulin (Novolog) for diabetes had an open date of [DATE] found inside the 100/200-hall nursing cart on [DATE]. It should have been discarded 28 days after opening.<BR/>5. The facility nurses did not administer Resident #38's Lorazepam 0.5 mg oral one tablet at bedtime for anxiety on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (total 10 days) because the medication was not available, and nurses did not re-order it on time. <BR/>These failures could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. <BR/>The findings included: <BR/>1. Record review of Resident #28's face sheet, dated [DATE], revealed Resident #28 was a [AGE] year-old female and admitted to the facility [DATE] with diagnoses of schizoaffective disorder (mental health problem psychosis as well as mood symptoms), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), muscle weakness, dysphagia (difficulty of swallowing), and hyperlipidemia (high level of fat). <BR/>Record review of Resident #28's Quarterly MDS assessment, dated [DATE], revealed the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #28's physician's order, dated [DATE], revealed the resident had the order of Humalog Kwik Pen subcutaneous Solution Pen Injector 100 unit/ml (insulin Lispro) inject as per sliding scale: if 70-150=no insulin, 151-200=1 units, 201-250=2 units, 251-300=3 units, 301-350= 4 units, if blood sugar over 350 5 units, subcutaneously before meals for diabetes.<BR/>Record review of Resident #28's medication administration record, dated from [DATE] to [DATE], revealed Resident #28 was receiving Humalog Kwik Pen subcutaneous Solution Pen Injector 100 unit/ml (insulin Lispro) inject as per sliding scale at 7:00 am, 11:00 am, and 4:00 pm. <BR/>Observation on [DATE] at 2:41 p.m. revealed Resident #28's insulin Kwik pen (Lispro=Humalog) for diabetes with open date of [DATE] inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:41 a.m. with LVN-D stated Resident #28's insulin Kwik pen (Lispro=Humalog) for diabetes with open date of [DATE] inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #28's insulin Kwik pen (Lispro=Humalog) for diabetes should have been discarded 28 days after opening, which was [DATE] because the nurses opened it on [DATE]. LVN-D did not know what reason the nurses did not discard the insulin pen. <BR/>2. Record review of Resident #25's face sheet, dated [DATE], revealed Resident #25 was an [AGE] year-old male and admitted to the facility [DATE] with diagnoses of type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), neurocognitive disorder (decreased mental function), psychosis, and hyperlipidemia (high level of fat). <BR/>Record review of Resident #25's Quarterly MDS assessment, dated [DATE], revealed the resident's BIMS score was 7 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #25's physician's order, dated [DATE], revealed the resident had the order of Insulin Lispro injection solution subcutaneous - inject as per sliding scale: if 0-150=no insulin, 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350= 8 units, 351-400=10 units if blood sugar over 400 give 12 units and notify doctor, subcutaneously two times a day for diabetes.<BR/>Record review of Resident #25's medication administration record, dated from [DATE] to [DATE], revealed Resident #25 was receiving Insulin Lispro subcutaneous Solution - inject as per sliding scale at 8:00 am and 8:00 pm. <BR/>Observation on [DATE] at 2:41 p.m. revealed Resident #25's insulin (Lispro) for diabetes with open date of [DATE] inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:41 a.m. with LVN-D stated Resident #25's insulin (Lispro) for diabetes with open date of [DATE] inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #25's insulin (Lispro) for diabetes should have been discarded 28 days after opening, which was [DATE] because the nurses opened it on [DATE]. LVN-D did not know what reason the nurses did not discard the insulin pen. <BR/>3. Record review of Resident #37's face sheet, dated [DATE], revealed Resident #37 was a [AGE] year-old male and admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses of paraplegia (inability to voluntarily move the lower parts of the body), radiculopathy (injury or damage to nerve roots in the area where they leave the spine), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and muscle weakness. <BR/>Record review of Resident #37's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognition was intact, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #37's physician's order, dated [DATE], revealed the resident had the order of Insulin Novolog injection solution subcutaneous - inject 16 units subcutaneously before meals for diabetes.<BR/>Record review of Resident #37's medication administration record, dated from [DATE] to [DATE], revealed Resident #37 was receiving Insulin Novolog injection solution subcutaneous - inject 16 units subcutaneously before meals for diabetes at 7:00 am, 11:00 am, and 4:00 pm. <BR/>Observation on [DATE] at 2:41 p.m. revealed Resident #37's insulin (Novolog) for diabetes with open date of [DATE] inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:41 p.m. with LVN-D stated Resident #37's insulin (Novolog) for diabetes with open date of [DATE] inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #37's insulin (Novolog) for diabetes should have been discarded 28 days after opening, which was [DATE] because the nurses opened it on [DATE]. LVN-D did not know what reason the nurses did not discard the insulin pen. <BR/>4. Record review of Resident #31's face sheet, dated [DATE], revealed Resident #31was a [AGE] year-old female and admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses of type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), and muscle weakness. <BR/>Record review of Resident #31's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 1 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #31's physician's order, dated [DATE], revealed the resident had the order of Insulin Aspart (Novolog) injection solution subcutaneous - inject as per sliding scale: if 150-199=4 units, 200-249=8 units, 250-299=12 units, 300-349=16 units, 350-400= 20 units and notify doctor, subcutaneously every 6 hours for diabetes.<BR/>Record review of Resident #31's medication administration record, dated from [DATE] to [DATE], revealed Resident #31 was receiving Insulin Aspart (Novolog) injection solution subcutaneous - inject as per sliding scale: if 150-199=4 units, 200-249=8 units, 250-299=12 units, 300-349=16 units, 350-400= 20 units and notify doctor, subcutaneously every 6 hours for diabetes at 2:00 am, 8:00 am, 4:00 pm, and 8:00 pm. <BR/>Observation on [DATE] at 2:41 p.m. revealed Resident #31's insulin (Novolog) for diabetes with open date of [DATE] inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:41 p.m. with LVN-D stated Resident #31's insulin (Novolog) for diabetes with open date of [DATE] inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #31's insulin (Novolog) for diabetes should have been discarded 28 days after opening, which was [DATE] because the nurses opened it on [DATE]. LVN-D did not know what reason the nurses did not discard the insulin pen. <BR/>Interview on [DATE] at 2:42 p.m. the DON stated facility nurses should have discarded insulins for diabetes to 28 days after opening and it was nurse's responsibility. The DON said DON and ADON sometimes reviewed nursing carts, but they did not know what reason these insulins were in the nursing cart. The potential harm was the insulins might be less effective. <BR/>5. Record review of Resident #38's face sheet, dated [DATE], revealed the resident was a [AGE] year-old male, originally admitted on [DATE], and re-admitted to the facility on [DATE] with diagnosis of hypertension (high blood pressure), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), hypokalemia (low level of potassium in the blood), anxiety disorder, muscle weakness, and insomnia (difficulty of sleeping). <BR/>Record review of Resident #38's Annual MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognitive function was intact and receiving antianxiety medication every day as ordered. <BR/>Record review of Resident #38's comprehensive care plan, revised [DATE], revealed At risk for side effects to medications, increased anxiety and anxiousness related to his anxiety. For intervention - encourage and remind resident to ask for and provide assistance as needed and monitor for side effects to medications.<BR/>Record review of Resident #38's physician order, dated [DATE], revealed the resident had the order of Lorazepam oral tablet 0.5 mg - Give one tablet by mouth at bedtime for anxiety.<BR/>Record review of Resident #38's medication administration record, dated from [DATE] to [DATE], revealed the resident was taking Lorazepam 0.5 mg one tablet by mouth at bedtime for anxiety at 7:00 pm as ordered. However, the resident did not receive his Lorazepam 0.5 mg one tablet by mouth at bedtime for anxiety at 7:00 pm on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (total 10 days) because of no medication. Further record review of the medication administration record revealed Resident #38 did not have any anxiety episode and side effect of anti-anxiety medication such as agitation or appetite change for [DATE]. <BR/>Record review of Resident #38's primary care physician's progress note, dated [DATE], revealed Anxiety - on Lorazepam. Will continue on it. No increased anxiety noted. Will monitor for any worsening symptoms and No specific pain issues noted.<BR/>Interview on [DATE] at 8:53 a.m. with Resident #38 stated that he was supposed to receive his Lorazepam every day for his anxiety but did not receive it some days in [DATE] because nurses said they did not have the medication. However, he was receiving his Lorazepam every day in [DATE] without any issues. Further interview with the resident said he did not have any anxiety or side effects in [DATE]. <BR/>Interview on [DATE] at 3:00 p.m. with LVN-B stated that LVN-B received the list of Resident #38's medications that needed to have refill and gave the list to ADON on [DATE]. The medication aide reported to LVN-B that the medication aide could not give Resident #38's Lorazepam on [DATE] to the resident because the medication was not available. LVN-B re-ordered it by calling to the pharmacy. LVN-B stated per the facility policy, nurses had responsibility to reorder medications before medications ran out. LVN-B did not know what reason nurses did not reorder it before Resident #38's Lorazepam ran out. Resident #38 did not have any sign or symptom related to anxiety. <BR/>Interview on [DATE] at 3:15 p.m. with ADON stated she did not receive the list of Resident #38's medications that needed to have refill. Per the facility policy, medication aides should click reorder button on the electronic medication administration record before medications ran out. If medications were not delivered on time, medication aides should report it to charge nurses, and charge nurse should contact physician or pharmacy to make sure reorder and gave medications to residents from emergency kit located in the medication room if the emergency kit had medications. Further interview with ADON said lack of communication among nurses and medication aides might cause missing administrations of Resident #38's Lorazepam for 10 days in [DATE]. <BR/>Interview on [DATE] at 3:16 p.m. with DON said DON became aware of missing administrations of Resident #38's Lorazepam for 10 days in [DATE] on [DATE] because the medication was not available. The DON called the primary care physician and reported it, and Resident #38's primary care physician visited and assessed the resident on face to face on [DATE] and noted the resident did not have any problem or negative outcomes regarding missing administrations of Resident #38's Lorazepam for 10 days in [DATE]. There was Resident #38's Lorazepam in the medication aide cart now, and medication aides administered it to the resident as ordered without any problem. However, it was medication error. The facility nurses should have contacted physician or pharmacy before the medication ran out. The DON said not receiving the medication may cause anxiety to Resident #38. <BR/>Record review of the facility policy, titled Administering medications, undated, revealed . 7. For unavailable, missing or missed medications: a. Notify the charge nurse. b. Unavailable medication: charge nurse will check the ekit to see if dose is available. If not in the ekit, the charge nurse will reach out to facility pharmacy to initiate emergency refill of the cutoff time has already passed for the next scheduled delivery. <BR/>Record review of the facility's policy, titled Insulin Expiration, undated, revealed . 2. All insulin, once opened or removed from the refrigerator must be dated. 3. All insulin, once or removed from refrigerator expired in 28 days and must be taken out of use and be replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 4 of 8 residents (Residents #37, #49, #31, and #54) reviewed for storage.<BR/>1. Resident #37's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened.<BR/>2. Resident #49's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened. <BR/>3. Resident #31's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened.<BR/>4. Resident #54's insulin (Novolog) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened.<BR/>These failures could place residents at risk of having not therapeutic effects by using old insulins. <BR/>The findings were:<BR/>1. Record review of Resident #37's face sheet, dated [DATE], revealed Resident #37 was a [AGE] year-old male and admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses of paraplegia (inability to voluntarily move the lower parts of the body), radiculopathy (injury or damage to nerve roots in the area where they leave the spine), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and muscle weakness. <BR/>Record review of Resident #37's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognition was intact, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #37's physician's order, dated [DATE], revealed the resident had the order of Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 50 unit subcutaneously two times a day for type 2 diabetes mellitus. <BR/>Record review of Resident #37's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 50 unit subcutaneously two times a day for type 2 diabetes mellitus at 8:00 am and 8:00 pm. <BR/>Observation on [DATE] at 2:47 p.m. revealed Resident #37's insulin Glargine (Lantus) for diabetes with no open date inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #37's insulin Glargine (Lantus) for diabetes with no open date was inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #37's insulin Glargine (Lantus) for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #37's insulin pen.<BR/>2. Record review of Resident #49's face sheet, dated [DATE], revealed Resident #49 was a [AGE] year-old male and admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses of atherosclerosis of coronary artery bypass graft (over time arteries can become narrowed and hardened by the build-up of fatty called plaques), hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and hypertension (high blood pressure). <BR/>Record review of Resident #49's Annual MDS, dated [DATE], revealed the resident's BIMS score was 13 out of 15, which indicated the resident's cognition was intact, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #49's physician's order, dated [DATE], revealed the resident had the order of Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 15 unit subcutaneously at bedtime for type 2 diabetes mellitus. <BR/>Record review of Resident #49's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 15 unit subcutaneously at bedtime for type 2 diabetes mellitus at 8:00 pm. <BR/>Observation on [DATE] at 2:47 p.m. revealed Resident #49's insulin Glargine (Lantus) for diabetes with no open date inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #49's insulin Glargine (Lantus) for diabetes with no open date was inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #49's insulin Glargine (Lantus) for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #49's insulin pen.<BR/>3. Record review of Resident #31's face sheet, dated [DATE], revealed Resident #31 was a [AGE] year-old female and admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses of type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), and muscle weakness. <BR/>Record review of Resident #31's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 1 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #31's physician's order, dated [DATE], revealed the resident had the order of Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 10 unit subcutaneously two times a day for type 2 diabetes mellitus. <BR/>Record review of Resident #31's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 10 unit subcutaneously two times a day for type 2 diabetes mellitus at 10:00 am and 4:00 pm. <BR/>Observation on [DATE] at 2:47 p.m. revealed Resident #31's insulin Glargine (Lantus) for diabetes with no open date inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #31's insulin Glargine (Lantus) for diabetes with no open date was inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #31's insulin Glargine (Lantus) for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #31's insulin pen.<BR/>4. Record review of Resident #54's face sheet, dated [DATE], revealed Resident #54 was a [AGE] year-old female and admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses of senile degeneration of brain (progressive decline in cognitive function, impacting memory, and reasoning), pneumonia (infection to the lung), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and muscle weakness. <BR/>Record review of Resident #54's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 4 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #54's physician's order, dated [DATE], revealed the resident had the order of Novolog injection solution 100 unit/ml - inject per sliding scale subcutaneously before meals for type 2 diabetes mellitus. <BR/>Record review of Resident #54's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Novolog injection solution 100 unit/ml - inject per sliding scale subcutaneously before meals for type 2 diabetes mellitus at 7:00 am, 11:00 am, and 4:00 pm. <BR/>Observation on [DATE] at 2:47 p.m. revealed Resident #54's insulin Novolog for diabetes with no open date inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #54's insulin Novolog for diabetes with no open date was inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #54's insulin Novolog for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #54's insulin pen.<BR/>Interview on [DATE] at 2:57 p.m. the DON said the facility nurses should have written open dates on insulins when they opened them to discard them 28 days after opened. Nurses would not know when they have to discard insulins if insulins did not have open dates, and it might cause improper use, and residents might not have therapeutic effects. DON said that it was nurse' responsibility, and DON and ADON sometimes reviewed nursing carts, but they did not know what reason nurses did not write the open dates. <BR/>Record review of the facility's policy, titled Insulin Expiration, undated, revealed . 2. All insulin, once opened or removed from the refrigerator must be dated. 3. All insulin, once or removed from refrigerator expired in 28 days and must be taken out of use and be replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #44) of 5 residents reviewed for infection control in that:<BR/>Resident #44's ventilator mask and oxygen nasal cannula tubing were left unbagged for 2 days when not in use.<BR/>This facility failure affects residents on oxygen therapy and could result in upper respiratory infections.<BR/>The findings included:<BR/>Record review of Resident #44's electronic face sheet, dated 02/20/2024, revealed the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: diabetes mellitus (a disease of inadequate control of blood levels of glucose), atherosclerotic heart disease (a common condition that develops when plaque builds up inside the arteries), obstructive sleep apnea (when the throat muscles relax and block the airway), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should).<BR/>Record review of Resident #44's quarterly MDS assessment with an ARD of 12/22/2023 reflected the resident scored a 15/15 on his BIMS which signified he was cognitively intact, and required moderate assistance with his ADL's. Further review revealed the resident was coded to have an active diagnosis of congestive heart failure (CHF) (a long-term condition that happens when the heart cannot pump blood well enough to give a body a normal supply, blood and fluid can collect in the lungs and legs).<BR/>Record review of Resident #44's comprehensive care plan, revised date 02/03/2024, revealed, Focus, altered respiratory status r/t DX of CHF, and acute/chronic respiratory failure, use of oxygen PRN and ventilator machine at NOC.<BR/>Record review of Resident #44's Active Orders as of: 02/20/2024 .Change O2 tubing, humidifier water, and bag to place tubing in weekly . 07/26/2023. May apply O2 via Nasal Cannula PRN SOB/hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain homeostasis): Titrate O2 2-5LPM to keep SPO2 equal or greater than 90%. Write liters per min of O2 as needed for SOB/Hypoxia Active 07/26/2023.<BR/>Observation on 02/22/2024 at 09:30 AM of Resident #44 revealed he was sitting in his room in a wheelchair and his ventilator mask was unbagged and his oxygen nasal cannula was hanging over the concentrator and was unbagged.<BR/>In an interview on 02/22/2024 at 09:40 AM with Resident #44, he stated he used the ventilator and oxygen at night.<BR/>Observation on 02/23/2024 at 10:00 AM of Resident #44 revealed he was sitting in his room in a wheelchair and his ventilator mask was unbagged and his oxygen nasal cannula was hanging over the concentrator and was unbagged.<BR/>Interview with LVN F on 02/23/2024 at 1:00 PM, LVN F stated Resident #44's oxygen tubing and ventilator mask needed to be bagged when not in use. LVN F stated it was important to put the tubing and mask in a bag to prevent dirt particles and dust from getting into the system and it could result in an infection. LVN F stated she had not checked it.<BR/>Interview with the DON on 02/24/2024 at 2:10 PM, the DON stated Resident #44's oxygen tubing and ventilator mask needed to be bagged when not in use to prevent cross contamination.<BR/>Record review of the facility titled Cleaning and Disinfecting Equipment (undated) reflected Resident care-equipment, including reusable items and durable medical equipment will be cleaned and disinfected.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 11 of 23 (Housekeeper N, CMA F, CNA G, LVN H, Dietary Aide I, RN J, CNA K, CNA L, LVN M, LVN/MDS, Dietary Manager) employees reviewed for training requirements. <BR/>The facility failed to implement and maintain a training program that ensured Housekeeper N, CMA F, CNA G, LVN H, Dietary Aide I, RN J, CNA K, CNA L, LVN M, LVN/MDS, Dietary Manager received required trainings annually. <BR/>The facility failed to implement and maintain a training program that ensured Dietary Manager received required trainings upon hire. <BR/>This failure could affect residents and place them at risk of being uninformed due to lack of staff training.<BR/>Findings include:<BR/>Record review of the personnel records for Housekeeper N revealed a hire date of 10/04/2016. Review of a training in-services for Housekeeper N from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training, QAPI training, ethics training, or falls training being provided annually. <BR/>Record review of the personnel records for CMA F revealed a hire date of 01/27/2020. Review of a training in-services for CMA F from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training, QAPI training, HIV training, restraint training or emergency preparedness training being provided annually.<BR/>Record review of the personnel records for CNA G revealed a hire date of 07/31/2023. Review of a training in-services for CNA G from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training, QAPI training or ethics training being provided annually. <BR/>Record review of the personnel records for LVN H revealed a hire date of 09/14/2023. Review of a training in-services for LVN H from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training being provided annually. <BR/>Record review of the personnel records for Dietary Aide I revealed a hire date of 12/08/2022. Review of a training in-services for Dietary Aide I from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training or behavioral health training being provided annually. <BR/>Record review of the personnel records for RN J revealed a hire date of 02/17/2023. Review of a training in-services for RN J from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training or Ethics training being provided annually.<BR/>Record review of the personnel records for CNA K revealed a hire date of 01/29/2024. Review of a training in-services for CNA K from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training, falls training, restraint training or emergency preparedness training being provided annually. <BR/>Record review of the personnel records for CNA L revealed a hire date of 03/18/2022. Review of a training in-services for CNA L from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually.<BR/>Record review of the personnel records for LVN M revealed a hire date of 02/10/2015. Review of a training in-services for LVN M from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually.<BR/>Record review of the personnel records for LVN/MDS revealed a hire date of 03/18/2022. Review of a training in-services for LVN/MDS from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training, HIV training, or emergency preparedness training being provided annually. <BR/>Record review of the personnel records for Dietary Manager revealed a hire date of 10/23/2024. Review of a training in-services for Dietary Manager from the previous 12 months, provided by the HR Coordinator revealed no evidence of behavior health training or HIV training being provided upon hire. <BR/>Interview with the HR Coordinator on 04/04/2025 at 1:34 PM, revealed she initiates in-service trainings every month and every month was a different topic. The HR Coordinator stated she presented the in-services to the department heads, and they present them to their staff. The HR Coordinator stated it was the responsibility of the department heads to complete the in-services and her responsibility to verify all staff have completed the assigned in-service each month. The HR Coordinator stated staff were notified they need to complete in-service trainings only when department heads present the trainings to them. The HR Coordinator stated she followed an on-boarding checklist for new employees that includes trainings. The HR Coordinator stated she was not sure why all Dietary Manager's trainings were not completed upon hire. The HR Coordinator stated it was important that staff received their initial and annual trainings to ensure they are providing quality care to the residents. The HR Coordinator stated this could affect the residents leaving them vulnerable to abuse, neglect, and exploitation. <BR/>Interview with the DON on 04/04/2025 at 2:34 PM, revealed she received the in-services from the HR Coordinator monthly and presented them to her staff. The DON stated it is the responsibility of department heads to present the in-services to their staff. The DON stated once the in-services were complete the HR Coordinator verifies all employees had completed the in-service. The DON stated completing the in-services was important to ensure staff had the knowledge to complete their jobs effectually and safely. The DON stated if staff were not trained annually, it could leave resident's vulnerable to receiving poor care. <BR/>Interview with the Administrator 04/04/2025 at 2:43 PM revealed the facility provides staff with an in-service each month and each month the in-service reflected a different required training topic. The Administrator stated HR Coordinator initiated each in-service and provided them to the department heads so that they could train their staff. The Administrator stated it was the responsibility of department heads to train their staff each month and the responsibility of the HR Coordinator to verify each staff completed the in-services. The Administrator stated having untrained staff could lead to negative outcomes such as staff not knowing how to comminate or care for residents properly. <BR/>Record review of facility policy titled In-Service Education, undated, revealed 1. <BR/>Each year the administration or other designee will develop and implement an educational calendar to include (but not limited to) the following topics:<BR/>1. <BR/>Range of Motion<BR/>2. <BR/>Communication<BR/>3. <BR/>QAPI Program<BR/>4. <BR/>Sensory and Communication Impairments<BR/>5. <BR/>Dementia Care/ Alz management (Quarterly: see Dementia Education Policy 20.01)<BR/>6. <BR/>Resident Rights<BR/>7. <BR/>Skin Care and Pressure Ulcer Prevention<BR/>8. <BR/>Universal/Standard Precautions<BR/>9. <BR/>AED Training (Nurses Quarterly; use manufacturers recommendation)<BR/>I 0. <BR/>Fire Safety<BR/>11. <BR/>Toileting Programs<BR/>12. <BR/>Incontinence<BR/>13. <BR/>Disaster Plan/Emergency Preparedness<BR/>14. <BR/>Wandering/Elopement<BR/>15. <BR/>General Safety Precautions<BR/>16. <BR/>Smoking Policy<BR/>17. <BR/>Infection Control Program<BR/>18. <BR/>Grievance Policy<BR/>19. <BR/>Incidents and Accidents<BR/>20. <BR/>Mechanical Transfers and Lifts (use manufacturers recommendation)<BR/>21. <BR/>Falls and Fall Prevention<BR/>22. <BR/>Infection Diseases (TB Hep B overview incl. vaccinations)<BR/>23. <BR/>Sexual Harassment<BR/>24. <BR/>Professional & Appropriate Communication<BR/>25. <BR/>Geriatric Pharmacology (Nurses/CMAs)<BR/>26. <BR/>Advanced Directive and Guardianship<BR/>27. <BR/>Pain Assessment and Management<BR/>28. <BR/>ADL's<BR/>29. <BR/>Catheter Care<BR/>30. <BR/>Urinary and Fecal Incontinence<BR/>3 I. <BR/>Workplace Violence<BR/>32. <BR/>Constipation <BR/>33. <BR/>HIV/AIDS <BR/>34. <BR/>UTIs <BR/>35. <BR/>Unusual Occurrences Policy <BR/>36. <BR/>Material Safety Data Sheets (MSDS)<BR/>37. <BR/>Nutrition and Hydration <BR/>38. <BR/>HIPAA <BR/>39. <BR/>Abuse, Neglect, Exploitation Prevention and Reporting Program <BR/>40. <BR/>Compliance and Ethics Program <BR/>41. <BR/>Behavior Interventions <BR/>42. <BR/>Intellectual/Mental Disability <BR/>43. <BR/>Trauma Informed Care <BR/>44. <BR/>Hand Washing Return Demonstration <BR/>45. <BR/>Appropriate use of PPE <BR/>46. <BR/>Restraints <BR/>47. <BR/>Antibiotic Stewardship Policy <BR/>48. <BR/>HR 49 - 1105B - Elder Justice Act <BR/>49. <BR/>Facility Assessment <BR/>50. <BR/>Respiratory and Trach Care (Nurses) <BR/>51. <BR/>Narcan (naloxone) (Nurses) <BR/>52. <BR/>Enhanced Barrier Precautions <BR/>53. <BR/>Psychological Changes of Aging <BR/>54. <BR/>Common Emergencies in Geriatrics <BR/>55. <BR/>IV Therapy (Nurses) <BR/>56. <BR/>Assisting Residents with Eating

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bowel and bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #4) reviewed for incontinence care.<BR/>When CNA-A was providing incontinent care to Resident #4 on 04/03/2025, CNA-A did not separate the resident's labia and did not clean the base of her labia. <BR/>This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. <BR/>The findings included:<BR/>Record review of Resident #4's face sheet, dated 04/04/2025, revealed a [AGE] year-old female, admitted to the facility originally on 03/24/2015, and re-admitted to the facility on [DATE] with diagnoses of vascular disorder of intestine (blood flow to the intestines slows), pervasive developmental disorder (developmental delays that affect social and communication skills), hemiplegia (brain damage that leads to paralysis on one side of the body), dysphagia (difficulty swallowing), and hyperlipidemia (high level of fat). <BR/>Record review of Resident #4's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment, the resident had frequently urinary bladder incontinence and always bowel incontinence, and required dependent assistance (helper does all of the efforts) to all activities of daily living such as chair-to-bed and toilet transfer. <BR/>Record review of Resident #4's comprehensive care plan, dated 07/23/2015, revealed the resident had bowel and bladder incontinence related to impaired mobility - Monitor/document for signs and symptoms of urinary tract infection. <BR/>Observation on 04/03/2025 at 10:00 a.m. revealed CNA-A cleaned Resident #4's left and right groin area, then just cleaned the middle one of the resident's genital areas without separating the resident's labia area. Further observation revealed CNA-A turned the resident to her left side and cleaned the resident's bottom area, then put a new and clean brief and closed it. <BR/>Interview on 04/03/2025 at 10:12 a.m. with CNA-A stated she did not separate Resident #4's labia area and did not clean the base of the resident's labia area. Further interview with CNA-A said she forgot to separate the resident's labia area to clean the base of labia because she was so nervous. CNA-a stated she should have separated Resident #4's labia area and cleaned the base of the resident's labia area. <BR/>Interview on 04/03/2025 at 1:56 p.m. the DON stated CNA-A should have separated Resident #4's labia area to clean the base of labia to prevent possible urinary tract infection. Checking CNA-A's skills for perineal care was DON's responsibility, and DON conducted the skill check-off of CNA-A on 03/13/2025, and CNA-A demonstrated correct skills for perineal care on 03/13/2025. <BR/>Record review of the facility policy, titled Perineal Care, undated, revealed . 9. Female perineal care F. use one gloves hand to stabilize and separate the labia, with other hands wash from front to back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide basic life support , including CPR, to a resident requiring such emergency care prior to the arrival of medical personnel and subject to related physician orders and the resident's advanced directives for 1(Resident #69) of 24 residents reviewed for advanced directives. <BR/>The facility failed to provide emergency care subject to physician orders and the resident's advanced directives when Resident #69 was readmitted to the facility. On [DATE] at 09:30 AM Resident #69 was found unresponsive without a pulse and had a full code initiated to include CPR for approximately 25 minutes when he had an OOH DNR.<BR/>An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:55 p.m. While the IJ was removed on [DATE] at 2:55 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to evaluate the plan of removal.<BR/>This facility failure placed residents at risk of not having their rights honored, to include pain, fractures, psychological and physical harm.<BR/>The findings included:<BR/>Record review of Resident #69's electronic face sheet dated [DATE] reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: diabetes mellitus (a disease of inadequate control of blood glucose levels), cognitive communication deficit (difficulty with thinking and how someone uses language), chronic kidney disease (when the kidneys have become damaged over time (for at least 3 months) and have a hard time doing all their functions), CVA (cerebral vascular accident or brain attack) and osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection. Resident #69's electronic face sheet reflected he had Full Code (desired CPR) status.<BR/>Record review of Resident #69's significant change MDS assessment dated [DATE] reflected he scored a 12/15 on his BIMS which signified he was cognitively intact. He could usually understand others and could usually be understood. He required extensive assistance with his ADL's.<BR/>Record review of Resident #1's comprehensive care plan revised on [DATE] reflected Focus, the resident/family are requesting DNR status, Goal, resident/family wishes will be honored through next review, Interventions/Tasks, Activate EMS as indicated, if transferred out of facility, notify receiving facility and EMS of DNR status, initiate CPR as indicated.<BR/>Record review of Resident #69's readmission assessment dated [DATE] reflected resident desired to have DNR status under advanced directives.<BR/>Record review of Resident #69's Order Details dated [DATE] reflected Admit to .under .Hospice, DX. CVA, Code Status: DNR.<BR/>Record review of the facility shift change report dated [DATE] from the night shift nurse (LVN B) to the day shift nurse (LVN C) reflected ADMISSIONS: Resident #69 admitted at 01:00 AM to .Hospice, on pleasure feedings, regular diet, multiple breakdowns noted. No mention of Code Status.<BR/>Record review of Resident #69's progress notes written by LVN E dated [DATE] at 10:45 AM, reflected Resident #69 was found unresponsive without a pulse. PCC checked and resident listed as Full Code status. Crash cart was brought into room, Resident #69 placed on the floor. CPR was initiated at 09:28 AM, no respirations, no pulse, no BP, pupils fixed and dilated, skin cool to touch, non-responsive, EMS arrived at 09:45 AM and took over CPR, artificial airway placed. CPR stopped at 09:53 AM after electronic DNR located and provided to EMT's. Pronounced at 09:59 AM via phone by MD for EMS Fire/EMS, and local police.<BR/>Record review of Resident #69's progress notes dated [DATE] at 1:21 PM, reflected that during an interview with the local police, LVN A located an OOH DNR for Resident #69 under the miscellaneous tab in PCC.<BR/>Record review of Resident #69's OOH DNR reflected it was signed and dated on [DATE], prior to his readmission to the facility.<BR/>Interview on [DATE] at 10:46 AM with LVN C, she stated she and LVN A initiated the code for Resident #69. LVN C stated that LVN A found him, called for help, and came out of his room and they checked PCC and found Full Code status was noted on his electronic face sheet. LVN C stated she did not check his orders. LVN C stated the police and EMS was notified and they arrived within 5 minutes. LVN C stated she was trained on how to put a resident's code status and orders into PCC. LVN C stated she did not recall being told Resident #69 was admitted with DNR status from LVN B. LVN C stated it was important to honor a resident's wishes for advanced directives otherwise their rights would be violated.<BR/>Interview on [DATE] at 10:58 AM with LVN A, she stated she found Resident #69 and called for help. LVN A stated she and LVN C checked his EMR and found he was full code status in PCC. LVN A stated she did not check his admission orders. LVN A stated when a police officer asked her about his medications, she looked under his miscellaneous tab in PCC and saw the OOH DNR. LVN A stated she felt bad when that happened and immediately took the OOH DNR to show to the EMT responders and they stopped CPR. LVN A stated Resident #69 was pronounced deceased by the MD.<BR/>Interview on [DATE] at 11:44 AM with LVN B, she stated she was the nurse that did the admission assessment for Resident #69. LVN B stated she put his information into PCC, to include his code status, and she did not know why it was not reflected on Resident #69's face sheet because she felt like she did everything right. LVN B stated his code status was reflected in his admission orders and she communicated it to the night shift nurse LVN C. LVN B stated it was important for the resident's rights and advanced directive desires to be noted and communicated to the nursing staff because if he had a cardiac event, he did not want to be resuscitated.<BR/>Interview on [DATE] at 12:00 PM with the DON, she stated she was called by LVN A, and she told her to check Resident #69's chart. The DON stated she did not realize that Resident #69 received a full course of CPR, and when she realized what had happened, she knew she needed to in-service the nurses on the PCC order entry process. The DON stated LVN B must have failed to discontinue the previous full code order, and this resulted in the change of code status not populating onto the face sheet.<BR/>Interview on [DATE] at 12:15 PM with the Administrator, she stated she reported Resident #69's death as required under long term care death notifications for a death within 24 hours of transfer, however she did not realize the issue with Resident #69's advanced directives not being honored, or she would have reported it to HHSC right away.<BR/>Record review of the facility policy and procedure titled Resident Rights (undated) reflected Purpose, to ensure the resident rights are respected and protected. Further review of the policy and procedure reflected, The resident has a right: To a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.<BR/>Record review of the facility pamphlet (undated) titled Treatment Choices reflected Code Status Policy. Purpose, to provide each resident/responsible party with the education and opportunity to make an informed decision regarding their code status. The facility will maintain a system of clearly identifying, documenting, and communicating the resident's code status decisions to essential facility personnel.<BR/>The Administrator was notified of an IJ on [DATE] at 5:55 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on [DATE] at 2:55 p.m. and included the following:<BR/>Alleged Failure #1 - Failed to properly input code status in the Point Click Care (PCC) Electronic Medical Record (EMAR) upon admission.<BR/>Alleged Failure #2 - Failed to honor the rights of Resident # 1's wishes to die a dignified death by failing to honor a signed out of hospital do not resuscitate (DNR).<BR/>Director of Nursing completed an audit of all resident code statuses on [DATE], 8:00pm, and all were found to be accurate.<BR/>In-servicing/education provided in response (bullet point narrative):<BR/>-Start/stop time and date:<BR/>-On [DATE] at 6:30pm education began for Nurses (LVN and RN) staff in regards to properly complete Order Entry of code status in the PCC/EMAR of a resident. Nurses will reference PCC in the event of an emergency situation.<BR/>-o Nurses that aren't present will be in-serviced by the DON before the start of their next regularly scheduled shift, utilizing a staff roster to ensure training and ensure a passing score on Post Test. <BR/>-o The education/in-service of Order Entry of Code Status in a Resident PCC/EMAR will be included in the new hire process for all Nurses.<BR/>oThe education will be completed by the DON<BR/>-o All the education on this topic will be complete [DATE] by 10:00pm for Nurse staff present.<BR/>oA 4 question post-test will be given to verify retention of knowledge related Order Entry of code status into resident PCC/EMAR.<BR/>-Administrator will randomly issue post test regarding education/in-service on Order Entry of code status into PCC/EMAR provided for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. <BR/>-Director of Nursing will randomly request a Nurse to perform order entry of code status into PCC/EMAR and will document competence for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. <BR/>Record reviews of sampled residents #9, #14, #22, #23, #26, #33, #35, #36, #38, #43, #44 and #56 EMR's and face sheets reflected code status was accurate.<BR/>Verification of the POR<BR/>Record review of facilities incident response binder revealed the facility completed the in-service with nursing staff on topics where to find the resident's code, how to enter resident's code status for new admissions and status changes, the purpose of code status, and resident's rights-choosing their code status. <BR/>-Record review of facilities incident response binder revealed the facility conducted a post test for each nursing staff that received the in-service. Facility has documented 100% of their nursing (all 19 nurses) staff have completed the posttest and received a 100% on the post test. Interview on [DATE] at 1:05 p.m. with the DON revealed she in-serviced 100% (all 19 nurses) staff were on [DATE] after 6 PM and the remainder were in serviced on [DATE].<BR/>OUT OF 19 TOTAL NURSES-16 WERE INTERVIEWED FOR VERIFICATION (84%) <BR/>Phone interview with RN N at 9:40 AM on [DATE]. She stated she received training on [DATE] on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Administrator will randomly issue posttest regarding education/in-service on Order Entry of code status into PCC/EMAR provided for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. <BR/>-Director of Nursing will randomly request a Nurse to perform order entry of code status into PCC/EMAR and will document competence for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. <BR/>-5 DAY SHIFT NURSES<BR/>-Interview with LVN D on [DATE] at 12:21 p.m. revealed she had training on code status, how to put in the code status and to respect their rights. <BR/>-Interview with the DON, RN at 9:51 AM on [DATE]. RN conducted the training with all nursing staff. RN started training on [DATE] and completed training on [DATE]. RN had all staff complete a posttest to ensure they understood the in-service. <BR/>-Interview with MDS Nurse at 10:42 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN E ADON, at 11:02 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN F on [DATE] at 11:52 AM revealed she just had training on DNR and how to put in the code status into PCC. We also check the chart. It is important because it is the resident rights. <BR/>-4 EVENING SHIFT NURSES<BR/>-Interview with LVN G, on [DATE] at 11:39 AM, and I went in this am and had training. The training was how to find the code status of a resident. Why code status is important because it is their rights. We also were advised to check the chart. <BR/>-Interview with LVN C, at 10:46 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN H on [DATE] at 11:45 AM, she stated she had code training on updating the code, and we check the orders. We check the paper chart. Respect wishes of resident. <BR/>-Interview with LVN I at 11:36 AM on [DATE]. She stated she received training yesterday on DNR status and full code. We went over where to find the code status and how to change it in PCC. We would check the chart also.<BR/>-2 NIGHT SHIFT NURSES<BR/>-Interview with LVN J at 11:25 AM on [DATE]. Received training today at 08:00 a.m. [DATE]. The training was on DNR and code status, how to enter PCC properly. What the code status means. We were trained to also check the chart. The importance of code status indicates the resident's rights. <BR/>-Interview with LVN B on [DATE] at 11:47 AM she stated she had code training on updating the code and we check the orders. We check the paper chart. It is important because it is their rights. <BR/>-Interview with RN K on [DATE] at 11:58 AM revealed she had training on code status. Following the resident wishes. How to change in PCC. It is their rights. <BR/>-Interview with RN L, at 11:06 AM on [DATE]. She received training on [DATE], of how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN M, at 11:11 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN A, at 10:58 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Phone interview with RN N at 9:40 AM on [DATE]. Received training on [DATE] on how to enter the code status, where to enter the code status and the importance11:36 of ensuring the code status is accurate. <BR/>Interview on [DATE] at 1:32 PM, with the DON, she stated the auditing for the effectiveness of the Plan of Removal will begin on Monday [DATE]. Nurses will be randomly selected, and observed and evaluated with the post test, and this will continue for 4 weeks.<BR/>Record Review of facilities incident response binder revealed the facility has implemented a procedure to make random observations with licensed nursing staff by DON for the next 4 weeks starting [DATE]. Post observation the Administrator will administer a posttest to ensure staff understand they understand the training. <BR/>On [DATE] at 08:48 AM, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to monitor the implementation and effectiveness of its plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain medical records on each resident that are-accurately documented for 1 (Resident #44) of 24 residents reviewed for accurate medical records in that:<BR/>LVN F initialed off on Resident #44's MAR that the resident's compression stockings were applied on 02/22/2024, when they were not.<BR/>This deficient practice could affect residents who have medical records and could result in misinformation about professional care provided.<BR/>The findings included:<BR/>Record review of Resident #44's electronic face sheet, dated 02/20/2024, revealed the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: diabetes mellitus (a disease of inadequate control of blood levels of glucose), atherosclerotic heart disease (a common condition that develops when plaque builds up inside the arteries), obstructive sleep apnea (when the throat muscles relax and block the airway), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should).<BR/>Record review of Resident #44's quarterly MDS assessment with an ARD of 12/22/2023 revealed the resident scored a 15/15 on his BIMS which signified he was cognitively intact, and required moderate assistance with his ADL's. Further review revealed the resident was coded to have an active diagnosis of congestive heart failure (CHF) (a long-term condition that happens when the heart cannot pump blood well enough to give a body a normal supply, blood and fluid can collect in the lungs and legs).<BR/>Record review of Resident #44's comprehensive care plan, revised date 10/01/2020, revealed, Focus, at risk for breakdown r/t decreased mobility, occasional incontinence, edema and CHF (Congestive Heart Failure). Further review revealed the resident's need for compression stockings were not reflected as an intervention for the resident's edema.<BR/>Record review of Resident #44's Active Orders as of: 02/20/2024 reflected Check edema every shift every shift Active 12/28/2022 .Compression stockings to BLE. Apply in AM and remove at HS one time a day for edema Active 12/05/2023.<BR/>Record review of Resident #44's MAR for February 2024 revealed the resident was being checked for edema each shift and his compression stockings were applied in the morning and taken off in the evening to include 02/22/2024 being initialed off as having been applied.<BR/>Observation on 02/22/2024 at 09:30 AM of Resident #44 revealed he was sitting in his room in a wheelchair. Further observation revealed the resident had [NAME] stockings on. <BR/>In an interview on 02/22/2024 at 09:40 AM with Resident #44, he stated he did not always get his special stockings applied.<BR/>Interview with LVN F on 02/23/2024 at 1:00 PM, LVN F stated she relied on the aides to put on Resident #44's compression stockings. LVN F stated the resident was supposed to get them put on in the morning and taken off at bedtime. LVN F stated she had not checked and initialed off that the resident had them put on. LVN F stated she should have checked, but she relied on the aides to tell her if they were not applied.<BR/>Interview with the DON on 02/24/2024 at 2:10 PM, the DON stated LVN F should not have initialed off on Resident #44's MAR that the resident's compression stockings were applied because they were not, and that would be false documentation. The DON stated she was accountable for the nursing staff and needed to remind them to check the residents prior to initialing off in the MAR.<BR/>Review of the facility policy and procedure titled Documentation-Nursing (undated) reflected Nursing documentation will be concise, clear, pertinent, accurate and evidence based .medication administration records and treatment administration records are completed with each medication or treatment completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 resident (Resident #35) of 24 residents reviewed for MDS assessments.<BR/>Resident #35's MDS assessment did not accurately reflect she had limitations on her upper extremities and she was on continuous oxygen therapy.<BR/>This deficient practice could result in missed or inaccurate care.<BR/>The findings included:<BR/>Record review of Resident #35's electronic face sheet dated 02/21/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks), bacteremia (viable bacteria in the blood), pressure ulcer of right hip, stage IV (may look like a reddish crater in the skin. Muscles, bones, and/or tendons may also be visible at the bottom of the stage IV), dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), dysphagia (difficulty swallowing) and contracture of muscle multiple sites (muscles, tendons, joints, or other tissues tighten or shorten causing a deformity).<BR/>Record review of Resident #35's quarterly MDS assessment with an ARD of 01/09/2024 reflected she was not a candidate for a BIMS which signified she was severely cognitively impaired. She could usually understand and usually be understood. She was noted to have No impairment of her Upper extremities (shoulder, elbow, wrist, and hand). She was not coded to have oxygen therapy while a resident. She required total assistance with her ADL's.<BR/>Record review of Resident #35's comprehensive person-centered care plan revised date 01/19/2024, Focus, has an ADL, self-care performance deficit, mobility, transfers, eating, bathing, dressing and personal hygiene. Resident #35's comprehensive care plan did not address her contractures or oxygen therapy.<BR/>Record review of Resident #35's Active Orders as of: 02/02/2024 reflected 02 at 2-5L per NC to maintain sp02 &gt;90% every shift .for dyspnea .Active 01/02/2024.<BR/>Record review of Resident #35's progress notes for the week of 01/02/2024 to 01/09/2024 reflected she was on Oxygen therapy at 2L/NC.<BR/>Observation on 02/22/2024 at 09:30 AM of Resident #35 revealed she was lying in bed and had oxygen infusing at 2.5 L/min via NC.<BR/>Observation on 02/20/2024 at 10:23 AM of Resident #35 revealed she was lying in bed and had oxygen infusing at 2.5 L/min via NC, and she had a rolled-up washcloth in her right hand which appeared contracted. Her left hand was contracted.<BR/>Observation and interview on 02/22/2024 at 11:50 AM, RN F provided G-tube (is a tube inserted through the belly that brings nutrition directly to the stomach) medication to Resident #69, she was in bed on oxygen therapy and her bilateral hands contracted. RN F stated Resident #69's hands wasere contracted and was on continuous oxygen therapy for at least a month.<BR/>Interview on 02/24/2024 at 2:00 PM with the MDS nurse, she stated Resident #69's quarterly MDS with an ARD of 01/09/2024 was inaccurate. She stated the resident was on oxygen therapy and it was within the look back time and it should have been coded. She stated Resident #69's upper limitations should have been coded. She did not know why they were not. She stated it was important for the MDS to be accurate because it provides information for the resident's care plan and she could miss needed care without it being addressed.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON, she stated Resident #69's MDS was inaccuratei, and it was important to be correct to communicate to nursing staff the care required for the resident. She stated she was accountable for overseeing the MDS's.<BR/>Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received assistance devices to prevent accidents for 1 of 3 Residents (Resident #14) reviewed for accidents and hazards.<BR/>CNA X did not widen the base of the mechanical lift while transferring Resident #14 from bed to his wheelchair on 2/23/24.<BR/>This deficient practice could placed residents transferred via mechanical lift at risk of falls which could result in injury and hospitalization.<BR/>The findings were:<BR/>Review of Resident #14's face sheet, dated 2/24/24, revealed he was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) without Dyskinesia (a condition that causes involuntary, erratic movements of different body parts), and Cerebral Infarction (Stroke).<BR/>Review of Resident #14's quarterly MDS assessment, dated 1/2/24, revealed his BIMS was 11 reflective of moderate cognitive impairment and he was dependent to go from a sit to stand position. <BR/>Review of Resident #14's Care Plan, revised 2/1/24, revealed he had an ADL performance deficit and required TOTAL ASSIST for transfers and requires Mechanical Hoyer lift for transfers. Provide 2 person for transfer.<BR/>Observation on 2/23/24 at 03:55 PM revealed CNA X and CNA U transferring Resident #14 from the bed to his wheelchair. CNA X was operating the mechanical lift and positioned it under the bed. Further observation revealed CNA X did not widen the base and did not lock the lift. CNA U secured the harness to the lift and CNA X lifted Resident #14 from the bed while CNA U guided him. CNA X pulled the mechanical lift back and away from the bed and turned the lift towards the wheelchair. CNA X then widened the base and CNA U positioned the wheelchair between the base of the lift. CNA X did not lock the lift. CNA X lowered Resident #14 into the wheelchair. Once sitting in the wheelchair CNA U unfastened the harness from the lift. <BR/>Interview on 2/23/24 at 4:00 PM with CNA X and CNA U, revealed CNA X stated she did not widen the base of the mechanical lift until she positioned Resident #14 over the wheelchair. CNA X also stated she did not remember locking the lift at any point. CNA U stated she did not notice that CNA X did not widen the base; she stated she was not paying attention. CNA X stated she should have widened the base and locked the lift once she positioned the base under the bed. She stated this would provide stability while lifting Resident #14 up in the air. She stated the lift could tilt over because she did not widen the base or lock the lift and the Resident could have fallen.<BR/>Review of an in-service conducted on mechanical lift policy dated 5/15/23 revealed neither CNA X or CNA U signed the in-service to reflect they received the training.<BR/>Interview on 2/23/24 at 5:29 PM with the ADON and the DON revealed staff should widened the base of the mechanical lift and lock it before lifting a resident into the air to provide stability and to prevent the lift from tilting over. The ADON and the DON stated the lift could tilt over and a resident could fall if the base was not widened and or locked. The DON stated nursing staff should provide periodic oversight for the CNA's while operating a mechanical lift to ensure correct operation. They should also provide corrective training as needed and stated the last inservice they provided staff was during June 2023. <BR/>Review of facility policy, Mechanical or Hydraulic Lift, undated, read: They hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed or obese, or too weak to transfer without complete assistance. It requires two or three staff members to safely operate and accomplish the transfer. Procedure: 7. Raise the bed to accommodate the lift under the bed. 8. Prepare the lift by setting the adjustable base to its widest position and lock in place.<BR/>Review of the Patient lift owners manual and instructions for the patient lift, undated, read: Safety Summary, Warning! When using an adjustable base lift, the legs much be in the maximum opened/locked position before lifting the patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 4 of 8 residents (Residents #37, #49, #31, and #54) reviewed for storage.<BR/>1. Resident #37's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened.<BR/>2. Resident #49's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened. <BR/>3. Resident #31's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened.<BR/>4. Resident #54's insulin (Novolog) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened.<BR/>These failures could place residents at risk of having not therapeutic effects by using old insulins. <BR/>The findings were:<BR/>1. Record review of Resident #37's face sheet, dated [DATE], revealed Resident #37 was a [AGE] year-old male and admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses of paraplegia (inability to voluntarily move the lower parts of the body), radiculopathy (injury or damage to nerve roots in the area where they leave the spine), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and muscle weakness. <BR/>Record review of Resident #37's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognition was intact, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #37's physician's order, dated [DATE], revealed the resident had the order of Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 50 unit subcutaneously two times a day for type 2 diabetes mellitus. <BR/>Record review of Resident #37's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 50 unit subcutaneously two times a day for type 2 diabetes mellitus at 8:00 am and 8:00 pm. <BR/>Observation on [DATE] at 2:47 p.m. revealed Resident #37's insulin Glargine (Lantus) for diabetes with no open date inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #37's insulin Glargine (Lantus) for diabetes with no open date was inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #37's insulin Glargine (Lantus) for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #37's insulin pen.<BR/>2. Record review of Resident #49's face sheet, dated [DATE], revealed Resident #49 was a [AGE] year-old male and admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses of atherosclerosis of coronary artery bypass graft (over time arteries can become narrowed and hardened by the build-up of fatty called plaques), hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and hypertension (high blood pressure). <BR/>Record review of Resident #49's Annual MDS, dated [DATE], revealed the resident's BIMS score was 13 out of 15, which indicated the resident's cognition was intact, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #49's physician's order, dated [DATE], revealed the resident had the order of Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 15 unit subcutaneously at bedtime for type 2 diabetes mellitus. <BR/>Record review of Resident #49's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 15 unit subcutaneously at bedtime for type 2 diabetes mellitus at 8:00 pm. <BR/>Observation on [DATE] at 2:47 p.m. revealed Resident #49's insulin Glargine (Lantus) for diabetes with no open date inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #49's insulin Glargine (Lantus) for diabetes with no open date was inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #49's insulin Glargine (Lantus) for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #49's insulin pen.<BR/>3. Record review of Resident #31's face sheet, dated [DATE], revealed Resident #31 was a [AGE] year-old female and admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses of type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), and muscle weakness. <BR/>Record review of Resident #31's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 1 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #31's physician's order, dated [DATE], revealed the resident had the order of Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 10 unit subcutaneously two times a day for type 2 diabetes mellitus. <BR/>Record review of Resident #31's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 10 unit subcutaneously two times a day for type 2 diabetes mellitus at 10:00 am and 4:00 pm. <BR/>Observation on [DATE] at 2:47 p.m. revealed Resident #31's insulin Glargine (Lantus) for diabetes with no open date inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #31's insulin Glargine (Lantus) for diabetes with no open date was inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #31's insulin Glargine (Lantus) for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #31's insulin pen.<BR/>4. Record review of Resident #54's face sheet, dated [DATE], revealed Resident #54 was a [AGE] year-old female and admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses of senile degeneration of brain (progressive decline in cognitive function, impacting memory, and reasoning), pneumonia (infection to the lung), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and muscle weakness. <BR/>Record review of Resident #54's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 4 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. <BR/>Record review of Resident #54's physician's order, dated [DATE], revealed the resident had the order of Novolog injection solution 100 unit/ml - inject per sliding scale subcutaneously before meals for type 2 diabetes mellitus. <BR/>Record review of Resident #54's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Novolog injection solution 100 unit/ml - inject per sliding scale subcutaneously before meals for type 2 diabetes mellitus at 7:00 am, 11:00 am, and 4:00 pm. <BR/>Observation on [DATE] at 2:47 p.m. revealed Resident #54's insulin Novolog for diabetes with no open date inside the 100/200-hall nursing cart. <BR/>Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #54's insulin Novolog for diabetes with no open date was inside the 100/200-hall nursing cart. Further interview, LVN-D said Resident #54's insulin Novolog for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #54's insulin pen.<BR/>Interview on [DATE] at 2:57 p.m. the DON said the facility nurses should have written open dates on insulins when they opened them to discard them 28 days after opened. Nurses would not know when they have to discard insulins if insulins did not have open dates, and it might cause improper use, and residents might not have therapeutic effects. DON said that it was nurse' responsibility, and DON and ADON sometimes reviewed nursing carts, but they did not know what reason nurses did not write the open dates. <BR/>Record review of the facility's policy, titled Insulin Expiration, undated, revealed . 2. All insulin, once opened or removed from the refrigerator must be dated. 3. All insulin, once or removed from refrigerator expired in 28 days and must be taken out of use and be replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in experimental research, and to formulate an advance directive for 1(Resident #69) of 24 residents reviewed for advanced directives. <BR/>The facility failed to honor the rights of Resident #69's wishes to die a dignified death by failing to honor a signed OOH DNR order on [DATE] at 9:30 AM when Resident #69 was found unresponsive without a pulse and had a full code initiated to include CPR for approximately 25 minutes.<BR/>An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:55 p.m. While the IJ was removed on [DATE] at 2:55 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to evaluate the plan of removal.<BR/>This facility failure placed residents at risk of not having their rights honored, to include pain, fractures, psychological and physical harm.<BR/>The findings included:<BR/>Record review of Resident #69's electronic face sheet dated [DATE] reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: diabetes mellitus (a disease of inadequate control of blood glucose levels), cognitive communication deficit (difficulty with thinking and how someone uses language), chronic kidney disease (when the kidneys have become damaged over time (for at least 3 months) and have a hard time doing all their functions), CVA (cerebral vascular accident or brain attack) and osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection. Resident #69's electronic face sheet reflected he had Full Code (desired CPR) status.<BR/>Record review of Resident #69's significant change MDS assessment dated [DATE] reflected he scored a 12/15 on his BIMS which signified he was cognitively intact. He could usually understand others and could usually be understood. He required extensive assistance with his ADL's.<BR/>Record review of Resident #1's comprehensive care plan revised on [DATE] reflected Focus, the resident/family are requesting DNR status, Goal, resident/family wishes will be honored through next review, Interventions/Tasks, Activate EMS as indicated, if transferred out of facility, notify receiving facility and EMS of DNR status, initiate CPR as indicated.<BR/>Record review of Resident #69's readmission assessment dated [DATE] reflected resident desired to have DNR status under advanced directives.<BR/>Record review of Resident #69's Order Details dated [DATE] reflected Admit to .under .Hospice, DX. CVA, Code Status: DNR.<BR/>Record review of the facility shift change report dated [DATE] from the night shift nurse (LVN B) to the day shift nurse (LVN C) reflected ADMISSIONS: Resident #69 admitted at 01:00 AM to .Hospice, on pleasure feedings, regular diet, multiple breakdowns noted. No mention of Code Status.<BR/>Record review of Resident #69's progress notes written by LVN E dated [DATE] at 10:45 AM, reflected Resident #69 was found unresponsive without a pulse. PCC checked and resident listed as Full Code status. Crash cart was brought into room, Resident #69 placed on the floor. CPR was initiated at 09:28 AM, no respirations, no pulse, no BP, pupils fixed and dilated, skin cool to touch, non-responsive, EMS arrived at 09:45 AM and took over CPR, artificial airway placed. CPR stopped at 09:53 AM after electronic DNR located and provided to EMT's. Pronounced at 09:59 AM via phone by MD for EMS Fire/EMS, and local police.<BR/>Record review of Resident #69's progress notes dated [DATE] at 1:21 PM, reflected that during an interview with the local police, LVN A located an OOH DNR for Resident #69 under the miscellaneous tab in PCC.<BR/>Record review of Resident #69's OOH DNR reflected it was signed and dated on [DATE], prior to his readmission to the facility.<BR/>Interview on [DATE] at 10:46 AM with LVN C, she stated she and LVN A initiated the code for Resident #69. LVN C stated that LVN A found him, called for help, and came out of his room and they checked PCC and found Full Code status was noted on his electronic face sheet. LVN C stated she did not check his orders. LVN C stated the police and EMS was notified and they arrived within 5 minutes. LVN C stated she was trained on how to put a resident's code status and orders into PCC. LVN C stated she did not recall being told Resident #69 was admitted with DNR status from LVN B. LVN C stated it was important to honor a resident's wishes for advanced directives otherwise their rights would be violated.<BR/>Interview on [DATE] at 10:58 AM with LVN A, she stated she found Resident #69 and called for help. LVN A stated she and LVN C checked his EMR and found he was full code status in PCC. LVN A stated she did not check his admission orders. LVN A stated when a police officer asked her about his medications, she looked under his miscellaneous tab in PCC and saw the OOH DNR. LVN A stated she felt bad when that happened and immediately took the OOH DNR to show to the EMT responders and they stopped CPR. LVN A stated Resident #69 was pronounced deceased by the MD.<BR/>Interview on [DATE] at 11:44 AM with LVN B, she stated she was the nurse that did the admission assessment for Resident #69. LVN B stated she put his information into PCC, to include his code status, and she did not know why it was not reflected on Resident #69's face sheet because she felt like she did everything right. LVN B stated his code status was reflected in his admission orders and she communicated it to the night shift nurse LVN C. LVN B stated it was important for the resident's rights and advanced directive desires to be noted and communicated to the nursing staff because if he had a cardiac event, he did not want to be resuscitated.<BR/>Interview on [DATE] at 12:00 PM with the DON, she stated she was called by LVN A, and she told her to check Resident #69's chart. The DON stated she did not realize that Resident #69 received a full course of CPR, and when she realized what had happened, she knew she needed to in-service the nurses on the PCC order entry process. The DON stated LVN B must have failed to discontinue the previous full code order, and this resulted in the change of code status not populating onto the face sheet.<BR/>Interview on [DATE] at 12:15 PM with the Administrator, she stated she reported Resident #69's death as required under long term care death notifications for a death within 24 hours of transfer, however she did not realize the issue with Resident #69's advanced directives not being honored, or she would have reported it to HHSC right away.<BR/>Record review of the facility policy and procedure titled Resident Rights (undated) reflected Purpose, to ensure the resident rights are respected and protected. Further review of the policy and procedure reflected, The resident has a right: To a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.<BR/>Record review of the facility pamphlet (undated) titled Treatment Choices reflected Code Status Policy. Purpose, to provide each resident/responsible party with the education and opportunity to make an informed decision regarding their code status. The facility will maintain a system of clearly identifying, documenting, and communicating the resident's code status decisions to essential facility personnel.<BR/>The Administrator was notified of an IJ on [DATE] at 5:55 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on [DATE] at 2:55 p.m. and included the following:<BR/>Alleged Failure #1 - Failed to properly input code status in the Point Click Care (PCC) Electronic Medical Record (EMAR) upon admission.<BR/>Alleged Failure #2 - Failed to honor the rights of Resident # 1's wishes to die a dignified death by failing to honor a signed out of hospital do not resuscitate (DNR).<BR/>Director of Nursing completed an audit of all resident code statuses on [DATE], 8:00pm, and all were found to be accurate.<BR/>In-servicing/education provided in response (bullet point narrative):<BR/>-Start/stop time and date:<BR/>-On [DATE] at 6:30pm education began for Nurses (LVN and RN) staff in regards to properly complete Order Entry of code status in the PCC/EMAR of a resident. Nurses will reference PCC in the event of an emergency situation.<BR/>-o Nurses that aren't present will be in-serviced by the DON before the start of their next regularly scheduled shift, utilizing a staff roster to ensure training and ensure a passing score on Post Test. <BR/>-o The education/in-service of Order Entry of Code Status in a Resident PCC/EMAR will be included in the new hire process for all Nurses.<BR/>o The education will be completed by the DON<BR/>-o All the education on this topic will be complete [DATE] by 10:00pm for Nurse staff present.<BR/>o A 4 question post-test will be given to verify retention of knowledge related Order Entry of code status into resident PCC/EMAR.<BR/>-Administrator will randomly issue post test regarding education/in-service on Order Entry of code status into PCC/EMAR provided for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. <BR/>-Director of Nursing will randomly request a Nurse to perform order entry of code status into PCC/EMAR and will document competence for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. <BR/>Record reviews of sampled residents #9, #14, #22, #23, #26, #33, #35, #36, #38, #43, #44 and #56 EMR's and face sheets reflected code status was accurate.<BR/>Verification of the POR<BR/>Record review of facilities incident response binder revealed the facility completed the in-service with nursing staff on topics where to find the resident's code, how to enter resident's code status for new admissions and status changes, the purpose of code status, and resident's rights-choosing their code status. <BR/>-Record review of facilities incident response binder revealed the facility conducted a post test for each nursing staff that received the in-service. Facility has documented 100% of their nursing (all 19 nurses) staff have completed the posttest and received a 100% on the post test. Interview on [DATE] at 1:05 p.m. with the DON revealed she in-serviced 100% (all 19 nurses) staff were on [DATE] after 6 PM and the remainder were in serviced on [DATE].<BR/>OUT OF 19 TOTAL NURSES-16 WERE INTERVIEWED FOR VERIFICATION (84%) <BR/>Phone interview with RN N at 9:40 AM on [DATE]. She stated she received training on [DATE] on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Administrator will randomly issue posttest regarding education/in-service on Order Entry of code status into PCC/EMAR provided for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. <BR/>-Director of Nursing will randomly request a Nurse to perform order entry of code status into PCC/EMAR and will document competence for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. <BR/>-5 DAY SHIFT NURSES<BR/>-Interview with LVN D on [DATE] at 12:21 p.m. revealed she had training on code status, how to put in the code status and to respect their rights. <BR/>-Interview with the DON, RN at 9:51 AM on [DATE]. RN conducted the training with all nursing staff. RN started training on [DATE] and completed training on [DATE]. RN had all staff complete a posttest to ensure they understood the in-service. <BR/>-Interview with MDS Nurse at 10:42 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN E ADON, at 11:02 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN F on [DATE] at 11:52 AM revealed she just had training on DNR and how to put in the code status into PCC. We also check the chart. It is important because it is the resident rights. <BR/>-4 EVENING SHIFT NURSES<BR/>-Interview with LVN G, on [DATE] at 11:39 AM, and I went in this am and had training. The training was how to find the code status of a resident. Why code status is important because it is their rights. We also were advised to check the chart. <BR/>-Interview with LVN C, at 10:46 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN H on [DATE] at 11:45 AM, she stated she had code training on updating the code, and we check the orders. We check the paper chart. Respect wishes of resident. <BR/>-Interview with LVN I at 11:36 AM on [DATE]. She stated she received training yesterday on DNR status and full code. We went over where to find the code status and how to change it in PCC. We would check the chart also.<BR/>-2 NIGHT SHIFT NURSES<BR/>-Interview with LVN J at 11:25 AM on [DATE]. Received training today at 08:00 a.m. [DATE]. The training was on DNR and code status, how to enter PCC properly. What the code status means. We were trained to also check the chart. The importance of code status indicates the resident's rights. <BR/>-Interview with LVN B on [DATE] at 11:47 AM she stated she had code training on updating the code and we check the orders. We check the paper chart. It is important because it is their rights. <BR/>-Interview with RN K on [DATE] at 11:58 AM revealed she had training on code status. Following the resident wishes. How to change in PCC. It is their rights. <BR/>-Interview with RN L, at 11:06 AM on [DATE]. She received training on [DATE], of how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN M, at 11:11 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN A, at 10:58 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Phone interview with RN N at 9:40 AM on [DATE]. Received training on [DATE] on how to enter the code status, where to enter the code status and the importance11:36 of ensuring the code status is accurate. <BR/>Interview on [DATE] at 1:32 PM, with the DON, she stated the auditing for the effectiveness of the Plan of Removal will begin on Monday [DATE]. Nurses will be randomly selected, and observed and evaluated with the post test, and this will continue for 4 weeks.<BR/>Record Review of facilities incident response binder revealed the facility has implemented a procedure to make random observations with licensed nursing staff by DON for the next 4 weeks starting [DATE]. Post observation the Administrator will administer a posttest to ensure staff understand they understand the training. <BR/>On [DATE] at 08:48 AM, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to monitor the implementation and effectiveness of its plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide basic life support , including CPR, to a resident requiring such emergency care prior to the arrival of medical personnel and subject to related physician orders and the resident's advanced directives for 1(Resident #69) of 24 residents reviewed for advanced directives. <BR/>The facility failed to provide emergency care subject to physician orders and the resident's advanced directives when Resident #69 was readmitted to the facility. On [DATE] at 09:30 AM Resident #69 was found unresponsive without a pulse and had a full code initiated to include CPR for approximately 25 minutes when he had an OOH DNR.<BR/>An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:55 p.m. While the IJ was removed on [DATE] at 2:55 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to evaluate the plan of removal.<BR/>This facility failure placed residents at risk of not having their rights honored, to include pain, fractures, psychological and physical harm.<BR/>The findings included:<BR/>Record review of Resident #69's electronic face sheet dated [DATE] reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: diabetes mellitus (a disease of inadequate control of blood glucose levels), cognitive communication deficit (difficulty with thinking and how someone uses language), chronic kidney disease (when the kidneys have become damaged over time (for at least 3 months) and have a hard time doing all their functions), CVA (cerebral vascular accident or brain attack) and osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection. Resident #69's electronic face sheet reflected he had Full Code (desired CPR) status.<BR/>Record review of Resident #69's significant change MDS assessment dated [DATE] reflected he scored a 12/15 on his BIMS which signified he was cognitively intact. He could usually understand others and could usually be understood. He required extensive assistance with his ADL's.<BR/>Record review of Resident #1's comprehensive care plan revised on [DATE] reflected Focus, the resident/family are requesting DNR status, Goal, resident/family wishes will be honored through next review, Interventions/Tasks, Activate EMS as indicated, if transferred out of facility, notify receiving facility and EMS of DNR status, initiate CPR as indicated.<BR/>Record review of Resident #69's readmission assessment dated [DATE] reflected resident desired to have DNR status under advanced directives.<BR/>Record review of Resident #69's Order Details dated [DATE] reflected Admit to .under .Hospice, DX. CVA, Code Status: DNR.<BR/>Record review of the facility shift change report dated [DATE] from the night shift nurse (LVN B) to the day shift nurse (LVN C) reflected ADMISSIONS: Resident #69 admitted at 01:00 AM to .Hospice, on pleasure feedings, regular diet, multiple breakdowns noted. No mention of Code Status.<BR/>Record review of Resident #69's progress notes written by LVN E dated [DATE] at 10:45 AM, reflected Resident #69 was found unresponsive without a pulse. PCC checked and resident listed as Full Code status. Crash cart was brought into room, Resident #69 placed on the floor. CPR was initiated at 09:28 AM, no respirations, no pulse, no BP, pupils fixed and dilated, skin cool to touch, non-responsive, EMS arrived at 09:45 AM and took over CPR, artificial airway placed. CPR stopped at 09:53 AM after electronic DNR located and provided to EMT's. Pronounced at 09:59 AM via phone by MD for EMS Fire/EMS, and local police.<BR/>Record review of Resident #69's progress notes dated [DATE] at 1:21 PM, reflected that during an interview with the local police, LVN A located an OOH DNR for Resident #69 under the miscellaneous tab in PCC.<BR/>Record review of Resident #69's OOH DNR reflected it was signed and dated on [DATE], prior to his readmission to the facility.<BR/>Interview on [DATE] at 10:46 AM with LVN C, she stated she and LVN A initiated the code for Resident #69. LVN C stated that LVN A found him, called for help, and came out of his room and they checked PCC and found Full Code status was noted on his electronic face sheet. LVN C stated she did not check his orders. LVN C stated the police and EMS was notified and they arrived within 5 minutes. LVN C stated she was trained on how to put a resident's code status and orders into PCC. LVN C stated she did not recall being told Resident #69 was admitted with DNR status from LVN B. LVN C stated it was important to honor a resident's wishes for advanced directives otherwise their rights would be violated.<BR/>Interview on [DATE] at 10:58 AM with LVN A, she stated she found Resident #69 and called for help. LVN A stated she and LVN C checked his EMR and found he was full code status in PCC. LVN A stated she did not check his admission orders. LVN A stated when a police officer asked her about his medications, she looked under his miscellaneous tab in PCC and saw the OOH DNR. LVN A stated she felt bad when that happened and immediately took the OOH DNR to show to the EMT responders and they stopped CPR. LVN A stated Resident #69 was pronounced deceased by the MD.<BR/>Interview on [DATE] at 11:44 AM with LVN B, she stated she was the nurse that did the admission assessment for Resident #69. LVN B stated she put his information into PCC, to include his code status, and she did not know why it was not reflected on Resident #69's face sheet because she felt like she did everything right. LVN B stated his code status was reflected in his admission orders and she communicated it to the night shift nurse LVN C. LVN B stated it was important for the resident's rights and advanced directive desires to be noted and communicated to the nursing staff because if he had a cardiac event, he did not want to be resuscitated.<BR/>Interview on [DATE] at 12:00 PM with the DON, she stated she was called by LVN A, and she told her to check Resident #69's chart. The DON stated she did not realize that Resident #69 received a full course of CPR, and when she realized what had happened, she knew she needed to in-service the nurses on the PCC order entry process. The DON stated LVN B must have failed to discontinue the previous full code order, and this resulted in the change of code status not populating onto the face sheet.<BR/>Interview on [DATE] at 12:15 PM with the Administrator, she stated she reported Resident #69's death as required under long term care death notifications for a death within 24 hours of transfer, however she did not realize the issue with Resident #69's advanced directives not being honored, or she would have reported it to HHSC right away.<BR/>Record review of the facility policy and procedure titled Resident Rights (undated) reflected Purpose, to ensure the resident rights are respected and protected. Further review of the policy and procedure reflected, The resident has a right: To a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.<BR/>Record review of the facility pamphlet (undated) titled Treatment Choices reflected Code Status Policy. Purpose, to provide each resident/responsible party with the education and opportunity to make an informed decision regarding their code status. The facility will maintain a system of clearly identifying, documenting, and communicating the resident's code status decisions to essential facility personnel.<BR/>The Administrator was notified of an IJ on [DATE] at 5:55 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on [DATE] at 2:55 p.m. and included the following:<BR/>Alleged Failure #1 - Failed to properly input code status in the Point Click Care (PCC) Electronic Medical Record (EMAR) upon admission.<BR/>Alleged Failure #2 - Failed to honor the rights of Resident # 1's wishes to die a dignified death by failing to honor a signed out of hospital do not resuscitate (DNR).<BR/>Director of Nursing completed an audit of all resident code statuses on [DATE], 8:00pm, and all were found to be accurate.<BR/>In-servicing/education provided in response (bullet point narrative):<BR/>-Start/stop time and date:<BR/>-On [DATE] at 6:30pm education began for Nurses (LVN and RN) staff in regards to properly complete Order Entry of code status in the PCC/EMAR of a resident. Nurses will reference PCC in the event of an emergency situation.<BR/>-o Nurses that aren't present will be in-serviced by the DON before the start of their next regularly scheduled shift, utilizing a staff roster to ensure training and ensure a passing score on Post Test. <BR/>-o The education/in-service of Order Entry of Code Status in a Resident PCC/EMAR will be included in the new hire process for all Nurses.<BR/>oThe education will be completed by the DON<BR/>-o All the education on this topic will be complete [DATE] by 10:00pm for Nurse staff present.<BR/>oA 4 question post-test will be given to verify retention of knowledge related Order Entry of code status into resident PCC/EMAR.<BR/>-Administrator will randomly issue post test regarding education/in-service on Order Entry of code status into PCC/EMAR provided for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. <BR/>-Director of Nursing will randomly request a Nurse to perform order entry of code status into PCC/EMAR and will document competence for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. <BR/>Record reviews of sampled residents #9, #14, #22, #23, #26, #33, #35, #36, #38, #43, #44 and #56 EMR's and face sheets reflected code status was accurate.<BR/>Verification of the POR<BR/>Record review of facilities incident response binder revealed the facility completed the in-service with nursing staff on topics where to find the resident's code, how to enter resident's code status for new admissions and status changes, the purpose of code status, and resident's rights-choosing their code status. <BR/>-Record review of facilities incident response binder revealed the facility conducted a post test for each nursing staff that received the in-service. Facility has documented 100% of their nursing (all 19 nurses) staff have completed the posttest and received a 100% on the post test. Interview on [DATE] at 1:05 p.m. with the DON revealed she in-serviced 100% (all 19 nurses) staff were on [DATE] after 6 PM and the remainder were in serviced on [DATE].<BR/>OUT OF 19 TOTAL NURSES-16 WERE INTERVIEWED FOR VERIFICATION (84%) <BR/>Phone interview with RN N at 9:40 AM on [DATE]. She stated she received training on [DATE] on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Administrator will randomly issue posttest regarding education/in-service on Order Entry of code status into PCC/EMAR provided for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. <BR/>-Director of Nursing will randomly request a Nurse to perform order entry of code status into PCC/EMAR and will document competence for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. <BR/>-5 DAY SHIFT NURSES<BR/>-Interview with LVN D on [DATE] at 12:21 p.m. revealed she had training on code status, how to put in the code status and to respect their rights. <BR/>-Interview with the DON, RN at 9:51 AM on [DATE]. RN conducted the training with all nursing staff. RN started training on [DATE] and completed training on [DATE]. RN had all staff complete a posttest to ensure they understood the in-service. <BR/>-Interview with MDS Nurse at 10:42 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN E ADON, at 11:02 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN F on [DATE] at 11:52 AM revealed she just had training on DNR and how to put in the code status into PCC. We also check the chart. It is important because it is the resident rights. <BR/>-4 EVENING SHIFT NURSES<BR/>-Interview with LVN G, on [DATE] at 11:39 AM, and I went in this am and had training. The training was how to find the code status of a resident. Why code status is important because it is their rights. We also were advised to check the chart. <BR/>-Interview with LVN C, at 10:46 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN H on [DATE] at 11:45 AM, she stated she had code training on updating the code, and we check the orders. We check the paper chart. Respect wishes of resident. <BR/>-Interview with LVN I at 11:36 AM on [DATE]. She stated she received training yesterday on DNR status and full code. We went over where to find the code status and how to change it in PCC. We would check the chart also.<BR/>-2 NIGHT SHIFT NURSES<BR/>-Interview with LVN J at 11:25 AM on [DATE]. Received training today at 08:00 a.m. [DATE]. The training was on DNR and code status, how to enter PCC properly. What the code status means. We were trained to also check the chart. The importance of code status indicates the resident's rights. <BR/>-Interview with LVN B on [DATE] at 11:47 AM she stated she had code training on updating the code and we check the orders. We check the paper chart. It is important because it is their rights. <BR/>-Interview with RN K on [DATE] at 11:58 AM revealed she had training on code status. Following the resident wishes. How to change in PCC. It is their rights. <BR/>-Interview with RN L, at 11:06 AM on [DATE]. She received training on [DATE], of how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN M, at 11:11 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Interview with LVN A, at 10:58 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. <BR/>-Phone interview with RN N at 9:40 AM on [DATE]. Received training on [DATE] on how to enter the code status, where to enter the code status and the importance11:36 of ensuring the code status is accurate. <BR/>Interview on [DATE] at 1:32 PM, with the DON, she stated the auditing for the effectiveness of the Plan of Removal will begin on Monday [DATE]. Nurses will be randomly selected, and observed and evaluated with the post test, and this will continue for 4 weeks.<BR/>Record Review of facilities incident response binder revealed the facility has implemented a procedure to make random observations with licensed nursing staff by DON for the next 4 weeks starting [DATE]. Post observation the Administrator will administer a posttest to ensure staff understand they understand the training. <BR/>On [DATE] at 08:48 AM, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to monitor the implementation and effectiveness of its plan of removal.

Observation, interview and record review revealed the facility failed to ensure the residents had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 4 hallways (100) and in 2 of 2 shower rooms (men and women's) observed for environmental conditions.<BR/>1. The facility failed to ensure the floor on 100 hall was a flat and even surface.<BR/>2. The facility failed to ensure the men and women's shower stall had an even floor surface and the water drained while residents were showered.<BR/>These deficient practices could affect any resident and could contribute to trips, falls and unsatisfactory shower room condition for residents.<BR/>The findings were:<BR/>1. Review of an invoice revealed from a local contractor revealed on 2/29/16 the wing 100 and 200 were lifted and stabilized.<BR/>Observation on 02/20/24 at 1 PM revealed an area at the end of 100 hall which was cracked, buckled and uneven.<BR/>Observation and interview on 02/23/24 at 03:05 PM revealed an area at the end of 100 hall which was cracked, buckled and uneven. The MS stated he had worked at the facility for about 2 years and the floor on the 100 hallway had always been in its present condition. He stated the 100 wing was leveled and it created the floor surface to shift and crack. He stated it could be a trip hazard. The MS measured the area and the diameter was 2'.5 x 1'. <BR/>Interview on 02/22/24 at 3:00 PM during a group meeting revealed Resident #23, Resident #26 and Resident #32 expressed concern about the floor being uneven and cracked in the main hallway on the 100 hall. They stated it made it difficult to propel over the area and it made it a trip hazard.<BR/>2. Observation and interview on 02/23/24 at 3:15 PM of the 100 women's shower room revealed there were 2 shower stalls. The tiled floor in each shower room was uneven. The MS stated he believed the shower room was updated in house and was a poor design. He stated the floor was uneven and the water did not drain properly because the drain was not positioned lower that the floor to allow the water to drain. The MS stated the water flowed backwards beyond the black seal/threshold into the shower room itself. Further observation revealed the MS demonstrated and turned on the water. The water started to gather on the floor and started to flow backwards and beyond the threshold. The MS stated it could be a major slip hazard. The MS stated staff had mentioned these problems and stated he had talked with the ADM about it but he had not reached out to contractors to get a bid. He stated staff had been using a squeegee to push the water back into the stall so it would drain. The MS further stated he had worked at the facility for 2 years and the showers had been in their present condition since his employment.<BR/>Observation and interview on 02/23/24 at 3:15 PM of 400 men's shower room revealed the same evidence noted in the 100 women's shower room was also noted in the 400 men's shower room. The MS stated the shower tiled floors were uneven, the water would gather and flow backwards beyond the threshold and into the shower room itself.<BR/>Interview on 02/22/24 at 3:00 PM during a group meeting revealed Resident #23, Resident #26 and Resident #32 expressed concern about the 100 women's shower room. They stated the water would gather and flow backwards into the shower room itself. They stated staff had to use a squeegee to push the water back towards the stall. The Resident's commented it was not very homelike and they did not feel comfortable with the conditions of the shower room.<BR/>Interview on 02/23/24 at 03:53 PM with CNA W revealed he showered residents in the 100 and 400 shower rooms. CNA W stated the water would flow back beyond the black strip and would have to squeegee the water back into the stall. <BR/>Interview on 02/23/24 at 04:05 PM with CNA U and CNA X revealed they showered residents in the 100 and 400 shower rooms. CNAs U and X stated the water would gather, flow backwards beyond the black strip and would have to squeegee the water back into the stall. <BR/>Interview on 02/25/24 at 10:00 AM with the ADM revealed the MS talked with her about the shower rooms and the uneven surface on the 100 hallway. The ADM stated she did not realize the floors were uneven in the women's and men's shower stalls causing the water to flow backwards into the shower room itself. The ADM stated the MS also mentioned to her that it was a poor design. The ADM stated nursing staff would have reported any incidents or accidents during the morning meetings and there had not been any reported problems. The ADM further stated she was aware the floor on the 100 hallway was uneven since the wing was leveled but again stated it had not created a problem for the residents. Although, the ADM stated she understood the safety risks the condition of the shower stalls and the uneven surface on the 100 hallway created for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure alleged violations involving abuse, neglect, exploitationexploitation, or mistreatment, including injuries, of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation was reported for 1 (Resident #69) of 4 residents reviewed for reporting of alleged violations. <BR/>The facility failed to report that Resident #69's wishes to die a dignified death was not honored and that nursing staff failed to honor a signed OOH DNR order on [DATE] at 09:30 AM when Resident #69 was found unresponsive without a pulse and had a full code initiated to include CPR for approximately 25 minutes.<BR/>This facility failure affects residents involved in incidents and could result in alleged violations not being investigated in a timely and proper manner.<BR/>The findings included:<BR/>Record review of Resident #69's electronic face sheet dated [DATE] reflected he was originally admitted to the facility on [DATE]. His diagnoses included: diabetes mellitus (a disease of inadequate control of blood glucose levels), cognitive communication deficit (difficulty with thinking and how someone uses language), chronic kidney disease (when the kidneys have become damaged over time (for at least 3 months) and have a hard time doing all their functions), CVA (cerebral vascular accident or brain attack) and osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection. Resident #69's electronic face sheet reflected he had Full Code (desired CPR) status.<BR/>Record review of Resident #69's significant change MDS assessment dated [DATE] reflected he scored a 12/15 on his BIMS which signified he was cognitively intact. He could usually understand others and could usually be understood. He required extensive assistance with his ADL's.<BR/>Record review of Resident #69's comprehensive care plan revised on [DATE] reflected Focus, the resident/family are requesting DNR status, Goal, resident/family wishes will be honored through next review, Interventions/Tasks, Activate EMS as indicated, if transferred out of facility, notify receiving facility and EMS of DNR status, initiate CPR as indicated.<BR/>Record review of Resident #69's readmission assessment dated [DATE] reflected resident desired to have DNR status under advanced directives.<BR/>Record review of Resident #69's Order Details dated [DATE] reflected Admit to .under .Hospice, DX. CVA, Code Status: DNR.<BR/>Record review of the facility shift change report dated [DATE] from the night shift nurse (LVN B) to the day shift nurse (LVN C) reflected ADMISSIONS: Resident #69 admitted at 01:00 AM to .Hospice, on pleasure feedings, regular diet, multiple breakdowns noted. No mention of Code Status.<BR/>Record review of Resident #69's progress notes written by LVN E dated [DATE] at 10:45 AM, reflected Resident #69 was found unresponsive without a pulse. PCC checked and resident listed as Full Code status. Crash cart was brought into room, resident #69 placed on the floor. CPR was initiated at 09:28 AM, no respirations, no pulse, no BP, pupils fixed and dilated, skin cool to touch, non-responsive, EMS arrived at 09:45 AM and took over CPR, artificial airway placed. CPR stopped at 09:53 AM after electronic DNR located and provided to EMT's. Pronounced at 09:59 AM via phone by MD for EMS Fire/EMS, and local police.<BR/>Record review of Resident #69's progress notes dated [DATE] at 1:21 PM, reflected that during an interview with the local police, LVN A located an OOH DNR for Resident #69 under the miscellaneous tab in PCC.<BR/>Record review of Resident #69's OOH DNR reflected it was signed and dated on [DATE], prior to his readmission to the facility.<BR/>Interview on [DATE] at 10:46 AM with LVN C, she stated she and LVN A initiated the code for Resident #69. She stated that LVN A found him, yelled for help, and came out of his room and they checked PCC and found Full Code status was noted on his electronic face sheet. She stated she did not check his orders. She said that the police and EMS was notified and they arrived within 5 minutes. She said that she was trained on how to put a resident's code status and orders into PCC. She did not recall being told Resident #69 was admitted with DNR status from LVN B. She stated it was important to honor a resident's wishes for advanced directives otherwise their rights would be violated.<BR/>Interview on [DATE] at 10:58 AM with LVN A, she stated she found Resident #69 and called for help. She stated she and LVN C checked his EMR and found he was full code status in PCC. She stated she did not check his admission orders. She stated when a police officer asked her about his medications, she looked under his miscellaneous tab in PCC and saw the OOH DNR. She stated she felt bad when that happened and immediately took the OOH DNR to show to the EMT responders and they stopped CPR. She stated Resident #69 was pronounced deceased by the MD.<BR/>Interview on [DATE] at 11:44 AM with LVN B, she stated she was the nurse that did the admission assessment for Resident #69. She stated she put his information into PCC, to include his code status, and she did not know why it was not reflected on Resident #69's face sheet because she felt like she did everything right. She stated his code status was reflected in his admission orders and she communicated it to the night shift nurse LVN C. She stated it was important for the resident's rights and advanced directive desires to be noted and communicated to the nursing staff because if he had a cardiac event, he did not want to be resuscitated.<BR/>Interview on [DATE] at 12:00 PM with the DON, she stated she was called by LVN A, and she told her to check Resident #69's chart. She stated she did not realize that Resident #69 received a full course of CPR, and when she realized what had happened, she knew she needed to in-service the nurses on the PCC order entry process.<BR/>Interview on [DATE] at 12:15 PM with the Administrator, she stated she reported Resident #69's death as required under long term care death notifications for a death within 24 hours of transfer, however she did not realize the issue with Resident #69's advanced directives not being honored, or she would have reported it to HHSC right away. <BR/>Review of the facility policy and procedure titled Prevention and Reporting of Suspected Resident Abuse and Neglect (undated) reflected This facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. This facility has implemented the following processes to provide residents and staff a comfortable and safe environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 resident (Resident #35) of 24 residents reviewed for MDS assessments.<BR/>Resident #35's MDS assessment did not accurately reflect she had limitations on her upper extremities and she was on continuous oxygen therapy.<BR/>This deficient practice could result in missed or inaccurate care.<BR/>The findings included:<BR/>Record review of Resident #35's electronic face sheet dated 02/21/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks), bacteremia (viable bacteria in the blood), pressure ulcer of right hip, stage IV (may look like a reddish crater in the skin. Muscles, bones, and/or tendons may also be visible at the bottom of the stage IV), dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), dysphagia (difficulty swallowing) and contracture of muscle multiple sites (muscles, tendons, joints, or other tissues tighten or shorten causing a deformity).<BR/>Record review of Resident #35's quarterly MDS assessment with an ARD of 01/09/2024 reflected she was not a candidate for a BIMS which signified she was severely cognitively impaired. She could usually understand and usually be understood. She was noted to have No impairment of her Upper extremities (shoulder, elbow, wrist, and hand). She was not coded to have oxygen therapy while a resident. She required total assistance with her ADL's.<BR/>Record review of Resident #35's comprehensive person-centered care plan revised date 01/19/2024, Focus, has an ADL, self-care performance deficit, mobility, transfers, eating, bathing, dressing and personal hygiene. Resident #35's comprehensive care plan did not address her contractures or oxygen therapy.<BR/>Record review of Resident #35's Active Orders as of: 02/02/2024 reflected 02 at 2-5L per NC to maintain sp02 &gt;90% every shift .for dyspnea .Active 01/02/2024.<BR/>Record review of Resident #35's progress notes for the week of 01/02/2024 to 01/09/2024 reflected she was on Oxygen therapy at 2L/NC.<BR/>Observation on 02/22/2024 at 09:30 AM of Resident #35 revealed she was lying in bed and had oxygen infusing at 2.5 L/min via NC.<BR/>Observation on 02/20/2024 at 10:23 AM of Resident #35 revealed she was lying in bed and had oxygen infusing at 2.5 L/min via NC, and she had a rolled-up washcloth in her right hand which appeared contracted. Her left hand was contracted.<BR/>Observation and interview on 02/22/2024 at 11:50 AM, RN F provided G-tube (is a tube inserted through the belly that brings nutrition directly to the stomach) medication to Resident #69, she was in bed on oxygen therapy and her bilateral hands contracted. RN F stated Resident #69's hands wasere contracted and was on continuous oxygen therapy for at least a month.<BR/>Interview on 02/24/2024 at 2:00 PM with the MDS nurse, she stated Resident #69's quarterly MDS with an ARD of 01/09/2024 was inaccurate. She stated the resident was on oxygen therapy and it was within the look back time and it should have been coded. She stated Resident #69's upper limitations should have been coded. She did not know why they were not. She stated it was important for the MDS to be accurate because it provides information for the resident's care plan and she could miss needed care without it being addressed.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON, she stated Resident #69's MDS was inaccuratei, and it was important to be correct to communicate to nursing staff the care required for the resident. She stated she was accountable for overseeing the MDS's.<BR/>Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 (Residents #35, #36, #44 and #56) of 16 residents reviewed for care plans.<BR/>1. Resident #35's comprehensive care plan did not address she was contracted in her hands.<BR/>2. Resident #36's comprehensive care plan did not address all areas affected by the resident's hemiplegia.<BR/>3. Resident #44's compression stockings were not reflected in the resident's care plan.<BR/>4. Resident #56's Renal Diet was not reflected in his care plan.<BR/>These failures placed residents at risk of not receiving needed care and services in accordance with their individually assessed needs which could result in not having their needs met and a decreased quality of life and quality of care.<BR/>The findings included:<BR/>1. Record review of Resident #35's electronic face sheet dated 02/21/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks), bacteremia (viable bacteria in the blood), pressure ulcer of right hip, stage IV (may look like a reddish crater in the skin. Muscles, bones, and/or tendons may also be visible at the bottom of the stage IV), dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), dysphagia (difficulty swallowing) and contracture of muscle multiple sites (muscles, tendons, joints, or other tissues tighten or shorten causing a deformity).<BR/>Record review of Resident #35's quarterly MDS assessment with an ARD of 01/09/2024 revealed the resident was not a candidate for a BIMS which signified she was severely cognitively impaired. Further review revealed the resident could usually understand and usually be understood, was noted to have No impairment of her Upper extremities (shoulder, elbow, wrist, and hand), and required total assistance with her ADL's.<BR/>Record review of Resident #35's comprehensive person-centered care plan revised date 01/19/2024, Focus, has an ADL, self-care performance deficit, mobility, transfers, eating, bathing, dressing and personal hygiene. Further review revealed Resident #35's comprehensive care plan did not address her contractures.<BR/>Observation on 02/20/2024 at 10:23 AM of Resident #35 revealed she was lying in bed and had a rolled-up washcloth in her right hand which appeared contracted. Further observation revealed the resident's left had was contracted.<BR/>Observation on 02/22/2024 at 11:50 AM of RN F provided G-tube medication to Resident #69 and the resident had contracted hands.<BR/>Interview on 02/22/2024 at 11:55 AM with RN F who was Resident #69's nurse, she stated Resident #69's hands were contracted.<BR/>Interview on 02/24/2024 at 2:00 PM with the MDS Nurse, she stated Resident #69's comprehensive care plan did not reflect the resident's hand contractions. The MDS Nurse stated it was important for the care plan to be accurate because it provides information for the resident's care, she could miss needed care without it being addressed.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON, she stated Resident #69's care plan did not reflect her contractions and it was important to be in the care plan to communicate to nursing staff the care required for the resident. She stated she was accountable for overseeing the care plans.<BR/>2. Review of Resident #36's face sheet, dated 2/24/24, revealed the resident was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis (paralysis on one side) following Cerebral Infarction (stroke) affecting non-dominant side and memory deficit following Cerebral Infarction.<BR/>Review of Resident #36's MDS assessment, dated 1/25/24, revealed her BIMS was 3 reflecting severe cognitive impairment and she was dependent for eating, toileting hygiene, shower, upper and lower body dressing, putting and taking off footwear and personal hygiene.<BR/>Review of Resident #36's Care Plan, revised 2/2/24 revealed, The resident requires assistance with ADLs. bed mobility, transfers, locomotion, dressing, toilet use, eating, personal hygiene and bathing. The interventions only addressed Resident #36 was totally dependent for bed mobility and transfers. It did not reflect the level of assistance Resident #36 required for the other ADLs. Further review revealed the Care Plan identified Resident #36 was hemiplegic but there were no interventions included on how staff would assist Resident #36 related to being hemiplegic.<BR/>Interview on 02/23/24 at 11:26 AM with MDS Coordinator revealed Resident #36's Care Plan's interventions only addressed bed mobility and transfer and there were no interventions for hermiparesis. The MDS Coordinator stated the Care Plan was started but never completed. MDS Coordinator stated it was important to ensure the Care Plan accurately reflected the care and services Resident #36 needed because the information transferred to Resident #36's [NAME]. The MDS Coordinator further stated the CNA's relied on this information to determine the level of care Resident #36 required.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON revealed it was important for it to be her care plan to communicate to nursing staff the care required for the resident. The DON stated she was accountable for overseeing the care plans.<BR/>3. Record review of Resident #44's electronic face sheet, dated 02/20/2024, revealed the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: diabetes mellitus (a disease of inadequate control of blood levels of glucose), atherosclerotic heart disease (a common condition that develops when plaque builds up inside the arteries), obstructive sleep apnea (when the throat muscles relax and block the airway), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should).<BR/>Record review of Resident #44's quarterly MDS assessment with an ARD of 12/22/2023 revealed the resident scored a 15/15 on his BIMS which signified he was cognitively intact, and required moderate assistance with his ADL's. Further review revealed the resident was was coded to have an active diagnosis of congestive heart failure (CHF) (a long-term condition that happens when the heart cannot pump blood well enough to give a body a normal supply, blood and fluid can collect in the lungs and legs).<BR/>Record review of Resident #44's comprehensive care plan revised date 10/01/2020 reflected Focus, at risk for breakdown r/t decreased mobility, occasional incontinence, edema and CHF (Congestive Heart Failure). Further review revealed the resident's need for compression stockings was not reflected as an intervention for his edema.<BR/>Record review of Resident #44's Active Orders as of: 02/20/2024 reflected Check edema every shift every shift Active 12/28/2022 .Compression stockings to BLE. Apply in AM and remove at HS one time a day for edema Active 12/05/2023.<BR/>Record review of Resident #44's MAR for February 2024 reflected he was being checked for edema each shift and his compression stockings were applied in the morning and taken off in the evening.<BR/>Observation on 02/22/2024 at 09:30 AM of Resident #44 revealed he was sitting in his room in a wheelchair and the resident had [NAME] (a pattern used on items of clothing such as socks or sweaters, consisting of diamond shapes of various colors) socks on. <BR/>In an interview on 02/22/2024 at 09:40 AM with Resident #44, he stated he does not always get his special stockings applied.<BR/>Observation on 02/23/2024 at 10:00 AM of Resident #44 revealed he was sitting in his room in a wheelchair. Further observation revealed the resident had black compression stockings on his BLE's. <BR/>Interview on 02/23/2024 at 10:05 AM with Resident #44, he stated he wore the special stockings to keep his lower legs from swelling. <BR/>Interview on 02/23/2024 at 1:00 PM with LVN F, she stated she relied on the aides to put on Resident #44's compression stockings. LVN F stated he was supposed to get them put on in the morning and taken off at bedtime. LVN F stated the resident's compression stockings should be in his care plan because he needed them.<BR/>Interview on 02/24/2024 at 2:00 PM with the MDS Nurse, she stated Resident #44's comprehensive care plan did not reflect the resident's compression stockings. The MDS Nurse stated it was important for the care plan to be accurate because it provides information for the resident's care, the resident could miss needed care without it being addressed.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON, she stated Resident #44's care plan did not reflect the resident's compression stockings, she stated it was important for it to be in his care plan to communicate to nursing staff the care required for the resident. The DON stated she was accountable for overseeing the care plans.<BR/>4. Record review of Resident #56's electronic face sheet, dated 02/20/2024, revealed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included: hypertension (when the pressure in the blood vessels is too high), diabetes mellitus (a disease of inadequate control of blood levels of glucose), chronic atrial fibrillation (an irregular heart rhythm), renal disease (when chronic kidney disease causes loss of kidney function) and unspecified protein-calorie malnutrition (the lack of sufficient energy or protein to meet the body's metabolic demands).<BR/>Record review of Resident #56's quarterly MDS assessment with an ARD of 11/17/2023 reflected he scored a 14/15 on his BIMS which signified he was cognitively intact, and required extensive assistance with his ADL's. Further review revealed the resident was on a therapeutic diet and had an active diagnosis of renal disease.<BR/>Record review of Resident #56's comprehensive care plan revised 02/28/2022 reflected, Focus, has DX/HX Renal Disease, Interventions/Tasks, ensure resident is ready for dialysis, remind dietary of need for to go meal to take with them. Further review revealed the resident's therapeutic diet, a renal diet was not addressed in his care plan.<BR/>Record review of Resident #56's Active Orders as of: 02/20/2024 reflected, Renal diet Regular texture, Regular/Thin consistency Active 05/04/2023.<BR/>Observation on 02/20/2024 at 12:30 PM of Resident #56 in the dining room and record review of his meal ticket reflected, Renal Diet.<BR/>In an interview on 02/20/2024 at 12:35 PM with Resident #56, he stated he received extra protein servings, and was on a special diet.<BR/>Interview on 02/24/2024 at 2:00 PM with the MDS Nurse, she stated Resident #56's comprehensive care plan did not reflect his renal diet. The MDS Nurse stated it was important for the care plan to be accurate because it provides information for the resident's care, she could miss needed care without it being addressed.<BR/>Interview on 02/24/2024 at 2:10 PM with the DON, she stated Resident #56's care plan did not reflect the resident's renal diet, she stated it was important for it to be in his care plan to communicate to nursing staff the care required for the resident. The DON stated she was accountable for overseeing the care plans.<BR/>Record review of the facilities policy and procedure titled Comprehensive Care Plans (undated) reflected, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received assistance devices to prevent accidents for 1 of 3 Residents (Resident #14) reviewed for accidents and hazards.<BR/>CNA X did not widen the base of the mechanical lift while transferring Resident #14 from bed to his wheelchair on 2/23/24.<BR/>This deficient practice could placed residents transferred via mechanical lift at risk of falls which could result in injury and hospitalization.<BR/>The findings were:<BR/>Review of Resident #14's face sheet, dated 2/24/24, revealed he was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) without Dyskinesia (a condition that causes involuntary, erratic movements of different body parts), and Cerebral Infarction (Stroke).<BR/>Review of Resident #14's quarterly MDS assessment, dated 1/2/24, revealed his BIMS was 11 reflective of moderate cognitive impairment and he was dependent to go from a sit to stand position. <BR/>Review of Resident #14's Care Plan, revised 2/1/24, revealed he had an ADL performance deficit and required TOTAL ASSIST for transfers and requires Mechanical Hoyer lift for transfers. Provide 2 person for transfer.<BR/>Observation on 2/23/24 at 03:55 PM revealed CNA X and CNA U transferring Resident #14 from the bed to his wheelchair. CNA X was operating the mechanical lift and positioned it under the bed. Further observation revealed CNA X did not widen the base and did not lock the lift. CNA U secured the harness to the lift and CNA X lifted Resident #14 from the bed while CNA U guided him. CNA X pulled the mechanical lift back and away from the bed and turned the lift towards the wheelchair. CNA X then widened the base and CNA U positioned the wheelchair between the base of the lift. CNA X did not lock the lift. CNA X lowered Resident #14 into the wheelchair. Once sitting in the wheelchair CNA U unfastened the harness from the lift. <BR/>Interview on 2/23/24 at 4:00 PM with CNA X and CNA U, revealed CNA X stated she did not widen the base of the mechanical lift until she positioned Resident #14 over the wheelchair. CNA X also stated she did not remember locking the lift at any point. CNA U stated she did not notice that CNA X did not widen the base; she stated she was not paying attention. CNA X stated she should have widened the base and locked the lift once she positioned the base under the bed. She stated this would provide stability while lifting Resident #14 up in the air. She stated the lift could tilt over because she did not widen the base or lock the lift and the Resident could have fallen.<BR/>Review of an in-service conducted on mechanical lift policy dated 5/15/23 revealed neither CNA X or CNA U signed the in-service to reflect they received the training.<BR/>Interview on 2/23/24 at 5:29 PM with the ADON and the DON revealed staff should widened the base of the mechanical lift and lock it before lifting a resident into the air to provide stability and to prevent the lift from tilting over. The ADON and the DON stated the lift could tilt over and a resident could fall if the base was not widened and or locked. The DON stated nursing staff should provide periodic oversight for the CNA's while operating a mechanical lift to ensure correct operation. They should also provide corrective training as needed and stated the last inservice they provided staff was during June 2023. <BR/>Review of facility policy, Mechanical or Hydraulic Lift, undated, read: They hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed or obese, or too weak to transfer without complete assistance. It requires two or three staff members to safely operate and accomplish the transfer. Procedure: 7. Raise the bed to accommodate the lift under the bed. 8. Prepare the lift by setting the adjustable base to its widest position and lock in place.<BR/>Review of the Patient lift owners manual and instructions for the patient lift, undated, read: Safety Summary, Warning! When using an adjustable base lift, the legs much be in the maximum opened/locked position before lifting the patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 Resident (Resident #38) whose records were reviewed for oxygen care.<BR/>The facility failed to ensure Resident #38's oxygen concentrator was cleaned and the filter was not covered in lint. <BR/>This deficient practice could affect residents residents on oxygen at risk of decreased efficiency of the concentrator and infection.<BR/>The findings were:<BR/>Review of Resident #38's face sheet, dated 2/21/24, revealed she was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (lungs are susceptible to infections) and Chronic Systolic (Congestive) Heart Failure. <BR/>Review of Resident #38's quarterly MDS assessment, dated 1/28/23, revealed her BIMS was a 15 reflective of no cognitive impairment and she was receiving Hospice care and on oxygen therapy.<BR/>Review of Resident #38's Care Plan, revised on 1/24/24, revealed Resident #38 had oxygen therapy related to Congestive Heart Failure.<BR/>Review of Resident #38's consolidated physician orders revealed an order for oxygen, 2l-5l via n/c continuous. Further review did not reveal instructions for the maintenance of the filter, oxygen tubing or humidifier.<BR/>Observation on 02/20/24 at 11:14 AM revealed there was an oxygen sign on Resident #38's door. Resident #38 was sitting on the side of the bed, in lower position, with oxygen infusing via a nasal cannula at 3 liters per hour. Further observation revealed the oxygen concentrator's filter had built up lint on the filter that was white in color. <BR/>Observation on 02/21/24 at 9:21 AM revealed Resident #38 was lying in bed with oxygen infusing via nasal cannula at 3 liters per hour. Further observation revealed the oxygen concentrator's filter had built up lint on the filter that was white in color. <BR/>Interview with MA V and LVN H on 02/21/24 at 9:21 AM, at the same time as the observation, revealed MA V and LVN H stated Resident #38's oxygen concentrator's filter was white because of the built up lint. LVN H stated she was new and did not know the process of cleaning the filters but would find out. MA V stated the oxygen concentrator filter was, really dirty. <BR/>Interview on 02/23/24 at 4:00 PM with the DON revealed the nursing staff should clean the oxygen filters every Sunday. The DON further stated if it was a hospice oxygen concentrator then nursing staff should call hospice and they would provide clean filters. The DON stated either way nursing staff should ensure the filter was cleaned to ensure it provided a clean air path because residents using oxygen were susceptible to upper respiratory infections. The DON stated it was her responsibility to ensure this was done. The DON stated the Administrator had audited all oxygen concentrators last week and Resident #38's filter was probably skipped over because she was receiving hospice services.<BR/>Review of facility policy, Oxygen Administration undated, read: Purpose: To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. Procedures 9. Check and clean oxygen equipment (including filter), masks, tubing and cannula. If visibly soiled, or otherwise known to be contaminated, replace masks, tubing and/or cannula. Regular replacement intervals are not required, but not otherwise prohibited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain medical records on each resident that are-accurately documented for 1 (Resident #44) of 24 residents reviewed for accurate medical records in that:<BR/>LVN F initialed off on Resident #44's MAR that the resident's compression stockings were applied on 02/22/2024, when they were not.<BR/>This deficient practice could affect residents who have medical records and could result in misinformation about professional care provided.<BR/>The findings included:<BR/>Record review of Resident #44's electronic face sheet, dated 02/20/2024, revealed the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: diabetes mellitus (a disease of inadequate control of blood levels of glucose), atherosclerotic heart disease (a common condition that develops when plaque builds up inside the arteries), obstructive sleep apnea (when the throat muscles relax and block the airway), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should).<BR/>Record review of Resident #44's quarterly MDS assessment with an ARD of 12/22/2023 revealed the resident scored a 15/15 on his BIMS which signified he was cognitively intact, and required moderate assistance with his ADL's. Further review revealed the resident was coded to have an active diagnosis of congestive heart failure (CHF) (a long-term condition that happens when the heart cannot pump blood well enough to give a body a normal supply, blood and fluid can collect in the lungs and legs).<BR/>Record review of Resident #44's comprehensive care plan, revised date 10/01/2020, revealed, Focus, at risk for breakdown r/t decreased mobility, occasional incontinence, edema and CHF (Congestive Heart Failure). Further review revealed the resident's need for compression stockings were not reflected as an intervention for the resident's edema.<BR/>Record review of Resident #44's Active Orders as of: 02/20/2024 reflected Check edema every shift every shift Active 12/28/2022 .Compression stockings to BLE. Apply in AM and remove at HS one time a day for edema Active 12/05/2023.<BR/>Record review of Resident #44's MAR for February 2024 revealed the resident was being checked for edema each shift and his compression stockings were applied in the morning and taken off in the evening to include 02/22/2024 being initialed off as having been applied.<BR/>Observation on 02/22/2024 at 09:30 AM of Resident #44 revealed he was sitting in his room in a wheelchair. Further observation revealed the resident had [NAME] stockings on. <BR/>In an interview on 02/22/2024 at 09:40 AM with Resident #44, he stated he did not always get his special stockings applied.<BR/>Interview with LVN F on 02/23/2024 at 1:00 PM, LVN F stated she relied on the aides to put on Resident #44's compression stockings. LVN F stated the resident was supposed to get them put on in the morning and taken off at bedtime. LVN F stated she had not checked and initialed off that the resident had them put on. LVN F stated she should have checked, but she relied on the aides to tell her if they were not applied.<BR/>Interview with the DON on 02/24/2024 at 2:10 PM, the DON stated LVN F should not have initialed off on Resident #44's MAR that the resident's compression stockings were applied because they were not, and that would be false documentation. The DON stated she was accountable for the nursing staff and needed to remind them to check the residents prior to initialing off in the MAR.<BR/>Review of the facility policy and procedure titled Documentation-Nursing (undated) reflected Nursing documentation will be concise, clear, pertinent, accurate and evidence based .medication administration records and treatment administration records are completed with each medication or treatment completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #44) of 5 residents reviewed for infection control in that:<BR/>Resident #44's ventilator mask and oxygen nasal cannula tubing were left unbagged for 2 days when not in use.<BR/>This facility failure affects residents on oxygen therapy and could result in upper respiratory infections.<BR/>The findings included:<BR/>Record review of Resident #44's electronic face sheet, dated 02/20/2024, revealed the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: diabetes mellitus (a disease of inadequate control of blood levels of glucose), atherosclerotic heart disease (a common condition that develops when plaque builds up inside the arteries), obstructive sleep apnea (when the throat muscles relax and block the airway), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should).<BR/>Record review of Resident #44's quarterly MDS assessment with an ARD of 12/22/2023 reflected the resident scored a 15/15 on his BIMS which signified he was cognitively intact, and required moderate assistance with his ADL's. Further review revealed the resident was coded to have an active diagnosis of congestive heart failure (CHF) (a long-term condition that happens when the heart cannot pump blood well enough to give a body a normal supply, blood and fluid can collect in the lungs and legs).<BR/>Record review of Resident #44's comprehensive care plan, revised date 02/03/2024, revealed, Focus, altered respiratory status r/t DX of CHF, and acute/chronic respiratory failure, use of oxygen PRN and ventilator machine at NOC.<BR/>Record review of Resident #44's Active Orders as of: 02/20/2024 .Change O2 tubing, humidifier water, and bag to place tubing in weekly . 07/26/2023. May apply O2 via Nasal Cannula PRN SOB/hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain homeostasis): Titrate O2 2-5LPM to keep SPO2 equal or greater than 90%. Write liters per min of O2 as needed for SOB/Hypoxia Active 07/26/2023.<BR/>Observation on 02/22/2024 at 09:30 AM of Resident #44 revealed he was sitting in his room in a wheelchair and his ventilator mask was unbagged and his oxygen nasal cannula was hanging over the concentrator and was unbagged.<BR/>In an interview on 02/22/2024 at 09:40 AM with Resident #44, he stated he used the ventilator and oxygen at night.<BR/>Observation on 02/23/2024 at 10:00 AM of Resident #44 revealed he was sitting in his room in a wheelchair and his ventilator mask was unbagged and his oxygen nasal cannula was hanging over the concentrator and was unbagged.<BR/>Interview with LVN F on 02/23/2024 at 1:00 PM, LVN F stated Resident #44's oxygen tubing and ventilator mask needed to be bagged when not in use. LVN F stated it was important to put the tubing and mask in a bag to prevent dirt particles and dust from getting into the system and it could result in an infection. LVN F stated she had not checked it.<BR/>Interview with the DON on 02/24/2024 at 2:10 PM, the DON stated Resident #44's oxygen tubing and ventilator mask needed to be bagged when not in use to prevent cross contamination.<BR/>Record review of the facility titled Cleaning and Disinfecting Equipment (undated) reflected Resident care-equipment, including reusable items and durable medical equipment will be cleaned and disinfected.

Based on interview and record review, the facility failed conduct an initial Comprehensive Assessment within 14 days calendar days after admission 1 of 18 residents (Resident #1) reviewed for Comprehensive Assessments and timing. <BR/>The facility failed to ensure an MDS Assessment for Resident #1 was completed within 14 days after admission. <BR/>This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.<BR/>The Findings include:<BR/>Record review of Resident #18's face sheet dated 08/18/2023, revealed an original admission date of 01/16/2020 while the resident was on Respite Care (short period of rest or relief) and each time he would be Discharge Return Anticipated. The resident never returned until 07/21/2023 when he was officially admitted to the facility on Hospice. Resident #1 had diagnoses which included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), hemiplegia and hemiparesis (defined as paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one?sided weakness, but without complete paralysis), dysphagia (difficulty swallowing), peripheral vascular disease (a slow and progressive circulation disorder. narrowing, blockage, or spasms in a blood vessel), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), hypertension (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease) and depression (mood disorder). <BR/>Record review of Resident #1's medical record revealed that as of 08/18/2023, no admission assessment MDS had been completed. Section A of the MDS assessment was still showing section V as incomplete RN Signature missing and not sent. <BR/>Interview on 08/18/2023 at 10:32 a.m. with the DON revealed she only signed the Minimum Data Sets (MDSs) and knew nothing about the MDS.<BR/>Interview on 08/18/2023 at 10:45 a.m. with the MDS Coordinator revealed the admission MDS for Resident #1 was due within 14 days of admission and the admission MDS was due on 08/03/2023. The MDS Coordinator further replied when the MDS is completed she will wait 2 or 3 days before she transmits the MDS. The MDS Coordinator stated the MDS should have already been signed by the DON and the admission MDS for Resident #1 was late. When this surveyor asked the MDS Coordinator what could happen when there is a delay in transmitting the MDS. The MDS Coordinator stated well corporate will be down on me, we will get a deficiency for the state and resident care could be affected.<BR/>Interview with the Administrator on 08/18/2023 at 5 p.m. revealed the Administrator was not aware the admission Assessment MDS was late. <BR/>Review of the Facility Implemintation of the Minimum Data Set (MDS), no date provided stated in part: It is the policy of this facility to ensure a comprehensive assessment of each resident is completed and submitted according to the RAI manual set forth by CMS.<BR/>Record review of the MDS 3.0 RAI-Manual, V1.17.1,October 2019 revealed The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if: this is the resident's first time in this facility, OR the resident has been admitted to this facility and was discharged return not anticipated, OR the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: <BR/>1. There was a bag of tortilla chips in the dry storage room that had been opened and was not properly sealed.<BR/>2. There was a bag of corn tortillas in the walk-in cooler that had been opened, was not properly sealed, and was past its use-by date, and unopened bags of corn tortillas that were past their use-by date.<BR/>3. There was an open bag of diced carrots in a box in the walk-in freezer.<BR/>4. There was a bag of biscuits in the freezer that was not properly sealed and without a label indicating the date it was received or stored.<BR/>These deficient practices could place residents who ate food from the kitchen at risk for food borne illness.<BR/>The findings included:<BR/>1. Observation on 01/03/2023 at 10:25 AM in the dry storage room revealed a 1 lb. bag of tortilla chips had been opened, was rolled down, and was loosely secured with a small office clip. The clip was not adequate to seal the bag in a manner to prevent contents of the bag from being exposed to air and deteriorating.<BR/>Interview on 01/03/2023 on 01/03/2023 at 10:26 AM, [NAME] A confirmed that the bag of chips was not properly sealed.<BR/>2. Observation on 01/03/2023 at 10:30 AM in the walk-in cooler revealed one package of corn tortillas that had been opened. The package was not in a sealed bag or container, and the 8 tortillas in the bag had hardened and were unfit for consumption. The manufacturer's date on the bag was 09/28/2023. Further observation revealed an additional package of corn tortillas (24) in a plastic bag closed at the top with a knot. The manufacturer's date on the bag was 09/28/2023. There was also an unopened bag of corn tortillas (60 count) with the same date of 09/28/2023.<BR/>Interview with the Dietary Manager (DM) on 01/03/2023 at 10:32 AM, the DM confirmed that the open package of tortillas was not properly sealed and open to cross contamination and that all three packages of tortillas were past their use-by date.<BR/>3. Observation on 01/03/2023 at 10:34 AM in the walk-in freezer revealed there was a 30-lb. box of diced carrots on a shelf. The box was open and inside the box the carrots were in a bag that was also completely open. <BR/>4. Observation on 01/03/2023 at 10:35 AM revealed there was a plastic bag containing 18 biscuits in the freezer that was closed with a knot and was not labeled with the date it was received or a use-by date.<BR/>Interview with the DM on 01/03/2023 at 10:36 AM, the DM confirmed the diced carrots were completely exposed to the air in the freezer and the biscuits were in a bag that was not properly sealed and without a label indicating the date it was received or a use-by date. The DM stated that sometimes the cooks were in a rush and did not properly seal the items as they should in the walk-in cooler and freezer, and that the biscuits had been used that morning. The DM stated that the cooks and dietary aides were responsible for properly sealing, labeling and dating food items stored in the dry storage room, coolers and freezer. The DM further stated that it was important that food items be sealed and labeled/dated to maintain product quality, prevent cross contamination and serving residents food that could potentially contain harmful bacteria. The DM stated he had trained all staff on labeling and dating foods shortly after he had assumed the position in August 2022.<BR/>Review of training logs revealed the DM trained all dietary staff on labeling and dating food items on 08/03/2022. <BR/>Review of facility policy, Nutrition Center, undated, revealed: Procedure: 2. All foods will be covered with clear plastic wrap and dated or will be in the original sealed individual serving container. 4. The refrigerator will be cleaned out weekly. <BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. Except as specified in paragraphs (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and: <BR/>(1) The day the original container is opened in the food establishment shall be counted as Day 1; and<BR/>(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: <BR/>1. There was a bag of tortilla chips in the dry storage room that had been opened and was not properly sealed.<BR/>2. There was a bag of corn tortillas in the walk-in cooler that had been opened, was not properly sealed, and was past its use-by date, and unopened bags of corn tortillas that were past their use-by date.<BR/>3. There was an open bag of diced carrots in a box in the walk-in freezer.<BR/>4. There was a bag of biscuits in the freezer that was not properly sealed and without a label indicating the date it was received or stored.<BR/>These deficient practices could place residents who ate food from the kitchen at risk for food borne illness.<BR/>The findings included:<BR/>1. Observation on 01/03/2023 at 10:25 AM in the dry storage room revealed a 1 lb. bag of tortilla chips had been opened, was rolled down, and was loosely secured with a small office clip. The clip was not adequate to seal the bag in a manner to prevent contents of the bag from being exposed to air and deteriorating.<BR/>Interview on 01/03/2023 on 01/03/2023 at 10:26 AM, [NAME] A confirmed that the bag of chips was not properly sealed.<BR/>2. Observation on 01/03/2023 at 10:30 AM in the walk-in cooler revealed one package of corn tortillas that had been opened. The package was not in a sealed bag or container, and the 8 tortillas in the bag had hardened and were unfit for consumption. The manufacturer's date on the bag was 09/28/2023. Further observation revealed an additional package of corn tortillas (24) in a plastic bag closed at the top with a knot. The manufacturer's date on the bag was 09/28/2023. There was also an unopened bag of corn tortillas (60 count) with the same date of 09/28/2023.<BR/>Interview with the Dietary Manager (DM) on 01/03/2023 at 10:32 AM, the DM confirmed that the open package of tortillas was not properly sealed and open to cross contamination and that all three packages of tortillas were past their use-by date.<BR/>3. Observation on 01/03/2023 at 10:34 AM in the walk-in freezer revealed there was a 30-lb. box of diced carrots on a shelf. The box was open and inside the box the carrots were in a bag that was also completely open. <BR/>4. Observation on 01/03/2023 at 10:35 AM revealed there was a plastic bag containing 18 biscuits in the freezer that was closed with a knot and was not labeled with the date it was received or a use-by date.<BR/>Interview with the DM on 01/03/2023 at 10:36 AM, the DM confirmed the diced carrots were completely exposed to the air in the freezer and the biscuits were in a bag that was not properly sealed and without a label indicating the date it was received or a use-by date. The DM stated that sometimes the cooks were in a rush and did not properly seal the items as they should in the walk-in cooler and freezer, and that the biscuits had been used that morning. The DM stated that the cooks and dietary aides were responsible for properly sealing, labeling and dating food items stored in the dry storage room, coolers and freezer. The DM further stated that it was important that food items be sealed and labeled/dated to maintain product quality, prevent cross contamination and serving residents food that could potentially contain harmful bacteria. The DM stated he had trained all staff on labeling and dating foods shortly after he had assumed the position in August 2022.<BR/>Review of training logs revealed the DM trained all dietary staff on labeling and dating food items on 08/03/2022. <BR/>Review of facility policy, Nutrition Center, undated, revealed: Procedure: 2. All foods will be covered with clear plastic wrap and dated or will be in the original sealed individual serving container. 4. The refrigerator will be cleaned out weekly. <BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. Except as specified in paragraphs (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and: <BR/>(1) The day the original container is opened in the food establishment shall be counted as Day 1; and<BR/>(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 2 of 24 residents (Residents #31 and #61) reviewed for transmitting assessments, in that:<BR/>1. Resident #31's quarterly MDS assessment was not completed and transmitted within 14 days of completion.<BR/>2. Resident #61's quarterly MDS assessment was not completed and transmitted within 14 days of completion.<BR/>This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required.<BR/>Findings include:<BR/>1. Review of Resident #31's face sheet, dated 01/06/2023, revealed an admission date of 10/11/2016 and re-admission date of 05/15/2020 with diagnoses that included dementia, chronic obstructive pulmonary disease, heart disease, kidney disease, gastro-esophageal reflux disease, hypertension (high blood pressure), and dementia. <BR/>Review of Resident #31's electronic quarterly MDS assessment revealed a completion date of 08/15/2022. Record review of the most recent electronic quarterly MDS assessment revealed the target date for completion was 11/15/2022, and the assessment was in process, meaning it had not been electronically transmitted to CMS.<BR/>2. Review of Resident #61's face sheet, dated 01/06/2023 revealed an admission date of 03/18/2022 with diagnoses that included metabolic encephalopathy (neurologic disorder caused by a systemic illness); chronic kidney disease, cognitive communication deficit, bipolar disorder, dementia, and repeated falls.<BR/>Review of Resident #61's electronic quarterly MDS assessment revealed a completion date of 08/31/2022. Review of the most recent electronic quarterly MDS assessment revealed the target date for completion was 12/01/2022 and the assessment was in process, meaning it had not been electronically transmitted to CMS.<BR/>Interview on 01/05/2023 at 3:30 p.m. with the MDS Coordinator, the MDS Coordinator confirmed Resident #31's quarterly MDS assessment with target date 11/15/2023 was not completed and transmitted within the required 14 days and Resident #61's quarterly MDS assessment with target date 12/01/2022 was not completed and transmitted within the required 14 days. When asked why these reports were not submitted in a timely manner, the MDS Coordinator stated that she knew she was behind on completing and submitting the MDS' for several residents in a timely manner, and that the quarterly MDS for resident #31 was complete and would be sent in that day but the quarterly MDS for Resident #61 was not complete. The MDS Coordinator further stated she knew the timeframes during which they needed to be completed and turned in; however, she'd been ill and had several deaths in her immediate family which put her behind in her work. The MDS Coordinator further stated that she knew that not submitting the MDS' on time could result in incomplete resident records which could result in inadequate care. When asked who did her work when she was not there, the MDS Coordinator stated that her counterpart at the facility's corporate headquarters filled in.<BR/>Interview with the Administrator on 01/05/2023 at 4:30 PM, the Administrator stated that when the MDS Coordinator was absent, regional staff filled in. The Administrator further stated that the MDS Coordinator had experienced significant family losses that likely contributed to the residents' quarterly MDS' not being submitted in a timely manner.<BR/>Review of the facility's policy Section 18 - Minimum Data Set (MDS) revealed, It is the policy of this facility to ensure a comprehensive assessment of each resident is completed and submitted according to the RAI guidelines manual set forth by CMS. Procedure: Monitor the scheduling of MDS; Complete a comprehensive, quarterly, significant change or other appropriate MDS according to the guidelines of the RAI manual set forth by CMS.

Based on interview and record review, the facility failed to provide communications training for 4 of 23 employees (Housekeeper N, CMA F, CNA G, LVN H) reviewed for training, in that:<BR/>The facility failed to ensure effective communication training was provided to Housekeeper N, CMA F, CNA G and LVN H annually.<BR/>This failure could affect residents and place them at risk of being uninformed due to lack of staff training.<BR/>Findings include:<BR/>Record review of the personnel records for Housekeeper N revealed a hire date of 10/04/2016. Review of a training in-services for Housekeeper N from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training being provided annually. <BR/>Record review of the personnel records for CMA F revealed a hire date of 01/27/2020. Review of a training in-services for CMA F from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training being provided annually.<BR/>Record review of the personnel records for CNA G revealed a hire date of 07/31/2023. Review of a training in-services for CNA G from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training being provided annually. <BR/>Record review of the personnel records for LVN H revealed a hire date of 09/14/2023. Review of a training in-services for LVN H from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training being provided annually. <BR/>Interview with the HR Coordinator on 04/04/2025 at 1:34 PM, revealed she initiates in-service trainings every month and every month was a different topic. The HR Coordinator stated she presented the in-services to the department heads, and they present them to their staff. The HR Coordinator stated it was the responsibility of the department heads to complete the in-services and her responsibility to verify all staff have completed the assigned in-service each month. The HR Coordinator stated staff were notified they need to complete in-service trainings only when department heads present the trainings to them. The HR Coordinator stated she followed an on-boarding checklist for new employees that includes trainings. The HR Coordinator stated she was not sure why all Dietary Manager's trainings were not completed upon hire. The HR Coordinator stated it was important that staff received their initial and annual trainings to ensure they are providing quality care to the residents. The HR Coordinator stated this could affect the residents leaving them vulnerable to abuse, neglect, and exploitation. <BR/>Interview with the DON on 04/04/2025 at 2:34 PM, revealed she received the in-services from the HR Coordinator monthly and presented them to her staff. The DON stated it is the responsibility of department heads to present the in-services to their staff. The DON stated once the in-services were complete the HR Coordinator verifies all employees had completed the in-service. The DON stated completing the in-services was important to ensure staff had the knowledge to complete their jobs effectually and safely. The DON stated if staff were not trained annually, it could leave resident's vulnerable to receiving poor care. <BR/>Interview with the Administrator 04/04/2025 at 2:43 PM revealed the facility provides staff with an in-service each month and each month the in-service reflected a different required training topic. The Administrator stated HR Coordinator initiated each in-service and provided them to the department heads so that they could train their staff. The Administrator stated it was the responsibility of department heads to train their staff each month and the responsibility of the HR Coordinator to verify each staff completed the in-services. The Administrator stated having untrained staff could lead to negative outcomes such as staff not knowing how to comminate or care for residents properly. <BR/>Record review of facility policy titled In-Service Education, undated, revealed 1. <BR/>Each year the administration or other designee will develop and implement an educational calendar to include (but not limited to) the following topics: 2. <BR/>Communication

Based on interview and record review, the facility failed to ensure CNA received the required minimum 12 hours annual in-service for 3 of 6 CNAs (CNA G, CNA K, CNA L) reviewed for training. <BR/>The facility failed to provide the required 12 hours of annual training to CNA G, CNA K, CNA L. <BR/>This failure could affect residents and place them at risk of being uninformed due to lack of staff training.<BR/>The findings include:<BR/>Record review of the personnel records for CNA G revealed a hire date of 07/31/2023. Review of a training in-services for CNA G from the previous 12 months, provided by the HR Coordinator revealed no evidence that the facility provided the required 12 hours of in-service trainings including communication training, QAPI training or ethics training being provided annually. <BR/>Record review of the personnel records for CNA K revealed a hire date of 01/29/2024. Review of a training in-services for CNA K from the previous 12 months, provided by the HR Coordinator revealed no evidence that the facility provided the required 12 hours of in-service trainings including ethics training, falls training, restraint training or emergency preparedness training being provided annually. <BR/>Record review of the personnel records for CNA L revealed a hire date of 03/18/2022. Review of a training in-services for CNA L from the previous 12 months, provided by the HR Coordinator revealed no evidence that the facility provided the required 12 hours of in-service trainings including ethics training being provided annually.<BR/>Interview with the HR Coordinator on 04/04/2025 at 1:34 PM, revealed she initiates in-service trainings every month and every month was a different topic. The HR Coordinator stated she presented the in-services to the department heads, and they present them to their staff. The HR Coordinator stated it was the responsibility of the department heads to complete the in-services and her responsibility to verify all staff have completed the assigned in-service each month. The HR Coordinator stated staff were notified they need to complete in-service trainings only when department heads present the trainings to them. The HR Coordinator stated she followed an on-boarding checklist for new employees that includes trainings. The HR Coordinator stated she was not sure why all Dietary Manager's trainings were not completed upon hire. The HR Coordinator stated it was important that staff received their initial and annual trainings to ensure they are providing quality care to the residents. The HR Coordinator stated this could affect the residents leaving them vulnerable to abuse, neglect, and exploitation. <BR/>Interview with the DON on 04/04/2025 at 2:34 PM, revealed she received the in-services from the HR Coordinator monthly and presented them to her staff. The DON stated it is the responsibility of department heads to present the in-services to their staff. The DON stated once the in-services were complete the HR Coordinator verifies all employees had completed the in-service. The DON stated completing the in-services was important to ensure staff had the knowledge to complete their jobs effectually and safely. The DON stated if staff were not trained annually, it could leave resident's vulnerable to receiving poor care. <BR/>Interview with the Administrator 04/04/2025 at 2:43 PM revealed the facility provides staff with an in-service each month and each month the in-service reflected a different required training topic. The Administrator stated HR Coordinator initiated each in-service and provided them to the department heads so that they could train their staff. The Administrator stated it was the responsibility of department heads to train their staff each month and the responsibility of the HR Coordinator to verify each staff completed the in-services. The Administrator stated having untrained staff could lead to negative outcomes such as staff not knowing how to comminate or care for residents properly. <BR/>A policy addressing required minimum 12 hours annual in-service for CNA was requested from the HR Coordinator on 04/04/2025 at 1:34 PM but was not provided prior to exit. <BR/>A policy addressing required minimum 12 hours annual in-service for CNA was requested from the DON on 04/04/2025 at 2:34 PM but was not provided prior to exit. <BR/>A policy addressing required minimum 12 hours annual in-service for CNA was requested from the Administrator on 04/04/2025 at 2:43 PM but was not provided prior to exit.

Based on interview, record review, and observation, the facility failed to ensure residents have a right to personal privacy for 1 of 2 resident (Resident #6) reviewed for privacy, in that:<BR/>CNA A and CNA B did not close Resident #6's privacy curtain while providing incontinent care on 3/27/25. <BR/>This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.<BR/>The findings included:<BR/>Record review of Resident #6's face sheet, dated 03/27/2025, revealed an admission date of 03/14/2014 and, a readmission date of 05/18/2021 and, a readmission date of 11/09/2024, with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Vascular dementia (decline in cognitive abilities), Anxiety (A group of mental illnesses that cause constant fear and worry), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and, Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood).<BR/>Record review of Resident #6's Annual MDS assessment, dated 02/07/2025, revealed the resident had a BIMS score of 3, indicating he was severely impaired. Resident #6 was frequently incontinent of bowel and bladder. <BR/>Record review of Resident #6's care plan, dated 05/31/2022, revealed a problem of I have an ADL Self Care Performance (Bed Mobility, Transfers, Eating, Bathing, Dressing, and Personal Hygiene) Deficits r/t: impaired cognition, muscle weakness, impaired balance,, with an intervention of TOILET USE: Resident is limited to extensive care for toilet use/Incontinence management. They do not participate in process. Provide incontinence checks every 2 hours and PRN. Provide incontinence care as needed and position for comfort after care Resident does attempt to toilet self.<BR/>Observation on 03/27/2025 at 1:50 p.m. revealed CNA A and CNA B did not completely close the privacy curtain while they provided incontinent care for Resident #6, exposing the resident's genital area during care. The resident's end of the bed was completely uncovered and the resident's roommate was in the room at the time of care. <BR/>During an interview with CNA A and CNA B on 03/27/2025 at 1:56 p.m., CNA A and CNA B confirmed the privacy curtain was not completely closed while they provided care for Resident #6 but it should have been. They confirmed they received resident rights training within the year. <BR/>During an interview with the DON on 03/27/2024 at 2:30 p.m., the DON confirmed privacy must be provided during nursing care and Resident #6's privacy curtain should have been closed completely. She confirmed the staff had received training on resident rights within the year and the training was provided by the ADON and herself. They also checked the staff skills annually and as needed. <BR/>Review of the facility's policy titled Privacy, undated, revealed, When providing resident care, always provide privacy [ .] pulling a curtain around the bed [ .]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bowel and bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #4) reviewed for incontinence care.<BR/>When CNA-A was providing incontinent care to Resident #4 on 04/03/2025, CNA-A did not separate the resident's labia and did not clean the base of her labia. <BR/>This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. <BR/>The findings included:<BR/>Record review of Resident #4's face sheet, dated 04/04/2025, revealed a [AGE] year-old female, admitted to the facility originally on 03/24/2015, and re-admitted to the facility on [DATE] with diagnoses of vascular disorder of intestine (blood flow to the intestines slows), pervasive developmental disorder (developmental delays that affect social and communication skills), hemiplegia (brain damage that leads to paralysis on one side of the body), dysphagia (difficulty swallowing), and hyperlipidemia (high level of fat). <BR/>Record review of Resident #4's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment, the resident had frequently urinary bladder incontinence and always bowel incontinence, and required dependent assistance (helper does all of the efforts) to all activities of daily living such as chair-to-bed and toilet transfer. <BR/>Record review of Resident #4's comprehensive care plan, dated 07/23/2015, revealed the resident had bowel and bladder incontinence related to impaired mobility - Monitor/document for signs and symptoms of urinary tract infection. <BR/>Observation on 04/03/2025 at 10:00 a.m. revealed CNA-A cleaned Resident #4's left and right groin area, then just cleaned the middle one of the resident's genital areas without separating the resident's labia area. Further observation revealed CNA-A turned the resident to her left side and cleaned the resident's bottom area, then put a new and clean brief and closed it. <BR/>Interview on 04/03/2025 at 10:12 a.m. with CNA-A stated she did not separate Resident #4's labia area and did not clean the base of the resident's labia area. Further interview with CNA-A said she forgot to separate the resident's labia area to clean the base of labia because she was so nervous. CNA-a stated she should have separated Resident #4's labia area and cleaned the base of the resident's labia area. <BR/>Interview on 04/03/2025 at 1:56 p.m. the DON stated CNA-A should have separated Resident #4's labia area to clean the base of labia to prevent possible urinary tract infection. Checking CNA-A's skills for perineal care was DON's responsibility, and DON conducted the skill check-off of CNA-A on 03/13/2025, and CNA-A demonstrated correct skills for perineal care on 03/13/2025. <BR/>Record review of the facility policy, titled Perineal Care, undated, revealed . 9. Female perineal care F. use one gloves hand to stabilize and separate the labia, with other hands wash from front to back.

Based on interview and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of it's QAPI program for 5 of 23 employees (Housekeeper N, CNA G, Dietary Aide I, CMA F, RN J) employees reviewed for training requirements. <BR/>The facility failed to ensure required QAPI trainings was provided to Housekeeper N, CNA G, Dietary Aide I, CMA F, and RN J annually.<BR/>This failure could affect residents and place them at risk of being uninformed due to lack of staff training.<BR/>Findings include:<BR/>Record review of the personnel records for Housekeeper N revealed a hire date of 10/04/2016. Review of a training in-services for Housekeeper N from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training being provided annually. <BR/>Record review of the personnel records for CMA F revealed a hire date of 01/27/2020. Review of a training in-services for CMA F from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training being provided annually.<BR/>Record review of the personnel records for CNA G revealed a hire date of 07/31/2023. Review of a training in-services for CNA G from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training being provided annually. <BR/>Record review of the personnel records for Dietary Aide I revealed a hire date of 12/08/2022. Review of a training in-services for Dietary Aide I from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training being provided annually. <BR/>Record review of the personnel records for RN J revealed a hire date of 02/17/2023. Review of a training in-services for RN J from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training being provided annually.<BR/>Interview with the HR Coordinator on 04/04/2025 at 1:34 PM, revealed she initiates in-service trainings every month and every month was a different topic. The HR Coordinator stated she presented the in-services to the department heads, and they present them to their staff. The HR Coordinator stated it was the responsibility of the department heads to complete the in-services and her responsibility to verify all staff have completed the assigned in-service each month. The HR Coordinator stated staff were notified they need to complete in-service trainings only when department heads present the trainings to them. The HR Coordinator stated she followed an on-boarding checklist for new employees that includes trainings. The HR Coordinator stated she was not sure why all Dietary Manager's trainings were not completed upon hire. The HR Coordinator stated it was important that staff received their initial and annual trainings to ensure they are providing quality care to the residents. The HR Coordinator stated this could affect the residents leaving them vulnerable to abuse, neglect, and exploitation. <BR/>Interview with the DON on 04/04/2025 at 2:34 PM, revealed she received the in-services from the HR Coordinator monthly and presented them to her staff. The DON stated it is the responsibility of department heads to present the in-services to their staff. The DON stated once the in-services were complete the HR Coordinator verifies all employees had completed the in-service. The DON stated completing the in-services was important to ensure staff had the knowledge to complete their jobs effectually and safely. The DON stated if staff were not trained annually, it could leave resident's vulnerable to receiving poor care. <BR/>Interview with the Administrator 04/04/2025 at 2:43 PM revealed the facility provides staff with an in-service each month and each month the in-service reflected a different required training topic. The Administrator stated HR Coordinator initiated each in-service and provided them to the department heads so that they could train their staff. The Administrator stated it was the responsibility of department heads to train their staff each month and the responsibility of the HR Coordinator to verify each staff completed the in-services. The Administrator stated having untrained staff could lead to negative outcomes such as staff not knowing how to comminate or care for residents properly. <BR/>Record review of facility policy titled In-Service Education, undated, revealed 1. <BR/>Each year the administration or other designee will develop and implement an educational calendar to include (but not limited to) the following topics: 3. <BR/>QAPI Program

Based on interview and record review, the facility failed to provide mandatory ethics training for 7 of 23 employees (Housekeeper N, CNA G, RN J, CNA K, CNA L, LVN M, LVN/MDS) employees reviewed for training, in that:<BR/>The facility failed to ensure ethics training was provided to Housekeeper N, CNA G, RN J, CNA K, CNA L, LVN M, and LVN/MDS annually.<BR/>This failure could affect residents and place them at risk of being uninformed due to lack of staff training.<BR/>The findings include:<BR/>Record review of the personnel records for Housekeeper N revealed a hire date of 10/04/2016. Review of a training in-services for Housekeeper N from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. <BR/>Record review of the personnel records for CNA G revealed a hire date of 07/31/2023. Review of a training in-services for CNA G from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. <BR/>Record review of the personnel records for RN J revealed a hire date of 02/17/2023. Review of a training in-services for RN J from the previous 12 months, provided by the HR Coordinator revealed no evidence of Ethics training being provided annually.<BR/>Record review of the personnel records for CNA K revealed a hire date of 01/29/2024. Review of a training in-services for CNA K from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. <BR/>Record review of the personnel records for CNA L revealed a hire date of 03/18/2022. Review of a training in-services for CNA L from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually.<BR/>Record review of the personnel records for LVN M revealed a hire date of 02/10/2015. Review of a training in-services for LVN M from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually.<BR/>Record review of the personnel records for LVN/MDS revealed a hire date of 03/18/2022. Review of a training in-services for LVN/MDS from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. <BR/>Interview with the HR Coordinator on 04/04/2025 at 1:34 PM, revealed she initiates in-service trainings every month and every month was a different topic. The HR Coordinator stated she presented the in-services to the department heads, and they present them to their staff. The HR Coordinator stated it was the responsibility of the department heads to complete the in-services and her responsibility to verify all staff have completed the assigned in-service each month. The HR Coordinator stated staff were notified they need to complete in-service trainings only when department heads present the trainings to them. The HR Coordinator stated she followed an on-boarding checklist for new employees that includes trainings. The HR Coordinator stated she was not sure why all Dietary Manager's trainings were not completed upon hire. The HR Coordinator stated it was important that staff received their initial and annual trainings to ensure they are providing quality care to the residents. The HR Coordinator stated this could affect the residents leaving them vulnerable to abuse, neglect, and exploitation. <BR/>Interview with the DON on 04/04/2025 at 2:34 PM, revealed she received the in-services from the HR Coordinator monthly and presented them to her staff. The DON stated it is the responsibility of department heads to present the in-services to their staff. The DON stated once the in-services were complete the HR Coordinator verifies all employees had completed the in-service. The DON stated completing the in-services was important to ensure staff had the knowledge to complete their jobs effectually and safely. The DON stated if staff were not trained annually, it could leave resident's vulnerable to receiving poor care. <BR/>Interview with the Administrator 04/04/2025 at 2:43 PM revealed the facility provides staff with an in-service each month and each month the in-service reflected a different required training topic. The Administrator stated HR Coordinator initiated each in-service and provided them to the department heads so that they could train their staff. The Administrator stated it was the responsibility of department heads to train their staff each month and the responsibility of the HR Coordinator to verify each staff completed the in-services. The Administrator stated having untrained staff could lead to negative outcomes such as staff not knowing how to comminate or care for residents properly. <BR/>Record review of facility policy titled In-Service Education, undated, revealed 1. <BR/>Each year the administration or other designee will develop and implement an educational calendar to include (but not limited to) the following topics: 40. <BR/>Compliance and Ethics Program

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #3) of 3 residents reviewed, in that:<BR/>Resident #'3s personal refrigerator located in her room was observed on 04/01/2025. There was a small plastic cup inside the refrigerator, with no date and no label on the plastic cup. <BR/>This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled. <BR/>The findings included: <BR/>Record review of Resident #3's face sheet, dated 04/04/2025, reflected the resident was [AGE] years old female and was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: type 2 diabetes mellitus (not control blood sugar in the body), cholelithiasis (stone in the gallbladder), rheumatoid arthritis (chronic inflammatory affecting small joints in the hands and feet), intestinal obstruction (digested material is prevented from passing normally through the bowel), and dysphagia (difficulty of swallowing). <BR/>Record review of Resident #3's annual MDS, dated [DATE], reflected the resident's BIMS score was 15 out of 15 which indicated the resident's cognitive function was intact, and the resident was independent with eating and was dependent (helper does all of the efforts) for dressing and bed mobility. <BR/>Record review of Resident #3's comprehensive care plan, dated 02/12/2025, revealed the resident had Resident at nutritional risk. On mechanical soft and low concentrated sweet and for interventions - Encourage resident to eat meal out of bed and upright position for intake by mouth. <BR/>Observation on 04/01/2025 at 10:42 a.m. revealed Resident #3 was on the bed and sleeping in her room. There was a personal refrigerator in the room, and inside the refrigerator there was a small plastic cup with food, but no date and no label on the cup. <BR/>Interview on 04/01/2025 at 11:13 a.m. LVN-B stated Resident #3's refrigerator in her room had a small plastic cup with food, but it was not dated and labeled. LVN-B said that it looked like some kind of desert. The facility night nurses were supposed to check it every day. <BR/>Interview on 04/04/2025 at 4:00 p.m. the DON stated facility night nurses were responsible for overseeing Resident #3's personal refrigerator and also responsible for monitoring it daily. The DON stated the resident might have illness due to food. <BR/>Record review of the facility policy, titled Foods brought by family/visitors, undated, revealed . 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item, and the use by date.

Based on interview and record review, the facility failed to provide behavioral health training consistent with the requirements at &sect;483.40 and as determined by the facility assessment at &sect;483.71 for 2 of 28 (Dietary Aide I and Dietary Manager) employees reviewed for training, in that:<BR/>The facility failed to ensure behavioral health training was provided to Dietary Aide I annually.<BR/>The facility failed to ensure behavioral health training was provided to Dietary Manager upon hire.<BR/>This failure could affect residents and place them at risk of being uninformed due to lack of staff training.<BR/>The findings include:<BR/>Record review of the personnel records for Dietary Aide I revealed a hire date of 12/08/2022. Review of a training in-services for Dietary Aide I from the previous 12 months, provided by the HR Coordinator revealed no evidence of behavioral health training being provided annually. <BR/>Record review of the personnel records for Dietary Manager revealed a hire date of 10/23/2024. Review of a training in-services for Dietary Manager from the previous 12 months, provided by the HR Coordinator revealed no evidence of behavior health training being provided upon hire. <BR/>Interview with the HR Coordinator on 04/04/2025 at 1:34 PM, revealed she initiates in-service trainings every month and every month was a different topic. The HR Coordinator stated she presented the in-services to the department heads, and they present them to their staff. The HR Coordinator stated it was the responsibility of the department heads to complete the in-services and her responsibility to verify all staff have completed the assigned in-service each month. The HR Coordinator stated staff were notified they need to complete in-service trainings only when department heads present the trainings to them. The HR Coordinator stated she followed an on-boarding checklist for new employees that includes trainings. The HR Coordinator stated she was not sure why all Dietary Manager's trainings were not completed upon hire. The HR Coordinator stated it was important that staff received their initial and annual trainings to ensure they are providing quality care to the residents. The HR Coordinator stated this could affect the residents leaving them vulnerable to abuse, neglect, and exploitation. <BR/>Interview with the DON on 04/04/2025 at 2:34 PM, revealed she received the in-services from the HR Coordinator monthly and presented them to her staff. The DON stated it is the responsibility of department heads to present the in-services to their staff. The DON stated once the in-services were complete the HR Coordinator verifies all employees had completed the in-service. The DON stated completing the in-services was important to ensure staff had the knowledge to complete their jobs effectually and safely. The DON stated if staff were not trained annually, it could leave resident's vulnerable to receiving poor care. <BR/>Interview with the Administrator 04/04/2025 at 2:43 PM revealed the facility provides staff with an in-service each month and each month the in-service reflected a different required training topic. The Administrator stated HR Coordinator initiated each in-service and provided them to the department heads so that they could train their staff. The Administrator stated it was the responsibility of department heads to train their staff each month and the responsibility of the HR Coordinator to verify each staff completed the in-services. The Administrator stated having untrained staff could lead to negative outcomes such as staff not knowing how to comminate or care for residents properly. <BR/>Record review of facility policy titled In-Service Education, undated, revealed 1. <BR/>Each year the administration or other designee will develop and implement an educational calendar to include (but not limited to) the following topics: 41. <BR/>Behavior Interventions

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 2 of 24 residents (Residents #31 and #61) reviewed for transmitting assessments, in that:<BR/>1. Resident #31's quarterly MDS assessment was not completed and transmitted within 14 days of completion.<BR/>2. Resident #61's quarterly MDS assessment was not completed and transmitted within 14 days of completion.<BR/>This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required.<BR/>Findings include:<BR/>1. Review of Resident #31's face sheet, dated 01/06/2023, revealed an admission date of 10/11/2016 and re-admission date of 05/15/2020 with diagnoses that included dementia, chronic obstructive pulmonary disease, heart disease, kidney disease, gastro-esophageal reflux disease, hypertension (high blood pressure), and dementia. <BR/>Review of Resident #31's electronic quarterly MDS assessment revealed a completion date of 08/15/2022. Record review of the most recent electronic quarterly MDS assessment revealed the target date for completion was 11/15/2022, and the assessment was in process, meaning it had not been electronically transmitted to CMS.<BR/>2. Review of Resident #61's face sheet, dated 01/06/2023 revealed an admission date of 03/18/2022 with diagnoses that included metabolic encephalopathy (neurologic disorder caused by a systemic illness); chronic kidney disease, cognitive communication deficit, bipolar disorder, dementia, and repeated falls.<BR/>Review of Resident #61's electronic quarterly MDS assessment revealed a completion date of 08/31/2022. Review of the most recent electronic quarterly MDS assessment revealed the target date for completion was 12/01/2022 and the assessment was in process, meaning it had not been electronically transmitted to CMS.<BR/>Interview on 01/05/2023 at 3:30 p.m. with the MDS Coordinator, the MDS Coordinator confirmed Resident #31's quarterly MDS assessment with target date 11/15/2023 was not completed and transmitted within the required 14 days and Resident #61's quarterly MDS assessment with target date 12/01/2022 was not completed and transmitted within the required 14 days. When asked why these reports were not submitted in a timely manner, the MDS Coordinator stated that she knew she was behind on completing and submitting the MDS' for several residents in a timely manner, and that the quarterly MDS for resident #31 was complete and would be sent in that day but the quarterly MDS for Resident #61 was not complete. The MDS Coordinator further stated she knew the timeframes during which they needed to be completed and turned in; however, she'd been ill and had several deaths in her immediate family which put her behind in her work. The MDS Coordinator further stated that she knew that not submitting the MDS' on time could result in incomplete resident records which could result in inadequate care. When asked who did her work when she was not there, the MDS Coordinator stated that her counterpart at the facility's corporate headquarters filled in.<BR/>Interview with the Administrator on 01/05/2023 at 4:30 PM, the Administrator stated that when the MDS Coordinator was absent, regional staff filled in. The Administrator further stated that the MDS Coordinator had experienced significant family losses that likely contributed to the residents' quarterly MDS' not being submitted in a timely manner.<BR/>Review of the facility's policy Section 18 - Minimum Data Set (MDS) revealed, It is the policy of this facility to ensure a comprehensive assessment of each resident is completed and submitted according to the RAI guidelines manual set forth by CMS. Procedure: Monitor the scheduling of MDS; Complete a comprehensive, quarterly, significant change or other appropriate MDS according to the guidelines of the RAI manual set forth by CMS.

Based on interview, record review, and observation, the facility failed to ensure residents have a right to personal privacy for 1 of 2 resident (Resident #6) reviewed for privacy, in that:<BR/>CNA A and CNA B did not close Resident #6's privacy curtain while providing incontinent care on 3/27/25. <BR/>This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.<BR/>The findings included:<BR/>Record review of Resident #6's face sheet, dated 03/27/2025, revealed an admission date of 03/14/2014 and, a readmission date of 05/18/2021 and, a readmission date of 11/09/2024, with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Vascular dementia (decline in cognitive abilities), Anxiety (A group of mental illnesses that cause constant fear and worry), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and, Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood).<BR/>Record review of Resident #6's Annual MDS assessment, dated 02/07/2025, revealed the resident had a BIMS score of 3, indicating he was severely impaired. Resident #6 was frequently incontinent of bowel and bladder. <BR/>Record review of Resident #6's care plan, dated 05/31/2022, revealed a problem of I have an ADL Self Care Performance (Bed Mobility, Transfers, Eating, Bathing, Dressing, and Personal Hygiene) Deficits r/t: impaired cognition, muscle weakness, impaired balance,, with an intervention of TOILET USE: Resident is limited to extensive care for toilet use/Incontinence management. They do not participate in process. Provide incontinence checks every 2 hours and PRN. Provide incontinence care as needed and position for comfort after care Resident does attempt to toilet self.<BR/>Observation on 03/27/2025 at 1:50 p.m. revealed CNA A and CNA B did not completely close the privacy curtain while they provided incontinent care for Resident #6, exposing the resident's genital area during care. The resident's end of the bed was completely uncovered and the resident's roommate was in the room at the time of care. <BR/>During an interview with CNA A and CNA B on 03/27/2025 at 1:56 p.m., CNA A and CNA B confirmed the privacy curtain was not completely closed while they provided care for Resident #6 but it should have been. They confirmed they received resident rights training within the year. <BR/>During an interview with the DON on 03/27/2024 at 2:30 p.m., the DON confirmed privacy must be provided during nursing care and Resident #6's privacy curtain should have been closed completely. She confirmed the staff had received training on resident rights within the year and the training was provided by the ADON and herself. They also checked the staff skills annually and as needed. <BR/>Review of the facility's policy titled Privacy, undated, revealed, When providing resident care, always provide privacy [ .] pulling a curtain around the bed [ .]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to refer all residents with possible serious mental disorder or a related condition for level II resident review upon a significant change in status assessment for 2 of 6 Residents (Resident #9 and Resident #43) whose records were reviewed for mental disorders.<BR/>The facility failed to refer Resident #9 for a PASARR evaluation based on mental disorder diagnoses including Major Depressive Disorder and Psychosis.<BR/>The facility failed to refer Resident #43 for a PASARR evaluation based on mental disorder diagnoses including Major Depressive Disorder and Psychosis.<BR/>This deficient practice could affect residents with a mental illness and contribute to a delay in services needed.<BR/>The findings were:<BR/>1. Review of Resident #9's face sheet, dated 2/24/24, revealed she was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder (MDD) recurrent, dated 9/28/21 and Unspecified Psychosis not due to a substance or known physiological condition, dated 6/1/19.<BR/>Review of Resident #9's Care Plan, revised 2/3/24, revealed she had a diagnosis of Major Depressive Disorder and Psychosis.<BR/>Review of Resident #9's EHR revealed a PASARR Level 1 screening completed 12/5/18. Further review revealed it did not reflect Resident #9 had diagnoses of Major Depressive Disorder and Psychosis or that she had a mental illness or indicator that Resident #9 had a mental illness.<BR/>Review of psychiatry follow up note, dated 1/31/24, revealed follow up evaluation for medication management for MDD, Psychosis, and Vascular Dementia.<BR/>Interview on 02/22/24 at 02:04 PM with MDS Coordinator revealed she had not considered referring Resident #9 to the local authority for a PASARR evaluation. She stated Resident #9 was admitted prior to her employment. She confirmed Resident #9 was diagnosed with MDD and Psychosis which should trigger a referral for PASARR evaluation. MDS Coordinator stated she would want to refer Resident #9 for the evaluation to ensure she received the services she needed per local authority recommendation. <BR/>2. Review of Resident #43's annual MDS assessment, dated 12/11/23, revealed she was admitted to the facility on [DATE]. Further review revealed diagnoses including Depressive Disorder (MDD) and Psychosis.<BR/>Review of Resident #43's Care Plan, revised 2/20/24, revealed she had a diagnosis of Major Depressive Disorder and Psychosis.<BR/>Review of Resident 43's EHR revealed a PASARR Level 1 screening completed 11/2/22. Further review revealed it did not reflect Resident #43 had diagnoses of Major Depressive Disorder and Psychosis or that she had a mental illness or indicator that Resident #43 had a mental illness.<BR/>Interview on 02/22/24 at 01:58 PM with MDS Coordinator revealed she had not considered referring Resident #43 to the local authority for a PASARR evaluation. She stated Resident #43 was admitted prior to her employment. She confirmed Resident #43 was diagnosed with MDD and Psychosis which should trigger a referral for PASARR evaluation. MDS Coordinator stated she would want to refer Resident #43 for the evaluation to ensure she received the services she needed per local authority recommendation. <BR/>Review of a facility policy, undated, read It is the policy of this facility to ensure that all residents are screened and appropriately addressed via the PASARR process as outlined by regulations. The results of this process will be used to develop, review and revise the residents care plan. Procedures: 1. The facilities designated staff will review all potential admission for possible positive PASARR conditions and ensure that CMS Preadmission guidelines are followed.