HIGHLAND PINES NURSING HOME

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure residents were free from abuse for 1 of 8 residents (Resident #1) reviewed for resident abuse. <BR/>The facility did not ensure Resident # 1 was free from abuse on 2/20/25 when he was slapped on the top of his hand. <BR/>The noncompliance was identified as PNC. The noncompliance began on 2/20/25 and ended on 2/20/25. The facility had corrected the noncompliance before the investigation began.<BR/>This failure could place residents at risk of physical harm, mental anguish, or emotional distress.<BR/>The findings included: <BR/>Record Review of Resident #1's face sheet dated 11/20/24 indicated Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Dysphagia (Difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage), Cognitive Communication Deficit (Cognitive communication is the mental skills used to process information and communicate with others), Mild Cognitive Impairment (a condition characterized by a subtle decline in cognitive abilities, such as memory, attention, and reasoning, that is not severe enough to interfere with daily functioning). <BR/>Record Review of Resident #1's MDS assessment dated [DATE] indicated, Resident #1 usually understood others and usually made himself understood. The MDS assessment indicated Resident #1 had a BIMS score of 03, which indicated Resident #1 had severe cognitive impairment. Indicated that Resident #1 never rejected care. <BR/>Record Review of Resident #1's care plan, dated on 3/03/25, indicated Resident #1 requires tube feeding, is non-compliant with feeding and will eat other resident's food. Resident #1 has impaired cognitive function and has impaired thought processes. Resident #1 has a behavior he will open up his percutaneous endoscopic gastrostomy tube and suck the contents from his stomach. <BR/>During an interview on 3/3/25 at 3:31 p.m. CNA B said that on 2/20/25 that morning when she was passing breakfast trays, she could hear LVN A being loud in the room with Resident #1. She said she was curious of what was going on and that was when she heard LVN A hit the top of the hands of Resident #1. She said you could hear the skin-on-skin contact. She said she did not lightly tap the hands of Resident #1 but hit them hard like a slap. She said that Resident #1 was not crying and did not appear to be in any distress. She said she asked LVN A what was going on and she said she was trying to get Resident #1 to move his hands so she could feed him. She said that CNA C entered the room also to see what was going on. She said she told CNA C to go report what happened to their supervisor who then told the Administrator what happened. She said she never left Resident #1's side until after management got involved. She said she was trained on abuse and neglect, the timeframes and requirements for reporting abuse and neglect. She said that was how she knew to report and stay with the resident. She said she was then trained again in abuse and neglect after the incident.<BR/>During an interview on 3/3/25 at 3:40 p.m., the Administrator said that she did not witness the incident, but it was reported that CNA B witnessed LVN A hit the top of the hands of Resident #1 and that CNA C heard the skin on skin contact as well. She said that LVN A did speak loudly but she has never verbally abused anyone. She said LVN A speaks loudly because she was hearing impaired. She said that after the incident LVN A was suspended, a report was made to the Texas Health and Human Services Commission, and Resident #1 was assessed for any physical injury. She said that there was no physical injury, so he was evaluated by a counseling agency to determine if he had any trauma. Resident #1 who has a BIMS of 3 did not recall the incident, said the incident did not happen, and was not in any distress due to the incident. She said that after the incident occurred an investigation was started, and staff were re-trained on abuse and neglect.<BR/>During an interview on 3/3/25 at 3:54 p.m. Resident #1 was asked questions in an answer question format as he was unable to give full responses. Question: Resident #1 did you know LVN A? Answer: Yes. Question: Did LVN A hit you on the hand? Answer: No. Question: Resident #1 do you feel safe here? Answer: Yes.<BR/>During an interview on 3/3/25 at 4:05 p.m., CNA C said that on 2/20/25 while breakfast trays were being passed out, she heard a commotion in Resident #1's room. She said before she entered the room, she heard two loud slapping sounds. She said it sounded like skin-on-skin contact. She said when she entered the room CNA B was already inside and she said, She just hit him. She said she saw LVN A sitting with Resident #1 who was being fed. She said LVN A was being loud with the resident saying, Don't do that. She said CNA B said she needed to go get a supervisor. She said she then left the room and told a supervisor. She said she had been trained in abuse and neglect and was trained again after the incident. She said that when abuse or neglect occurs she should report to a supervisor or the Administrator what happened, ensure the resident is safe, and not allow the alleged perpetrator to stay with the resident. <BR/>During an interview on 3/4/25 at 8:50 a.m., LVN A said that on 2/20/25 she was feeding Resident #1. She said that Resident #1 has a history of interfering when he was being fed and pulling at his Gtube (a feeding tube). She said that on this day he was also pulling at his Gtube. She said she said to him in a loud voice, Stop and Don't do that. She said she did touch Resident #1's hands but it was to move them to his side. She said she did not tap or hit the hands of Resident #1. She said she was only trying to keep him from removing his Gtube. She said that CNA B and CNA C did not see what happened and they were both lying. She said they were both outside in the hallway and neither of them saw or heard her hit Resident #1. <BR/>During an interview and observation on 3/4/25 at 9:05 a.m. CNA B was asked to demonstrate the force used when she witnessed LVN A hit the top of Resident #1's hands. CNA B demonstrated what she witnessed, and the force used was very strong making aloud slapping noise on the table. She said that LVN A hit the top of Resident #1's hands very hard and it was not a light tap as if a child was being scolded. <BR/>During multiple staff interviews on 3/4/25 staff were able to identify the elements of abuse and neglect, timeframes for reporting abuse and neglect, who to report to, and that the resident involved should be made safe. Staff were also able to say that the alleged perpetrator should not have access to the alleged victim.<BR/>During an interview on 3/4/25 at 11:50 a.m., the Director of Nurses said that all newly hired staff and on occasion staff were trained in their abuse and neglect policy. She said staff were trained on when to report, who to report to, and how to protect residents that were suspected of being abused or neglected. She said she expects all her staff to follow facility policy regarding abuse and neglect. She said that a resident was placed at risk of harm if a staff abused them. <BR/>During an interview on 3/4/25 at 11:55 a.m., the Administrator said that the facility has developed abuse and neglect policies. She said that either herself or the Director of Nurses was to conduct the training. She said that their abuse and neglect policy teach on when to report abuse, who to report abuse to, and how to protect the resident if abuse was suspected or occurred. She said she expects that her staff would intervene if they see or suspect that abuse or neglect occurs. <BR/>Record review of the facility's provider investigation report dated 2/20/25 revealed that the facility conducted an investigation into the allegations that LVN A physically abused Resident #1 when CNA A observed LVN A hit Resident #1 on the top of his hands while LVN A was feeding the resident. The report showed that the time and date of the incident was 2/20/25 at 8:15 a.m. and that Resident #1 was physically assessed on 2/20/25 at 9:43 a.m. Further review showed that the incident was reported to the Texas Health and Human Services Commission on 2/20/25 at 10:01 a.m.<BR/>Record review of a skin assessment for Resident #1 dated 2/20/25, indicated that there were no skin impairments. Skin assessment was completed after the incident. <BR/>Record review of a trauma assessment for Resident #1 dated 2/20/25, indicated that there was no present trauma. Resident # 1 indicated no to the following questions: Has the event caused you to felt very scared, helpless, or horrified Has the event caused you to be constantly on guard, watchful, or easily startled Has the event caused you to feel numb, detached from others, actives, or your surroundings. <BR/>Record review of facility in-service dated 2/20/25 titled, Abuse and Neglect conducted by the Director of Nurses. In-service training reviewed the facilities abuse and neglect prohibition policy. Policy identified elements of abuse and timeframes for reporting abuse. <BR/>Record review of LVN A's personnel file on 03/4/25 indicated hire date of 1/15/19. The facility had performed background check and employee misconduct search. No concerns were identified.<BR/>Record review of LVN A's Corrective Action Memo, dated 2/25/25, indicated she was terminated for misconduct regarding allegations of Abuse.<BR/>The noncompliance began on 02/20/25 and ended on 02/20/25. The facility had corrected the noncompliance before the investigation began.<BR/>The surveyor confirmed PNC had been implemented sufficiently to remove the deficiency by:<BR/>Facility notification of abuse incident to responsible party, MD, Ombudsman and HHSC. <BR/>Completion of in-services on abuse. <BR/>Staff and management recognizing the steps to report abuse and neglect. <BR/>Termination of confirmed perpetrator.<BR/>Record Review of facility policy titled, Abuse Prevention and Prohibition dated 8/2020. Policy indicated, To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure each resident was informed before or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Resident #274, and Resident #275) reviewed for Medicare/Medicaid coverage. <BR/>The facility failed to ensure Resident #274, and Resident #275 were given a SNF ABN (a document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. <BR/>These failures could place residents at risk for not being aware of changes to provided services. <BR/>Findings included:<BR/>1. Record review of Resident #274's face sheet, dated 10/15/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included embolism and thrombosis of arteries of the upper extremities (a condition where blood clots form in the arms), and type 2 diabetes (a chronic condition where the levels of sugar, or glucose, build up in the body).<BR/>Record review of Resident #274's quarterly MDS assessment, dated 09/26/24, indicated she was able to make herself understood, and able to understand others. She had a BIMS score of 14, which indicated she had intact cognition. <BR/>Record review of the SNF Beneficiary Notification Review indicated Resident #274 received Medicare Part A skilled services on 11/22/23 and the last covered day of Part A was 07/01/24. The SNF Beneficiary Notification Review indicated the facility/provider notified the Resident of discharge from Medicare Part A services with a NOMNC form on 06/28/24. The review further did not contain a SNF ABN for Resident #274. <BR/>2. Record review of Resident #275's face sheet, dated 10/15/24, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood that affects brain function), and chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe). <BR/>Record review of Resident #275's admission MDS assessment, dated 03/14/24, indicated she was able to make herself understood, and was able to understand others. She had a BIMS score of 15, which indicated intact cognition. <BR/>Record review of the SNF Beneficiary Notification Review indicated Resident #275 received Medicare Part A skilled services on 03/12/24 and the last covered day of Part A was 05/13/24. The SNF Beneficiary Notification Review indicated the facility / provider notified the Resident of discharge from Medicare Part A services with a NOMNC form on 05/08/24. The review further did not contain a SNF ABN for Resident #275. <BR/>During an interview on 10/15/24 at 11:50 AM, SW E said that an ABN form was not provided to Resident #275. She did not realize the form was required to be given to the resident and stated it should have been provided. <BR/>During an interview on 10/15/24 at 12:20 PM, SW E said an ABN form was not provided to Resident #274. She said it was not provided for the same reason as Resident #275.<BR/>During an interview on 10/16/24 at 02:28 PM, SW E said Resident #275 and Resident #274 should have been provided an ABN form. She said it was important for them to receive the form because it was required by regulation. She said the ABN form should have been issued at the same time as the NOMNC. She said the risk was that the resident may not be aware of out-of-pocket costs after being discharged from Part A services.<BR/>During an interview on 10/16/24 at 02:34 PM, the Interim Administrator said Residents #274 and #275 should have received the ABN form. She said it was important for the residents to receive the form because it would have helped the residents understand the cost of their services if they stayed in the facility after they ran out of Part A days. She said the risk was they could be charged and not know the cost of their stay. She said it could also cause the resident to have increased anxiety.<BR/>Record review of the facility's policy, Beneficiary Notice Policy, effective 04/20/23, stated: <BR/> .A SNF ABN is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay . <BR/> .Deadline for providing ANB/NOMNC to resident or guardian: 48 hours before services are set to expire .<BR/> .The Social Service department is responsible for completing and issuing these forms to the resident and/or family to be signed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 13 residents (Resident #97) reviewed for PASRR Level I screenings.<BR/>1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #97. <BR/>This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.<BR/>Findings included:<BR/>Record review of Resident #97's face sheet, dated 10/14/2024, revealed he was a [AGE] year-old male, who was readmitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infarction (symptom that involves one-sided paralysis after blood flow to the brain is blocked or reduced), obstructive and reflux uropathy (when your urine can't flow (either partially or completely) through your ureter, bladder, or urethra due to some type of obstruction), and schizophrenia ( mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). <BR/>Record review of Resident #97's quarterly MDS, dated [DATE], indicated he had a BIMS score of 15, which indicated he was cognitively intact. Resident #97's MDS revealed an active diagnosis of Schizophrenia. <BR/>Record review of Resident # 97's PASARR level L1 dated 8/2/2023 indicated Resident #97 did not have a mental illness. <BR/>Record review of Resident #97's care plan, undated revealed Resident #97 required psychotropic medication for diagnosis of Schizophrenia. Resident #97's care plan did not indicate he was PASRR positive or negative.<BR/>Record review of Resident #97's PASRR Level 1 Screening, dated 08/03/2023, indicated in Section C Mental Illness was marked as no, which indicated Resident #97 did not have a mental illness.<BR/>During an interview on 10/17/2024 at 9:08 AM Social worker E said she does not complete any of the PASSR level one screenings or PASSR. Social worker E said she attends the meetings for care plans. Social worker E said she was not sure which residents were receiving PASSR services. She said she was aware that residents with mental illness and do not have dementia can qualify for services and those residents with intellectual disabilities. <BR/>During an interview on 10/17/2024 at 8:34 AM, MDS Coordinator V said all residents should have a PASSR level one. She said if a resident had a diagnosis of a mental illness or intellectual disability, they would be positive. She said there were 2 authorities depending on if the resident had mental illness or intellectual disabilities. MDS Coordinator V said she would be aware if a resident qualified if they received a negative letter. MDS Coordinator V said if the resident was positive, then the facility would schedule a meeting and the facility only care plans if a resident was positive. MDS Coordinate V said Resident # 97 had come to the facility with a diagnosis of schizophrenia and said the hospital incorrectly marked mental illness as no. MDS Coordinator said she had completed the form 1012 on 10/17/2024 and the local authority had already requested records. MDS Coordinator V said Resident #97 had already been receiving psychiatric services since 8/2/2023. <BR/>During an interview on 10/17/2024 at 9:33 AM, ADON N said she was not sure about PASRR.<BR/>During an interview on 10/17/2024 at 11:31 AM, Regional Nurse FF said the MDS nurse was responsible for ensuring the PASARR forms were completed. She said the resident's PASARR should have been positive with a diagnosis of schizophrenia. Regional Nurse FF said the MDS nurse should have identified the diagnosis and referred PASARR evaluation. She said she expected the nurses to complete the form 1012 when identified a resident had a mental illness. Regional Nurse FF said if the resident has proper orders in place, the care was coordinated to receive services.<BR/>During an interview on 10/17/2024 at 11:55 AM, the ADM said she had been the ADM since Monday. The ADM said a resident who had a mental illness should be evaluated for a positive PASSR. She said the resident could qualify for additional services. <BR/>Record review of the facility's policy, undated and titled Pre-admission Screening Resident Review (PASRR) stated: To ensure that all Facility applicants are screened for mental illness and/or intellectual disability prior to admission and to ensure this assessment effort is coordinated with the appropriate state agencies if indicated. PASARR is a federal requirement .A. PASSR level I screening is to be completed before the individual is admitted .B. All first-time applicants to the facility, regardless of Medicaid status or payor .ii. The state is responsible for providing specialized services to residents with MD/ID residing in Medicaid certified facilities .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to notify the State Mental Health Authority to inform them of a significant change in mental condition for 1 of 5 (Residents #93) residents reviewed for Preadmissions Screening and Annual Resident Review (PASRR).<BR/>1. The facility failed to notify the SMHA to ensure Resident #93 received a new PASRR level 1 screening following identification of his diagnosis of post-traumatic stress disorder on 01/25/24.<BR/>This failure could affect residents who may have a mental disorder diagnosis by placing them at risk for not receiving the necessary services that may benefit them daily. <BR/>Findings included:<BR/>Record review of Resident #93's face sheet, dated 10/14/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included post-traumatic stress disorder (a real disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), encephalopathy (a broad term for any brain disease that alters brain function or structure) and other specified depressive episodes (a diagnosis for a person who has symptoms of a depressive disorder but doesn't meet the full criteria for a specific depressive disorder).<BR/>Record review of Resident #93's quarterly MDS assessment, dated 9/20/24. The MDS indicated a BIMS score of 12 indicating Resident #93's cognition was moderately impaired. The MDS indicated Resident #93 was independent with activities of daily living. <BR/>Record review of Resident #93's admission record, dated 05/05/23, reflected his diagnoses included encephalopathy unspecified, onset date 05/05/23; and other specified depressive episodes, onset date 05/05/23. <BR/>Record review of Resident #93's face dated 10/14/24, indicated she had a diagnosis that included post-traumatic stress disorder.<BR/>Record review of Resident #93's PASRR Level 1 Screening, dated 05/05/23, indicated the resident did not have mental illness, intellectual disability, or developmental disability. <BR/>Record review of Resident #93's PASRR Level 1 Screening, dated on 01/25/24 or after PTSD diagnosis was not indicated, the resident did not have a PASRR Level 1 Screening.<BR/>Record review of Resident #'s Order Summary Report, dated 07/09/24, reflected: <BR/>1. Venlafaxine HCL 50 mg, two times daily for depression<BR/>During an interview on 10/15/24 at 8:35 A.M., with Resident #93 she said the facility was treating her depression and PTSD with medications and counseling.<BR/>During an interview on 10/15/24 at 2:37 P.M., with Regional MDS Coordinator X she said PTSD was not a diagnosis for a positive PASRR. <BR/>During an interview on 10/15/24 at 2:44 P.M., with MDS Coordinator V said she had not heard PTSD was a diagnosis for a positive PASRR. She said normally the residents have another diagnosis to go with PTSD for a positive PASRR. <BR/>During an interview on 10/15/24 at 3:58 P.M., Regional MDS Coordinator X notified the State Surveyor that they were going to do a 1012 Form for Resident #93 and they were going to get the doctor to sign the order tonight. She said they were going to enter the form in the portal and that will trigger PASRR to complete a PASRR level 1 evaluation. She said the facility would have an in-service for our MDS nurses for PASRR positive diagnosis. Regional MDS Coordinator X said after Resident #93 received the PTSD diagnosis she was supposed to have a PASRR Level 1 evaluation. <BR/>During an interview on 10/16/24 at 9:41 A.M., with Regional MDS Coordinator notified the state surveyor that 1012 was filed for Resident #93 and the facility was waiting for PASRR for an evaluation. <BR/>During an interview on 10/17/24 at 9:27 A.M., with MDS Coordinator V she said Resident #93 should have had a new PASRR eval done after she received a new diagnosis of PTSD. She said the PASRR eval was not done after the state surveyor intervention. She said the facility had filed a 1012 and called the MD. She said she had requested the PL1 and requested the records from the state. She said the negative effects of a resident not receiving PASRR services was residents with mental illness could miss out on counseling services and other services that could be offered. <BR/>During an interview on 10/17/24 at 10:54 A.M., with the Administrator she said she expected for residents to have an accurate PASRR assessment. She said the negative effects on residents not having an accurate PASRR evaluation could affect the resident's health and they could be paying for services that the PASRR benefits could cover.<BR/>Record review of facility's Pre-admission Screening Resident Review (PASRR) policy indicated . the facility also conducts a Level 1 screening for current residents who experience a significant change in their condition based on MDS 3.0 guidelines . a Level 1 PASRR is completed each time a resident is hospitalized and readmitted if there has been a significant change in condition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 7 residents reviewed for care plans. (Resident #72, Resident #98)<BR/>The facility failed to implement the care plan intervention to document Resident #72 and Resident #98's meal intake. <BR/>The facility failed to implement the care plan intervention for Resident #98 to receive his Frozen Nutritional Treats with meals. <BR/>These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services<BR/>Findings included:<BR/>1. Record review of a face sheet dated 08/30/23 indicated Resident #72 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses including Parkinson's (is a movement disorder. It causes tremors, stiffness, and slow movement), Alzheimer's (a progressive disease that destroys memory and other important mental functions), and fracture of left femur (is a break in the thighbone). <BR/>Record review of an admission MDS assessment dated [DATE] indicated Resident #72 was understood and understood others. The MDS indicated Resident #72 had a BIMS score of 12 which indicated moderately impaired cognition and required supervision for eating, extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated Resident #72 had nutritional malnutrition. <BR/>Record review a care plan dated 06/06/23 indicated Resident #72 had potential nutritional problem/malnutrition related to Alzheimer's, Parkinson's, poor dental health, and admission to nursing facility. Intervention included provide, serve diet as ordered. Monitor intake and record every meal. <BR/>Record review of Resident #72's Amount Eaten report dated 08/30/23 indicated no meal intake amount for:<BR/>*08/28/23: 9:00 am, 1:00 pm<BR/>*08/29/23: 9:00 am, 1:00 pm <BR/>*08/30/23: 9:00 am, 1:00 pm<BR/>2. Record review of a face sheet dated 08/28/23 indicated Resident #98 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Asperger's syndrome (a developmental disorder affecting ability to effectively socialize and communicate), muscle wasting and atrophy (is the wasting (thinning) or loss of muscle tissue), muscle weakness, need for assistance with personal care, dysphagia (difficulty swallowing foods or liquids), Type 2 diabetes (is a disease in which your blood glucose, or blood sugar, levels are too high), and protein calorie malnutrition (is the state of inadequate intake of food). <BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #98 was sometimes understood and usually understood others. The MDS indicated Resident #98 had adequate hearing, unclear speech, and highly impaired vision. The MDS indicated Resident #98 had a BIMS score of 05 which indicated severe cognitive impairment and required limited assistance for bathing and extensive assistance for bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident #98 had weight loss and was not on a physician prescribed weight-loss regimen. <BR/>Record review of a care plan dated 05/03/23 indicated Resident #98 had potential for pressure ulcer development. Intervention included monitor nutritional status. Serve diet as ordered, monitor intake and record.<BR/>Record review of a care plan revised on 08/07/23 indicated Resident #98 had potential nutritional problem related to Asperger's Syndrome. Intervention included 06/27/23 RD recommendations: 1. Frozen Nutritional Treat TID meals.<BR/>Record review of Resident #98's consolidated physician's order dated 06/22/23 indicated Frozen Nutritional Treat with meals for significant weight loss. <BR/>Record review of Resident #98's Amount Eaten report dated 08/30/23 indicated no meal intake amount for:<BR/>*08/28/23: 9:00 am, 1:00 pm<BR/>*08/29/23: 9:00 am, 1:00 pm <BR/>*08/30/23: 9:00 am, 1:00 pm<BR/>During an observation on 08/29/23 at 9:06 a.m., revealed Resident #98's breakfast tray had only one bite of ground sausage missing. No frozen treat was noted on Resident #98's tray or bedside table. Resident #98's meal ticket indicated frozen nutritional treat with meals. The observation revealed further that Resident #72's breakfast tray had one glass of milk drank and one bite of oatmeal. <BR/>During an observation on 08/29/23 at 1:25 p.m., revealed Resident #72 only ate his dessert, and his roommate gave him another dessert. Resident #72 did not eat his 2 chopped beef sandwiches. Resident #98's ate 50-75% of lunch. No frozen treat was noted on Resident #98's tray or bedside table.<BR/>During an observation on 08/29/23 at 6:36 p.m., revealed Resident #72 only drank his milk for dinner. Resident #98's ate 0-25% for dinner. No frozen treat was noted on Resident #98's tray or bedside table. <BR/>During an observation on 08/29/23 at 6:38 p.m., at the end of 300 hall, revealed a bucket with ice had frozen treats and house shakes. <BR/>During an observation on 08/30/23 at 8:56 a.m., revealed Resident #98 did not eat breakfast but drank a house shake. No frozen treat was noted on Resident #98's tray or bedside table.<BR/>During an interview on 08/30/23 at 9:03 a.m., CNA A said Resident #98 normally drank house shakes and today was the first time to hear he was supposed to have frozen treats with his meals. She said dietary was responsible for providing the frozen treats. CNA A said she had not gotten into the facility's electronic charting system and charted Resident #72 or Resident #98's meal intakes for the last 3 days. She said she had not looked at Resident #72 and Resident #98's care plan recently. She said Resident #98 and Resident #72 did not eat much the last three days. CNA A said maybe one day Resident #98 and Resident #72 ate 25-50% of their food. She said she was responsible for documenting meal intake and LVNs ensured it was inputted and correct. CNA A said it was important to document meal intake so the dietician would know if she needed to make changes. She said it was important to follow the care plan intervention to offer frozen treats to Resident #98 to help with weight loss and let the dietician know if the interventions worked. <BR/>During an interview on 08/30/23 at 2:07 p.m., LVN D said Resident #72 and Resident #98 were being monitored for weight loss. She said both residents were getting prescribed nutritional supplements by the nurses. LVN D said CNAs and LVNs should chart residents meal intakes. She said LVNs should make sure the meal intakes were documented at the end of the shift as the care plan intervention indicated. LVN D said the kitchen placed the house shakes and frozen treats on ice in a bucket on each hall. She said the CNAs should hand the nutrition frozen treats out to each resident. LVN D said the DON looked at the meal intake report to determine which resident needed to be seen by the dietician or dietary manager. She said dietary recommendations on the care plan should be followed to prevent further weight loss and improve nutritional status. LVN D said if recommendations were not followed, or meal intakes not documented residents were at risk for dehydration or illnesses. <BR/>During an interview on 08/31/23 at 8:20 a.m., LVN C said CNAs were responsible for documenting meal intakes. She said Resident #72 and Resident #98 were being monitored for weight loss. LVN C said Resident #72 normally ate 50% and Resident #98 75-100%. She said LVNs should make sure CNAs were documenting meal intakes. LVN C said it was important to document meal intakes to monitor for change of condition and know if a resident needed a supplement. She said dietary recommendation should be followed to prevent decline, skin breakdown, and improve nutrition. <BR/>During an interview on 08/31/23 at 9:45 a.m., the DON said CNAs and LVNs should document resident's meal intake in the facility's computer system. She said nursing staff were responsible for providing resident frozen treats per the doctor's orders and meal tickets. The DON said it was important to document meal intake and give dietary recommendations so dietary interventions could be planned, and new interventions developed, or revisions made to the care plan to prevent further weight loss. The DON said all nursing staff had access to resident's care plans on the facility's electronic charting system and should be followed. She said managers should review residents' charts to ensure it was being done and the dietician would also look at the information documented. <BR/>During an interview on 08/31/23 at 10:41 a.m., the ADM said CNAs should document meal intake amounts. He said nursing staff and dietary were responsible for dietary recommendations. The ADM said it was important to document and follow recommendation, to know if the resident received proper nutrition and prevent further weight loss. He said nursing administration should oversee this process. <BR/>Record review of a facility Care Planning policy revised 10/24/22 indicated .each resident's comprehensive care plan will describe the following .services that are to be furnished to attain or maintain the resident's highest practicable physical .well-being <BR/>Record review of a facility Nutrition/Hydration Management policy revised 06/20 indicated .to ensure that each resident maintains acceptable parameters of nutritional status .implementing the nutritional/hydration program .a comprehensive care plan is developed .that addresses nutrition/hydration and an individualized .management program based on individualized assessed needs

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 3 of 20 residents reviewed for ADLs. (Resident #'s 145, 76, and 145).<BR/>The facility failed to provide nail care for Resident #49.<BR/>The facility failed to provide facial hair grooming for Resident #76.<BR/>The facility failed to provide bathing for Resident #145.<BR/>These failures could place residents at risk for not receiving services/care and a decreased quality of life.<BR/>Findings included:<BR/>1.Record review of a face sheet dated 7/13/2022 indicated Resident #49 was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of Parkinson's disease, need for assistance with personal care and weakness.<BR/>The most recent Quarterly MDS dated [DATE] indicated Resident #49 understood others and was understood by others. Resident #49's brief interview memory score was a 2 indicating he had severe cognitive impairment. The MDS indicated Resident #49 required total assistance of one staff for personal hygiene.<BR/>Record review of a comprehensive care plan dated 6/2/2020 indicated Resident #49 had a self-care deficit with a goal of improvement with the intervention of bathing which included checking the nail length, trim and clean on bath days. <BR/>Record review of a 200 Hall shower schedule indicated Resident #49's bath days were Monday's, Wednesday's, and Friday's on the 6:00 a.m. to 6:00 p.m. shift.<BR/>During an observation on 7/11/2022 at 10:00 a.m. revealed Resident #49 was lying in his bed. His nails were long and with a brownish black material underneath the nails . Resident #49 said he would like have his nails cleaned and trimmed. <BR/>During an observation on 7/11/2022 at 12:55 p.m. revealed Resident #49's fingernails were approximately &frac12; inch long with a brownish black material underneath the fingernails.<BR/>During an observation on 7/11/2022 at 3:50 p.m. revealed Resident #49's fingernails continued to be long with brownish black material underneath the nails.<BR/>During an observation on 7/12/2022 at 2:00 p.m., Resident #49's nails continued to be long and with a brownish black material underneath the nails. <BR/>Record review of Resident #49's Shower Sheets indicated:<BR/>*7/1/2022 Resident #49's nails were cleaned with his bed bath.<BR/>*7/6/22022 Resident #49's nails were not cleaned with a refusal of a shower.<BR/>*7/08/2022 Resident #49's nails were not cleaned with his bed bath.<BR/>*7/11/2022 Resident #49's nails were cleaned with a bed bath.<BR/>*7/13/2022 Resident #49's nails were cleaned with a refusal of a shower.<BR/>2.Record review of a face sheet dated 7/13/2022 indicated Resident #145 was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of chronic respiratory failure, pneumonia, and seizures.<BR/>Record review of the most recent admission MDS dated [DATE] indicated Resident #145 understood others and was usually understood by others. The MDS indicated Resident #145's BIMS was a 10 indicating moderately impaired cognition. Under the section of Staff Assessment of Daily and Activity Preferences the MDS indicated Resident #145 preferred to have a bed bath. The MDS indicated Resident #145 was total assist of two staff for bed mobility, dressing, eating, personal hygiene and for bathing she required total assistance of one staff. <BR/>Record review of the comprehensive care plan dated 4/27/2022 and revised on 7/08/2022 indicated Resident #145 had an ADL self-care deficit related to myotonic muscular dystrophy (a multi-system disease affecting the skeletal muscles) . The care plan goal indicated Resident #145's needs would be met daily. The intervention was Resident #145 would have two staff to provide bathing.<BR/>Record review of an undated 200 Hall Shower Schedule indicated Resident #145 was to receive bathing on Tuesday's, Thursday's, and Saturday's on the 6:00 a.m. to 6:00 p.m. shift.<BR/>During an observation on 7/11/2022 at 9:40 a.m. revealed Resident #145's hair had a greasy appearance. Resident #145 was not interviewable due to her having the tracheostomy and unable to express self well concerning her bathing and hygiene. <BR/>Record review of the July 2022 point of care documentation from 7/01/2022 - 7/13/2022 indicated Resident #145 did not receive a bath on 7/02/2022 (Saturday) and on 7/07/2022 (Thursday). <BR/>Record review of the only shower sheet provided dated 7/05/2022 indicated Resident #145 received a shower, nails were cleaned, barrier cream applied, moisturizer applied, and her hair was not washed. <BR/>3. Record review of a face sheet dated 7/13/2022 indicated Resident #76 was an [AGE] year-old-female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's dementia and difficulty swallowing.<BR/>Record review of the most recent Quarterly MDS dated [DATE] indicated Resident #76 was sometimes understood by others and sometimes understands . The MDS indicated Resident #76's brief interview memory score was a 2 indicating a severe cognitive deficit. The MDS indicated Resident #76 required total assistance of one staff with personal hygiene including shaving.<BR/>Record review of the comprehensive care plan dated 4/11/2019 indicated Resident #76 had a self-care deficit with a goal of her needs would be met daily. The care plan indicated Resident #76 required one staff extensive assistance with personal hygiene.<BR/>During an observation on 7/11/2022 at 3:29 p.m. revealed Resident #76 had numerous gray colored facial hairs to her chin approximately 1 inch long . <BR/>During an observation on 7/12/2022 at 8:59 a.m. revealed Resident #76 continued to have long facial hairs to her chin. <BR/>During an observation on 7/12/2022 at 1:48 p.m. revealed Resident #76 continued to have long facial hairs to her chin. Resident #76 said she would like the hairs removed from her chin.<BR/>During an observation and interview on 7/14/2022 at 9:20 a.m. revealed Resident #76 continued to have long facial hairs to her chin. The DON indicated she would have the chin hairs taken care of today . <BR/>During an interview on 7/13/2022 at 9:50 a.m., CNA G indicated the CNAs were responsible for nail care, shaving and bathing on bath days and as needed. CNA G indicated the nurses would trim diabetic residents' nails, but the CNAs could clean anyone's fingernails. CNA G said residents could scratch themselves with long fingernails. CNA G said having dirty fingernails and eating was nasty. CNA G said if she did not get to a resident's bath on their scheduled day, she would get them the next day . CNA G indicated she was assigned to Resident's #76 and # 49.<BR/>During an interview on 7/13/2022 at 10:41 a.m., LVN D indicated the CNAs were responsible for bathing, shaving, and nail care. LVN D indicated nurses were responsible for ensuring the CNAs completed the ADLs. LVN D indicated monitoring of the ADLs occurred when the CNAs would turn in the shower sheets, she reviewed them and if there was a refusal she would try and encourage the resident to complete their ADLs. LVN D indicated she expected ADLs to be completed as scheduled and as needed.<BR/>During an interview on 7/13/2022 at 11:04 a.m., CNA E indicated she was responsible for ADLs. CNA E said she did not see the facial hair on Resident #76. CNA E indicated Resident #49's nails were now cleaned and trimmed. <BR/>During an interview on 7/14/2022 at 12:13 p.m., the DON indicated residents were encouraged to bathe/shower when they would refuse. The DON indicated if the resident prefers something different, she would be willing to implement the changes. The DON indicated she had done teaching with the staff to review their approach with the residents to ensure compliance with ADLs. The DON indicated the lack of ADLs could cause bacteria to form and illness to occur. The DON indicated the ADLs were monitored using the shower sheets, the computerized documentation, and with rounds. The DON expected the residents to receive their showers, nail care, and shaving on their scheduled days and as needed.<BR/>During an interview on 7/14/2022 at 1:05 p.m., the ADM indicated he expected the residents to receive their ADLs. The ADM indicated not receiving their ADLs could cause infection and affect the resident's dignity. He indicated the ADLs were monitored by nursing using the computerized documentation and with rounds.<BR/>During an interview on 7/14/2022 at 3:15 p.m., the DON indicated there were no policy and procedures for nailcare, shaving or bathing.<BR/>Record review of Care of Standards policy with a revised date of June 2020 indicated the purpose was to ensure all residents receive necessary care and services that were evidence-based and in accordance with accepted professional clinical standards of practice. Procedure l. The Director of Nursing Services (DON) ensured care and services were delivered according to accepted standards of clinical practice. Unless specifically addressed in an individual facility policy the Facility defers to the accepted national standards of clinical practice. ll.E. Skills and techniques for the New Nursing Assistant Textbook, 8th Edition ([NAME], [NAME]); F. Mosby's Textbook for Long-Term Care Nursing Assistants Sixth Edition ([NAME]) IV. The DON or designee evaluates staff competency in skills and techniques necessary to care for residents assessed needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 3 of 6 Residents (Resident #21, Resident #51, and Resident #79) whose records were reviewed for skin integrity.<BR/>The facility failed to ensure Resident #21, Resident #51, and Resident #79's pressure-relieving mattresses (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) were on the correct settings.<BR/>The facility failed to ensure Resident #79 received and/or documented wound care on 10/05/24, 10/06/24, 10/07/24, 10/10/24, 10/11/24, and 10/13/24. <BR/>These failures could place residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers.<BR/>Findings included:<BR/>1. Record review of Resident #21's face sheet dated 10/14/24 indicated Resident #21 was a 69-years-old female admitted on [DATE] with diagnoses including need for assistance with personal care, chronic kidney disease (is a long-term condition that occurs when the kidneys are damaged and can't filter blood properly), weakness, pain in right and left shoulder, diabetes mellitus (a group of diseases that affect how the body uses blood sugar (glucose)), and hidradenitis suppurativa (is a painful, long-term skin condition that causes skin abscesses and scarring on the skin). <BR/>Record review of Resident #21's quarterly MDS assessment dated [DATE] indicated Resident #21 was understood and understood others. Resident #21 had clear speech, adequate hearing, and adequate vision. Resident #21 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #21 had an indwelling catheter and was always incontinent for bowel. Resident #21 weighed 241 lbs. Resident #21 was at risk of developing pressure ulcers/injuries. Resident #21 had open lesions other than ulcers, rashes, cuts. Resident #21 had a pressure reducing device for bed as a skin and ulcer/injury treatment.<BR/>Record review of Resident #21's consolidated physician order active as of 10/16/24 indicated may use low air loss mattress. Check settings every shift to ensure settings within therapeutic range. Order date 07/31/23. <BR/>Record review of Resident #21's undated care plan indicated Resident #21 had the potential for pressure injury development/skin impairment related to disease process, immobility, and incontinence. On 12/07/23, Resident #21 continues to have skin injury to buttocks related to hidradenitis per wound care medical doctor. Intervention included notify nurse immediately of any new areas of skin breakdown.<BR/>Record review of Resident #21's weight summary dated 10/17/24 indicated:<BR/>*10/07/24 240.3 lbs.<BR/>*09/07/24 244.3 lbs.<BR/>*08/28/24 243.4 lbs. <BR/>During an observation and interview on 10/15/24 at 8:09 a.m., Resident #21 was lying in bed on a pressure relieving mattress. Resident #21's weight setting was 360 lbs. She said she did not know about the bed settings, but the bed made weird noises. <BR/>During an observation on 10/16/24 at 3:30 p.m., Resident #21 was lying in bed on a pressure relieving mattress. Resident #21's weight setting was 360 lbs.<BR/>2. Record review of Resident #51's face sheet dated 10/15/24 indicated Resident #51 was a 60-years-old female admitted on [DATE] and 12/08/20 with diagnoses including metabolic encephalopathy (is a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), muscle wasting and atrophy (shortening), and protein-calorie malnutrition (is a condition that occurs when someone doesn't get enough calories or the right nutrients). <BR/>Record review of Resident #51's quarterly MDS assessment dated [DATE] indicated Resident #51 was usually understood and usually understood others. Resident #51 had a BIMS score of 04 which indicated severe cognitive impairment. Resident #51 was dependent for ADL care. Resident #51 was always incontinent for bladder and bowel. Resident #51 weighed 78 lbs. Resident #51 was at risk for developing pressure ulcers/injuries. Resident #51 had pressure reducing device for bed.<BR/>Record review of Resident #51's consolidated physician order active as of 10/16/24 indicated may use low air loss mattress. Check settings every shift to ensure settings within therapeutic range. Order date 08/07/24. <BR/>Record review of Resident #51's undated care plan indicated Resident #51 had potential/actual impairment to skin integrity related to fragile skin and scratching buttocks and legs due to itching. Intervention included identify/document potential causative factors and eliminate/resolve where possible. <BR/>During an observation on 10/14/24 at 2:21 p.m., Resident #51 was lying on a low air loss mattress with boundaries. Resident #51's weight bed setting was 210 lbs. <BR/>During an observation on 10/15/24 at 10:56 a.m., Resident #51 was lying in bed asleep. Resident #51 was lying on a low air loss mattress with boundaries. Resident #51's weight bed setting was 210 lbs.<BR/>During an observation on 10/16/24 at 3:10 p.m., Resident #51 was lying in bed asleep. Resident #51 was lying on a low air loss mattress with boundaries. Resident #51's weight bed setting was 210 lbs. <BR/>3. Record review of Resident #79's face sheet dated 10/14/24 indicated Resident #79 was a 55-years-old male admitted on [DATE] and 05/01/24 with diagnoses including paraplegia (is paralysis that affects your legs, making it impossible to stand or walk), dependence on renal dialysis, pressure ulcer (are localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences) of sacral region (is a skin injury that occurs in the sacral region of the body, near the lower back and spine), Stage 4 (injuries extend to muscle, tendon, or bone), and muscle wasting and atrophy (shortening). <BR/>Record review of Resident #79's quarterly MDS assessment dated [DATE] indicated Resident #79 was understood and understood others. Resident #79 had clear speech, adequate hearing, and adequate vision with corrective lenses. Resident #79 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #79 had an indwelling catheter and was always incontinent of bowel. Resident #79 weighed 125 lbs. Resident #79 had a pressure ulcer/injury and one or more unhealed pressure ulcers/injuries. Resident #79 had two stage 4 pressure ulcers and pressure reducing device for bed and pressure ulcer/injury care for skin and ulcer/injury treatments. <BR/>Record review of Resident #79's undated care plan indicated:<BR/>*Resident #79 had stage 4 pressure injury to the sacrum related to immobility and disease process. Interventions included treat wounds as per medical doctor orders and follow facility policies/protocols for the prevention/treatment of skin breakdown. <BR/>*Resident #79 had a stage 4 pressure injury to his ischium related to disease process, immobility, returned from hospital with pressure injury now unstageable on 05/01/24. Interventions included administer treatments as ordered and monitor for effectiveness and the resident required the use of an air mattress. <BR/>*Resident #79 had a stage 4 pressure injury to his left ischium from worsening abscess related to disease process, history of ulcers, and immobility. Intervention included administer treatments as ordered and monitor for effectiveness. <BR/>Record review of Resident #79's consolidated physician order active as of 10/16/24 indicated:<BR/>*Pressure relieving mattress every shift for preventative. Start date 05/03/24. <BR/>*Wound care: Cleanse stage 4 pressure injury to left ischium with Dakin's or normal saline and pat dry. Fill dead space with collagen particles and Dakin's moistened gauze. Secure with bordered composite dressing. Change every shift and PRN soiling/saturation. Start date 10/15/24. <BR/>*Wound care: Cleanse stage 4 pressure injury to right ischium with Dakin's or normal saline and pat dry. Fill dead space with collagen particles and Dakin's moistened gauze. Secure with bordered composite dressing. Change every shift and PRN soiling/saturation. Start date 10/15/24. <BR/>*Wound care: Cleanse stage 4 pressure injury to sacrum with Dakin's or normal saline and pat dry. Fill dead space with collagen particles and Dakin's moistened gauze. Secure with bordered composite dressing. Change every shift and PRN soiling/saturation. Start date 10/15/24. <BR/>Record review of Resident #79's MAR dated 10/01/24-10/31/24 indicated:<BR/>*Wound care: Cleanse stage 4 pressure injury to left ischium with Dakin's or normal saline and pat dry. Fill dead space with calcium alginate. Secure with bordered foam dressing. Change every shift and PRN soiling/saturation, every shift for wound care. Order date 10/05/24. Discontinued 10/13/24. Resident #79's MAR did not have administration of wound care on 10/05/24 (night shift), 10/06/24 (day and night shift), 10/07/24 (night shift), 10/10/24 (day and night shift), 10/11/24 (night shift), and 10/13/24 (night shift)<BR/>*Wound care: Cleanse stage 4 pressure injury to left ischium with Dakin's or normal saline and pat dry. Fill dead space with collagen particles and Dakin's moistened gauze. Secure with bordered waterproof dressing. Change every shift and PRN soiling/saturation. Order date 10/13/24. <BR/>*Wound care: Cleanse stage 4 pressure injury to right ischium with Dakin's or normal saline and pat dry. Fill dead space with calcium alginate. Secure with bordered foam dressing. Change every shift and PRN soiling/saturation, every shift for wound care. Order date 10/05/24. Discontinued 10/13/24. Resident #79's MAR did not have administration of wound care on 10/05/24 (night shift), 10/06/24 (day and night shift), 10/07/24 (night shift), 10/10/24 (day and night shift), 10/11/24 (night shift), and 10/13/24 (night shift)<BR/>*Wound care: Cleanse stage 4 pressure injury to right ischium with Dakin's or normal saline and pat dry. Fill dead space with collagen particles and Dakin's moistened gauze. Secure with bordered waterproof dressing. Change every shift and PRN soiling/saturation. Order date 10/13/24. <BR/>*Wound care: Cleanse stage 4 pressure injury to sacrum with Dakin's or normal saline and pat dry. Fill dead space with calcium alginate. Secure with bordered foam dressing. Change every shift and PRN soiling/saturation, every shift for wound care. Order date 10/05/24. Discontinued 10/13/24. Resident #79's MAR did not have administration of wound care on 10/05/24 (night shift), 10/06/24 (day and night shift), 10/07/24 (night shift), 10/10/24 (day and night shift), 10/11/24 (night shift), and 10/13/24 (night shift)<BR/>*Wound care: Cleanse stage 4 pressure injury to sacrum with Dakin's or normal saline and pat dry. Fill dead space with collagen particles and Dakin's moistened gauze. Secure with bordered waterproof dressing. Change every shift and PRN soiling/saturation. Order date 10/13/24. <BR/>Record review of Resident #79's progress notes dated 10/10/24 by Wound Care DNP indicated .wound follow up .the following wounds were evaluated .Wound 1 Sacrum, Pressure Injury, Stage 4 .Wound 2 Right Ischium, Pressure Injury, Stage 4 .Wound 4 Left Ischium, Pressure Injury, Stage 4 .wound 1: subsequent- improving .wound 2: subsequent-improving .wound 4: subsequent-improving .<BR/>Record review of Resident #79's weight summary dated 10/17/24 indicated:<BR/>*10/16/24 136.8 lbs.<BR/>*10/09/24 134.6 lbs.<BR/>*10/04/24 130.67 lbs.<BR/>*10/02/24 127.2 lbs.<BR/>During an observation and interview on 10/15/24 at 3:30 p.m., Resident #79 was lying on a LAL mattress after wound care with Treatment Nurse M. Resident #79's weight bed setting was 490 lbs. Resident #79 said he probably weighed about 138 lbs. Treatment Nurse M said she had not noticed Resident #79's weight bed setting being 490 lbs. She said she did not know who was responsible for ensuring the resident's weight settings were accurate. Treatment Nurse M reviewed Resident #79's medical records and said he weighed 134.6 lbs. Resident #79 said sometimes his wound care was not done every day or shift. He said some nurses did not want to mess with it or were too new. He said he mostly missed treatments on the night shift. <BR/>During an interview on 10/17/24 at 8:15 a.m., RN H said she had been employed at the facility for 3 months. She said she took care of Resident #79. She said Resident #79's wound care was not done sometimes on her shift. She said Treatment Nurse M told her Resident #79's dressing changes were only due on day shift. She said the Treatment Nurse M told her the order only said every shift in case it got soiled or dislodged, there was an order for it. She said Treatment Nurse M told her to only change Resident #79's dressings at night if it got soiled. She said she only changed Resident #79's dressings once on night shift when it got soiled. She said she forgot to document the dressing changes on the TAR. She said she thought she documented the dressing changes on a progress note. She said she did not know she had to document Resident #79's dressing changes on the TAR. She said she should have followed the physicians orders not Treatment Nurse M. She said it was important to follow the physician's order because they ordered it that way for a reason. She said it was important to do the ordered wound care so it could heal faster. She said when wound care was not performed as scheduled, it risked the pressure ulcer not improving and infection. She said she did not know who was responsible for the LAL mattress weight settings. She said the TAR had an order for the resident to have a LAL or pressure relieving mattress but not checking the mattress's settings. She said the mattress settings were important to be set correctly to rotate the pressure off the resident's bony prominences. She said the wrong LAL mattress settings increased the resident's risk of skin breakdown. <BR/>During an interview on 10/17/24 at 9:34 a.m., Treatment Nurse M said she had been the treatment nurse for a month. She said she did not know who was responsible for checking LAL or pressure relieving mattress settings. She said she would start checking the mattress settings from now on. She said it was important for the mattress settings to be correct to relieve the correct amount of pressure and adjust correctly. She said wrong mattress settings could make pressure ulcers worsen. She said Resident #79's wound care should have been done every shift not once a day. She said she had recently educated the nurses on doing Resident #79's wound care dressing changes every shift. She said she did not remember if she had educated RN F. She said she was responsible for dressing changes Monday-Friday, day shift. She said the weekend supervisor and LVNs were responsible for the night and weekend dressing changes. She said she did not know why there were two day shift days not documented on Resident #79's MAR/TAR. <BR/>During an interview on 10/17/24 at 10:37 a.m., ADON N said the mattress company set up the resident's LAL or pressure relieving mattress. She said the treatment nurse should be responsible for the resident's weight settings. She said the mattress setting needed to be correct to prevent further pressure ulcer injury. She said wrong mattress setting placed the residents at risk for more damage to the skin and contractures. <BR/>On 10/17/24 at 11:48 a.m., called and left voicemail for LVN J. A return phone call was not received before or after exit. <BR/>During an interview on 10/17/24 at 2:05 p.m., Regional RN FF said the treatment nurse should check the resident's pressure relieving mattress settings daily. She said the correct mattress settings were important because there was a reason the resident was on the LAL mattress, and it needed to function correctly. She said the wrong mattress settings could cause skin issues. She said the DON should ensure the treatment nurse was monitoring LAL mattress settings. She said she expected nursing staff to document wound care dressing changes on the MAR/TAR. She said the treatment nurse or charge nurse should perform the dressing changes every shift or as ordered. She said if the treatment was not documented on the MAR/TAR, it could imply, it was not done. She said not performing wound care as ordered could lead to decreased wound healing, infection, and delayed wound healing. She said the DON should review the MAR/TARs daily to ensure the residents with wounds had scheduled wound care done. <BR/>During an interview on 10/17/24 at 2:58 p.m., the Interim ADM said the wound care nurse or LVNs should perform the resident's ordered wound care treatment. She said the treatment should be documented on the MAR/TAR by the treatment nurse or LVN. She said if the treatment was not documented, it was not done. She said not doing a resident's ordered treatments could cause infection, poor healing, and possible loss of a limb. She said the DON should be monitoring documentation. She said the treatment nurse or LVNs should check the resident's mattress settings for the current weight of the resident. She said the correct weight setting was important to protect the wound and better healing. She said when the resident had incorrect mattress settings, more skin breakdown could happen, or the pressure ulcer would not heal properly. She said the DON should be doing visual checks and reviewing the charts. <BR/>Record review of a facility's Wound Management revised date 06/2020 indicated .a resident who has a wound will receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure injuries from developing .<BR/>Review of Evaluation of a low-air-loss mattress system in the treatment of patients with pressure ulcers (1995) by M A [NAME], J Oldenbrook, C [NAME], www.pubmed.ncbi.nlm.nih.gov/7612140 was accessed on 10/22/2024 indicated .our observation indicate that use of the low-air-loss mattress system reduces the size and facilitates the healing of previously stable, chronic pressure ulcers .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of a face sheet dated 08/30/23 indicated Resident #79 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves.), contracture (reduce joint mobility and restrict activities of daily living) left and right ankle, stiffness in right and left shoulder, and need for assistance with personal care. <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #79 was understood and understood others. The MDS indicated Resident #79 had minimal difficulty hearing, clear speech, and adequate vision. The MDS indicated Resident #79 had a BIMS score of 11 which indicated moderate cognitive impairment and did not reject care. The MDS indicated Resident #79 required extensive assistance for bed mobility and personal hygiene, and total dependence for dressing, toilet use and bathing. The MDS indicated Resident #79 had limited range of motion bilateral (both)<BR/>upper and lower extremities. The MDS indicated Resident #79 was always incontinent of urinary and bowel. <BR/>Record review of a care plan dated 04/06/23 indicated Resident #79 had an ADL self-care performance deficit related to weakness and nerve damage related to Guillain Barre Syndrome. Intervention included toilet use required 1 staff extensive to dependent participation for toileting.<BR/>Record review of a care plan dated 04/06/23 indicated Resident #79 had bowel and bladder incontinence. Intervention included check the resident as required for incontinence. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes. <BR/>During an interview on 08/28/23 at 12:27 p.m., Resident #79 said she was normally changed at 9:30 a.m. and 3:30 p.m. She said yesterday (08/27/23) she was changed at 4:30 p.m. and not changed again until 5:30 a.m. by CNA E. Resident #79 said when she pushed the call light to be changed, staff made excuses why they could not change you. Resident #79 said CNAs did not make rounds every 2 hours to see if we needed to be changed. She said she was changed around 9:30 a.m. and was currently wet. Resident #79 said she took a water pill in the morning, so she needed to be changed more often. <BR/>During an interview on 08/29/23 at 8:53 a.m., Resident #79 said the last time she was changed was at 8:00 p.m. (08/28/23). She said she did not know who her CNA was today, and she had soaked through her brief and drawsheet. <BR/>During an interview and observation on 08/29/23 at 10:41 a.m., Resident #79 said she still had not been changed. Resident #79's drawsheet she was sitting on was wet with urine. <BR/>During an interview on 08/29/23 at 6:12 p.m., Resident #79 said she had been changed last at 3:30 p.m.<BR/>3. Record review of a face sheet dated 08/30/23 indicated Resident #89 was a [AGE] year-old female and admitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia (is a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide), limitation of activities due to disability, and need for assistance with personal care. <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #89 was understood and understood others. The MDS indicated Resident #89 had clear speech, adequate hearing, and adequate vision. The MDS indicated Resident #89 had a BIMS score of 10 which indicated moderately impaired cognition and did not reject care. The MDS indicated Resident #89 required limited assistance for bed mobility and personal hygiene, extensive assistance for dressing, total dependence for toilet use, bathing, and transfers. The MDS indicated Resident #89 was always incontinent of urinary and bowel. <BR/>Record review of a care plan dated 09/08/22 indicated Resident #89 had ADL self-care performance deficit. Intervention included toilet use required 2 staff participation to use toilet, transfers, and bed mobility. <BR/>Record review of an in-service training report, Incontinent care, dated 08/09/23 at 7:00 p.m. by the DON indicated .are residents on the night shift being changed timely when they have incontinent episodes? . every resident should be checked for incontinent episodes . rounds should be made every 2 hours .check the resident and the linen .change as needed . assist residents with toileting .keep the call light in reach at all times . 12 staff members signed the training. <BR/>During an interview on 08/28/23 at 11:25 a.m., Resident #89 said she was changed one-time on night shift by CNA E. <BR/>During an interview on 08/29/23 at 6:15 p.m., Resident #89 said she was changed one-time on night shift at 5:15 a.m. by CNA E. <BR/>During an interview on 08/30/23 at 9:03 a.m., CNA A said she tried to make rounds every 2 hours to check resident for incontinent episodes. She said on Mondays and Tuesdays she did not get to work until 7:30 am or 8:00 am so her first rounds were after breakfast. CNA A said Resident #79 was extremely wet on 08/29/23 when she changed her. She said Resident #79 told her she had not been changed all night. CNA A said she had started her shift and resident had been wet. She said Resident #79 and Resident #89 had complained about not getting changed at night and I told them to report it to upper management. CNA A said timely incontinent care was important to prevent skin breakdown and odors. <BR/>During an interview on 08/30/23 at 2:07 p.m., LVN D said resident should be changed as needed and every 2 hours. She said CNAs and LVNs were responsible for incontinent care. LVN D said LVNs should ensure resident were getting changed timely. She said it was important to prevent skin breakdown, infection, and pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin). <BR/>During an interview on 08/30/23 at 5:34 p.m., CNA E said she did work Sunday (08/27/23) and Monday (08/28/23) night shift on the 300 hall. She said she provided incontinent care every 2 hours, as needed, or when the resident called. CNA E said she did her last rounds at 4:30 a.m. She said timely incontinent care was important to prevent skin irritation and breakdown. <BR/>During an interview on 08/31/23 at 8:20 a.m., LVN C said resident should be changed every 2 hours and as needed. She said CNAs and LVNs were responsible for changing residents. LVN C said LVNs should ensure CNAs changed residents timely. She said timely changing was important for infection control, notice skin issues, hygiene, and dignity. <BR/>During an interview on 08/31/23 at 9:45 a.m., the DON said resident should be rounded on every 2 hours and as needed to check for incontinent episodes. She said CNAs and LVNs were responsible for timely incontinent care. The DON said LVNs should ensure resident were changed timely. She said managers should oversee the process by checking ADL sheets and rounding daily. The DON said incontinence care was important for hygiene, cleanliness, and skin care.<BR/>During an interview on 08/31/23 at 10:41 a.m., the ADM said resident should be changed as needed and when requested by the CNAs. He said it was important for infection control and identifying skin breakdown. The ADM said charge nurses and mangers should ensure timely incontinent care happened when requested and as needed.<BR/>Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 3 of 4 resident (Resident #5, #79, and #89) reviewed for incontinence and urinary catheters.<BR/>The facility failed to ensure Resident #5 had a physician's order for her indwelling urinary catheter with appropriate diagnosis for use. <BR/>The facility failed to provide timely incontinence care to Resident #79 and Resident #89. <BR/>These failures could place residents at risk for not receiving appropriate care, infections, skin breakdown and decreased quality of life. <BR/>Findings included: <BR/>1. Record review of Resident #5's face sheet dated 08/30/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (memory loss), neuromuscular dysfunction of bladder (bladder dysfunction caused by nervous system conditions), diabetes mellitus (a group of diseases that result in too much sugar in the blood) and essential hypertension (high blood pressure).<BR/>Record review of Resident #5's order summary report dated 08/30/23, did not indicate resident had an order for her indwelling urinary catheter. <BR/>Record review of Resident #5's comprehensive care plan revised on 03/24/23, indicated she had an indwelling catheter related to neurogenic bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition). The care plan interventions included to position catheter bag and tubing below the level of the bladder. <BR/>Record review of Resident #5's Admission/readmission Evaluation dated 07/26/23, indicated Resident #5 had a 16 French 10ml catheter.<BR/>Record review of Resident #5's annual MDS assessment dated [DATE], indicated Resident #5 had unclear speech, was usually understood, and usually understood others. The MDS indicated Resident #5 had a BIMS score of 5, which indicated her cognition was severely impaired. The MDS indicated Resident #5 required extensive assistance with bed mobility, dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #5 had an indwelling catheter.<BR/>During an observation on 08/28/23 at 10:58 AM, Resident #5 was lying in her bed. Resident #5 had her foley catheter hanging on the right side of the bed and was covered. <BR/>During an interview on 08/30/23 at 4:19 PM, ADON O said if a resident had a foley catheter then they should have an order for care and maintenance. ADON O said the nurse was responsible for ensuring the order for the foley catheter was placed in the resident's EMR. <BR/>During an interview on 08/30/23 at 04:50 PM, the Administrator said he expected a resident that had a foley catheter to have an order in place to provide care. The Administrator said not having an order could cause an adverse reaction. The Administrator said the charge nurse was responsible for ensuring the order for the foley catheter was in place.<BR/>During an interview on 08/30/23 at 05:22 PM, the DON said she expected a resident who had a foley catheter to have an order in place for care. The DON said the nurses were responsible for ensuring the resident had an order in place. The DON said the administrative nurses reviewed orders on any new admissions, readmissions or if there was a change.<BR/>During an interview on 08/31/23 at 08:48 AM, LVN CC said Resident #5 should have had an order for her foley catheter indicating the reason for the catheter use and catheter size. LVN CC said she was the nurse who readmitted Resident #5 on 07/26/23 and Resident #5 had a catheter upon admission. LVN CC said she must have missed inputting the order for Resident #5's catheter. LVN CC said she was the person responsible for ensuring Resident #5 had an order for her catheter. LVN CC said Resident #5 not having an order for her catheter with appropriate diagnoses could have caused her to have a UTI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 19 residents reviewed for respiratory care. (Resident #18, Resident #53).<BR/>The facility failed to properly store suction device (oral suctioning tool to clear the airway) and date tubing for Resident #18.<BR/>The facility failed to properly store a handheld nebulizer (HHN) and date tubing for Resident #53.<BR/>These failures could place residents who required respiratory care at risk for respiratory infections. <BR/>Findings included: <BR/>1. Record review Resident #18's face sheet dated 07/13/22 indicated Resident #18 was an [AGE] years old male, admitted to the facility with diagnoses of CVA (a stroke- is an interruption in the flow of blood to cells in the brain), Dysphagia (difficulty swallowing), Diabetes Mellitus (group of diseases that affect how your body uses blood sugar), Atrial Fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), and hypertension (high blood pressure).<BR/>Record review of Resident #18's most recent comprehensive MDS, dated [DATE], indicated Resident #18 rarely made himself understood and was rarely understood by others. Resident #18's brief interview for mental status score was not completed. The MDS indicated Resident #18 required extensive assist with bed mobility, dressing, eating, toileting, personal hygiene, and bathing. <BR/>Record review of the care plan dated 07/14/22 for Resident #18 indicated he required the use of a suction device for oral care, to remove secretion from his mouth due to cognitive impairment. The goal was to use suction machine with suction device to remove oral secretions.<BR/>Record review of physician's ordered dated 07/13/22 for Resident #18 indicated: May use suction device to suction secretions from cheeks while performing oral care and change suction device and tubing to suction machine Q week on Sunday and PRN.<BR/>During an observation on 07/12/22 at 8:34 a.m., revealed Resident #18's suction canister with about 500ml of blueish white liquid substance in color and the suction device tubing with no date and not bagged.<BR/>During an observation on 07/12/22 at 12:35 p.m., revealed Resident #18's suction canister with about 550 ml of blueish white liquid substance and the suction device tubing with no date and not in bag.<BR/>During an observation and interview on 07/13/22 at 9:55 a.m., revealed Resident #18's suction device tubing in a drawer without a cover and remained with no date. LVN K was in the room at this time and looked to verify the suction device tubing in the drawer with no date and not bagged. LVN K said the suction device tubing should be dated and, in a bag, when not in use and the suction canister and tubing should be changed on Saturday or Sunday nights. LVN K said having the suction device tubing in a bag would reduce the risk of getting a respiratory infection. <BR/>During an interview on 07/14/22 at 8:47 a.m., LVN M said she suctioned Resident #18 at least daily on her 7am-7pm shift. LVN M said she changes the set up on her first assigned day to work but it was ordered to be changed every Sunday night. LVN M said the suction device tubing should be kept in a bag to prevent respiratory infection.<BR/>2. Record review of the resident #53's face sheet dated 07/14/22 indicated Resident #53 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses of Schizophrenia (a serious mental disorder in which people interpret reality abnormally), COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing), Hypertension (high blood pressure), and Diabetes Mellitus. <BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #53 made herself understood and could understand others. Resident #53 had a BIMS score of 12 which indicated he was cognitively intact. The MDS indicated Resident #53 required total assist with bathing; extensive assist with bed mobility, dressing, toileting, personal hygiene; and set up for eating.<BR/>Record review of a Physician's order dated 07/14/22 indicated to give Ipratropium-Albuterol Solution 0.5-2.5mg/3ml vial, inhale orally every 6 hours for shortness of breath. Change nebulizer mask and tubing every Friday night.<BR/>Record review of care plan dated 02/04/22 indicated that Resident #53 had shortness of breath and diagnosis of COPD and asthma. Staff approach indicated: give aerosol or bronchodilators as ordered.<BR/>During an observation on 07/11/22 at 11:47 a.m., revealed Residents #53's HHN with no date on the tubing and was not bagged.<BR/>During an observation on 07/12/22 at 2:47 p.m., revealed Residents #53's HHN with no date on the tubing.<BR/>During an observation and interview on 07/13/22 at 10:06 a.m., revealed Residents #53's HHN nebulizer tubing was out of the bag with no date and the on bedside table. LVN K came to the room and verified the tubing was not dated and on the bedside table. LVN K said if tubing was not bagged it could cause a respiratory infection.<BR/>During an observation and interview on 07/14/22 at 8:47 a.m., LVN M went into Resident #53's room and verified that the HHN nebulizer tubing was not dated. LVN M said they would date the tubing and place back in bag when they finished to prevent infection. <BR/>During an interview on 07/14/22 at 9:30 a.m., the ADON H said tubing should be changed weekly some are on Friday's and some are Sundays; they should have an order for which date to change them. Vents are different. The ADON H said nurses are supposed to date and placed in a bag to prevent bacteria and germs. <BR/>During an interview on 07/14/22 at 9:55 a.m., LVN L said tubing should be changed every Sunday night. LVN L said nurses should put the date on them and place in a bag to keep away germs.<BR/>During an interview on 07/14/22 at 2:02 p.m., the DON said all tubing are scheduled to be changed on the MAR for Sunday nights. The DON said they do not have a policy on suction device or HHN tubing, but she expects tubing to be dated and properly stored. The DON said they have department heads who do ambassador rounds daily and nurse managers are to follow up to make sure they are dated and properly stored. The DON said failure to keep the tubing in bags could lead to illness related to bacteria.<BR/>During an interview on 07/14/22 at 1:29 p.m., the ADM said all tubing should be in a bag and dated. The ADM said he expected the ADON and DON to follow the protocol and failure to follow could lead to infection control issues. <BR/>Record review of the suctioning policy dated May 2017 indicated, It is the policy of this home that oral suctioning of a resident's mouth, pharynx and nasopharynx will be provided to remove mucus, drainage or salvia away from the resident's airway.<BR/>Record review of the aerosol therapy (hand0held Nebulizer) policy dated 04/18/16 indicated, the respiratory therapist or licensed nurse will provide .hand-held nebulizer therapy as ordered by physician The order should include medication, dose and frequency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of a face sheet dated 08/30/23 indicated Resident #23 was [AGE] year-old female and admitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), hypertension (high blood pressure), atherosclerotic heart disease (is caused by plaque buildup in the wall of the arteries that supply blood to the heart), nonrheumatic mitral valve stenosis (is the heart valve that controls the flow of blood from the heart's left atrium to the left ventricle), congestive heart failure (occurs when the heart muscle doesn't pump blood as well as it should), and aortocoronary bypass graft (also called heart bypass surgery, is a medical procedure to improve blood flow to the heart).<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #23 was understood and understood others. The MDS indicated Resident #23 had adequate hearing, clear speech, and impaired vision. The MDS indicated Resident #23 had a BIMS score of 15 which indicated intact cognition and only required supervision for dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #23 was always continent for urinary and bowel. The MDS indicated Resident #23 received a diuretic during the last days of the assessment period. <BR/>Record review of a care plan dated 06/29/21 indicated Resident #23 had hypertension. Intervention included give anti-hypertensive medications as ordered. <BR/>Record review of a care plan dated 06/29/21 indicated Resident #23 had diabetes mellitus. Intervention included diabetes medication as ordered by doctor.<BR/>Record review of a care plan dated 06/29/21 indicated Resident #23 had altered cardiovascular (relating to the heart and blood vessels) status as evidence by recent coronary artery bypass graft x2 (heart bypass surgery) due to myocardial infarction (heart attack). <BR/>Record review of Resident #23's consolidated physician order dated 06/24/21 indicated Clopidogrel Bisulfate (is an antiplatelet medicine. This means it reduces the risk of blood clots forming) 75mg, give 1 tablet by mouth in the morning for cardiovascular disease.<BR/>Record review of Resident #23's consolidated physician order dated 08/02/21 indicated Metformin tablet (is used to treat high blood sugar levels that are caused by a type of diabetes mellitus or sugar diabetes called type 2 diabetes) 500mg, give 1 tablet by mouth one time a day related to type 2 diabetes.<BR/>Record review of Resident #23's consolidated physician order dated 09/08/21 indicated Entresto (is a brand-name oral tablet prescribed to treat certain types of heart failure) tablet 24-26 MG, give 1 tablet by mouth by mouth two times a day related to congestive heart failure.<BR/>Record review of Resident #23's consolidated physician order dated 10/10/22 indicated Furosemide (Lasix; is used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease) 20mg, give 1 tablet by mouth one time a day for edema.<BR/>Record review of Resident #23's consolidated physician order dated 03/24/23 indicated Metoprolol Succinate Extended Release (is a beta-blocker used to treat chest pain (angina), heart failure, and high blood pressure) 24-hour 25mg, give 0.5 tablet by mouth in the morning for hypertension. <BR/>Record review of Resident #23's Electronic MAR indicated Clopidogrel Bisulfate 75MG scheduled for 8:00 a.m. indicated the following late administrations:<BR/>*08/19/23 at 3:41 p.m. by LVN D<BR/>*08/21/23 at 9:37 a.m. by LVN D<BR/>*08/22/23 at 11:29 a.m. by LVN C<BR/>*08/23/23 at 10:33 a.m. by LVN C<BR/>*08/24/23 at 9:19 a.m. by LVN D<BR/>*08/25/23 at 9:13 a.m. by LVN D<BR/>*08/27/23 at 10:46 a.m. by LVN C<BR/>*08/28/23 at 9:30 a.m. by LVN C<BR/>Record review of Resident #23's Electronic MAR indicated Metformin tablet 500mg scheduled for 8:00 a.m. indicated the following late administrations: <BR/>*08/19/23 at 3:41 p.m. by LVN D<BR/>*08/21/23 at 9:37 a.m. by LVN D<BR/>*08/22/23 at 11:29 a.m. by LVN C<BR/>*08/23/23 at 10:33 a.m. by LVN C<BR/>*08/24/23 at 9:19 a.m. by LVN D<BR/>*08/25/23 at 9:13 a.m. by LVN D<BR/>*08/27/23 at 10:46 a.m. by LVN C<BR/>*08/28/23 at 9:30 a.m. by LVN C<BR/>Record review of Resident #23's Electronic MAR indicated Entresto 24-26mg scheduled for 8:00 a.m. and 7:00 p.m. indicated the following late administrations:<BR/>*08/19/23 at 3:41 p.m. by LVN D<BR/>*08/21/23 at 9:37 a.m. by LVN D<BR/>*08/22/23 at 11:29 a.m. by LVN C<BR/>*08/23/23 at 10:33 a.m. by LVN C<BR/>*08/24/23 at 9:19 a.m. by LVN D<BR/>*08/25/23 at 9:13 a.m. by LVN D<BR/>*08/27/23 at 10:46 a.m. by LVN C<BR/>*08/28/23 at 9:30 a.m. by LVN C<BR/>Record review of Resident #23's Electronic MAR indicated Furosemide 20mg scheduled for 9:00 a.m. indicated the following late administrations:<BR/>*08/19/23 at 3:41 p.m. by LVN D<BR/>*08/22/23 at 11:30 a.m. by LVN C<BR/>*08/23/23 at 10:34 a.m. by LVN C<BR/>*08/27/23 at 10:47 a.m. by LVN C<BR/>Record review of Resident #23's Electronic MAR indicated Metoprolol Succinate Extended Release 24-hour 25mg scheduled for 8:00 a.m. indicated the following late administrations:<BR/>*08/17/23 at 10:20 a.m. by LVN C<BR/>*08/18/23 at 11:31 a.m. by LVN C<BR/>*08/21/23 at 9:37 a.m. by LVN D<BR/>*08/22/23 at 11:29 a.m. by LVN C<BR/>*08/23/23 at 10:33 a.m. by LVN C<BR/>*08/24/23 at 9:19 a.m. by LVN D<BR/>*08/25/23 at 9:13 a.m. by LVN D<BR/>*08/27/23 at 10:46 a.m. by LVN C<BR/>*08/28/23 at 9:30 a.m. by LVN C<BR/>During an interview on 08/29/23 at 8:41 a.m., Resident #23 said her medication were given late sometimes. <BR/>4. Record review of a face sheet dated 08/30/23 indicated Resident #79 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves.), contracture (reduce joint mobility and restrict activities of daily living) left and right ankle, chronic pain syndrome (is a common problem that presents a major challenge to health-care providers because of its complex natural history, unclear etiology, and poor response to therapy), and mood affective disorder (is a mental health condition that primarily affects your emotional state).<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #79 was understood and understood others. The MDS indicated Resident #79 had minimal difficulty hearing, clear speech, and adequate vision. The MDS indicated Resident #79 had a BIMS score of 11 which indicated moderate cognitive impairment and did not reject care. The MDS indicated Resident #79 required extensive assistance for bed mobility and personal hygiene, and total dependence for dressing, toilet use and bathing. The MDS indicated Resident #79 was always incontinent of urinary and bowel. The MDS indicated Resident #79 received scheduled pain medication regimen. The MDS indicated Resident #79 received 7 days of an anticoagulant, antidepressant, and opioid during the assessment period. <BR/>Record review of a care plan dated 04/06/23 indicated Resident #79 had GERD (Gastroesophageal reflux disease; is a common condition in which the stomach contents move up into the esophagus). Intervention included give medications as ordered. <BR/>Record review of a care plan dated 04/06/23 indicated Resident #79 was on anticoagulant (are medicines that help prevent blood clots) therapy related to atrial fibrillation (is an irregular and often very rapid heart rhythm). Intervention included monitor/document/report to MD as needed signs and symptoms of complications. <BR/>Record review of a care plan dated 04/06/23 indicated Resident #79 required pain management related to neuropathy (refers to any condition that affects the nerves outside your brain or spinal cord) and chronic pain syndrome. Intervention included anticipate resident's need for pain relief and respond immediately to any complaint of pain. <BR/>Record review of a care plan dated 04/06/23 indicated Resident #79 required antidepressant medication for diagnosis of depression. Intervention included give antidepressant medications ordered by physician.<BR/>Record review of Resident #79's consolidated physician order dated 03/21/23 indicated Eliquis (is used to lower the risk of stroke or a blood clot in people with a heart rhythm disorder called atrial fibrillation) Oral Tablet 5mg (Apixaban), give 1 tablet by mouth two times a day for AFIB. <BR/>Record review of Resident #79's consolidated physician order dated 04/04/23 indicated Hydrocodone-Acetaminophen (combine to treat moderate pain) Oral Tablet 10-325mg, give 1 tablet by mouth three times a day for chronic pain. <BR/>Record review of Resident #79's consolidated physician order dated 06/12/23 indicated Metoclopramide (is a medication that treats the symptoms of gastroesophageal reflux disease (GERD)) HCL Oral Tablet 5mg, give 5mg by mouth four times a day for GERD.<BR/>Record review of Resident #79's consolidated physician order dated 06/12/23 indicated Venlafaxine (is used to treat depression) HCL Oral Tablet 75mg, give 75mg by mouth two times a day for depression.<BR/>Record review of Resident #79's consolidated physician order dated 08/15/23 indicated Lasix (is used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease) Oral tablet 20mg (Furosemide), give 1 tablet by mouth one time a day for edema. <BR/>Record review of Resident #79's Electronic MAR indicated Eliquis Oral Tablet 5mg scheduled for 8:00 a.m. and 7:00 p.m. indicated the following late administrations:<BR/>*08/15/23 at 9:43 a.m. by LVN D<BR/>*08/16/23 at 9:23 a.m. by LVN D<BR/>*08/17/23 at 10:33 a.m. by LVN C<BR/>*08/18/23 at 11:26 a.m. by LVN C<BR/>*08/19/23 at 3:45 p.m. by LVN D<BR/>*08/20/23 at 10:07 a.m. by LVN D<BR/>*08/21/23 at 10:13 a.m. by LVN D<BR/>*08/21/23 at 8:45 p.m. by LVN BB<BR/>*08/22/23 at 11:33 a.m. by LVN C<BR/>*08/23/23 at 12:25 p.m. by LVN C<BR/>*08/24/23 at 10:20 a.m. by LVN D<BR/>*08/25/23 at 10:08 a.m. by LVN D<BR/>*08/27/23 at 10:24 a.m. by LVN C<BR/>*08/28/23 at 10:27 a.m. by LVN C<BR/>*08/29/23 at 9:23 a.m. by LVN C<BR/>Record review of Resident #79's Electronic MAR indicated Hydrocodone-Acetaminophen Oral Tablet 10-325mg scheduled for 9:00 a.m., 5:00 p.m. and 1:00 a.m. indicated the following late administrations:<BR/>*08/16/23 at 3:51 a.m. by LVN BB<BR/>*08/17/23 at 10:33 a.m. by LVN C<BR/>*08/18/23 at 2:22 a.m. by ADON K<BR/>*08/18/23 at 11:26 a.m. by LVN C<BR/>*08/19/23 at 3:45 p.m. by LVN D<BR/>*08/20/23 at 6:38 p.m. by LVN D<BR/>*08/21/23 at 2:13 a.m. by LVN BB<BR/>*08/21/23 at 7:30 p.m. by LVN D<BR/>*08/22/23 at 3:33 a.m. by LVN BB<BR/>*08/22/23 at 11:34 a.m. by LVN C<BR/>*08/23/23 at 12:25 p.m. by LVN C<BR/>*08/24/23 at 10:21 a.m. by LVN D<BR/>*08/25/23 at 3:15 a.m. by LVN BB<BR/>*08/25/23 at 7:20 p.m. by LVN BB<BR/>*08/ 27/23 at 10:25 a.m. by LVN C<BR/>*08/28/23 at 10:27 a.m. by LVN C<BR/>*08/29/23 at 4:38 a.m. by ADON K<BR/>Record review of Resident #79's Electronic MAR indicated Lasix Oral tablet 20mg scheduled for 9:00 a.m. indicated the following late administrations:<BR/>*08/17/23 at 10:33 a.m. by LVN C<BR/>*08/18/23 at 11:26 a.m. by LVN C<BR/>*08/19/23 at 3:45 p.m. by LVN D<BR/>*08/21/23 at 10:13 a.m. by LVN D<BR/>*08/22/23 at 11:34 a.m. by LVN C<BR/>*08/23/23 at 12:25 p.m. by LVN C<BR/>*08/24/23 at 10:21 a.m. by LVN D<BR/>*08/27/23 at 10:25 a.m. by LVN C<BR/>*08/28/23 at 10:27 a.m. by LVN C<BR/>Record review of Resident #79's Electronic MAR indicated Metoclopramide HCL Oral Tablet 5mg scheduled for 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. indicated the following late administrations:<BR/>*08/15/23 at 9:43 a.m. by LVN D<BR/>*08/15/23 at 1:22 p.m. by LVN D<BR/>*08/16/23 at 9:23 a.m. by LVN D<BR/>*08/17/23 at 12:42 a.m. by LVN BB<BR/>*08/17/23 at 10:33 a.m. by LVN C<BR/>*08/18/23 at 11:26 a.m. by LVN C<BR/>*08/19/23 at 3:45 p.m. by LVN D (due at 8:00 a.m.)<BR/>*08/19/23 at 3;45 p.m. by LVN D (due at 12:00 p.m.)<BR/>*08/20/23 at 10:07 a.m. by LVN D<BR/>*08/20/23 at 3:24 p.m. by LVN D (due at 12:00 p.m.)<BR/>*08/21/23 at 10:13 a.m. by LVN D<BR/>*08/21/23 at 7:30 p.m. by LVN D (due at 12:00 p.m.)<BR/>*08/22/23 at 11:33 a.m. by LVN C (due at 8:00 a.m.)<BR/>*08/23/23 at 12:25 p.m. by LVN C (due at 8:00 a.m.)<BR/>*08/24/23 at 10:20 a.m. by LVN D (due at 8:00 a.m.)<BR/>*08/24/23 at 2:13 p.m. by LVN D<BR/>*08/25/23 at 10:08 a.m. by LVN D<BR/>*08/25/23 at 2:39 p.m. by LVN D<BR/>*08/25/23 at 7:20 p.m. by LVN BB (due at 4:00 p.m.)<BR/>Record review of Resident #79's Electronic MAR indicated Venlafaxine HCL Oral tablet 75mg scheduled for 8:00 a.m. and 5:00 p.m. indicated the following late administrations:<BR/>*08/15/23 at 9:43 a.m. by LVN D<BR/>*08/16/23 at 9:23 a.m. by LVN D<BR/>*08/17/23 at 10:33 a.m. by LVN C<BR/>*08/18/23 at 11:26 a.m. by LVN C<BR/>*08/19/23 at 3:45 p.m. by LVN D<BR/>*08/20/23 at 10:07 a.m. by LVN D<BR/>*08/20/23 at 6:38 p.m. by LVN D<BR/>*08/21/23 at 10:13 a.m. by LVN D<BR/>*08/21/23 at 7:30 p.m. by LVN D<BR/>*08/22/23 at 11:33 a.m. by LVN C<BR/>*08/23/23 at 12:25 p.m. by LVN C<BR/>*08/24/23 at 10:21 a.m. by LVN D<BR/>*08/24/23 at 6:54 p.m. by LVN D<BR/>*08/25/23 at 10:08 a.m. by LVN D<BR/>*08/25/23 at 7:20 p.m. by LVN BB<BR/>*08/27/23 at 10:24 a.m. by LVN C<BR/>*08/28/23 at 10:27 a.m. by LVN C<BR/>*08/29/23 at 9:23 a.m. by LVN C<BR/>During an interview on 08/28/23 at 12:27 p.m., Resident #79 said her medication were not given on time. She said she did not get her morning medication until around 9:30 a.m. or 10:00 a.m. and her evening medications were late also. <BR/>During an interview on 08/30/23 at 2:07 p.m., LVN D said she documented her medication administration as she was passing medications or in real time. She said timed medications were allowed to be given 1 hour before or 1 hour after scheduled time. LVN D said if a medication said daily or in the AM/PM then it could be given between 7am-10am or 7pm-10pm. LVN D said residents did complain about their medication being given late. She said medication should be given at the ordered time to follow the facility's policy and to ensure the next dosage could be given at the right time. LVN D said the managers and DON should oversee LVNs to ensure medications were given on schedule. <BR/>During an interview on 08/31/23 at 8:20 a.m., LVN C said she pulled her medications, compared label with order, verified correct resident then administrated and documented on the electronic MAR. She said scheduled medication should be given 1 hour before or 1 hour after to be considered on time. LVN C said she had given late medications because sometimes crisis happened. She said it depended on the medication if it was an issue given multiple doses to close together. LVN C said sometime medication had to be given early or late to get the medication back on schedule. She said it was important to give scheduled medication on time because the body was used to get it at a certain time, and it could be a specific reason why it was ordered at that time. She said the managers and DON should oversee LVNs to ensure medications were given on schedule.<BR/>During an interview on 08/31/23 at 9:45 a.m., the DON said nurses should document medication given immediately after administration. She said scheduled medication should be given 1 hour before or 1 hour after to be considered on time. The DON said LVNs were responsible for timely medication administration. She said managers should review records randomly and weekly to ensure LVNs were administrating medication on time. The DON said it was important to administrate medication timely to provide better care to the residents. <BR/>During an interview on 08/31/23 at 10:41 a.m., the Administrator said medications should be passed as indicated. He said LVNs were responsible for timely medication administration. The Administrator said late medication could result in adverse reaction and cause change in a resident condition. <BR/>Record review of a facility General Guidelines for Medication Administration revised date 08/20 indicated .a schedule of routine dose administration times is established by the facility and utilized on the administration record .medications are administered within 60 minutes of the scheduled administration time .<BR/>Record review of facility's policy Controlled Substances revised on 08/2020, indicated .Medications classified as controlled substances by the Drug Enforcement Administration (DEA) are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with state and federal laws and regulations . 5. Accurate inventory of all controlled medications is maintained at all times. When a controlled substance is administered, the licensed nursing personnel administering the medication immediately enters the following information on the accountability record and the Medication Administration Record (MAR): a. Date and time of administration (MAR and Accountability Record) b. Amount administered (Accountability Record) c. Remaining quantity (Accountability Record) d. Signature of the nursing personnel administering the dose (Accountability Record) e. Initials of the nurse administering the dose, completed after the medication has been administered (MAR). 6. When a dose of a controlled medication is removed from the container of administration but is refused by the resident or not given for any reason, the dose is not placed back in inventory. The dose must be destroyed according to facility policy and the disposal documented on the accountability record on the line representing that dose .<BR/>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 4 of 6 residents (Resident #s 9, 68, 23, 79) reviewed for pharmacy services.<BR/>ADON K failed to ensure she had a witness when wasting Resident #9's acetaminophen-codeine 300-60mg tablet (controlled medication used for pain). <BR/>The facility failed to ensure Resident #68's Lorazepam (controlled antianxiety medication) was accurately reconciled.<BR/>The facility failed to administer Resident #23 and Resident #79's scheduled medication per the facility's policy timeframe.<BR/>These failures could place the residents at risk of not having medications available for use, not receiving medications, and drug diversion. <BR/>Findings include:<BR/>1. Record review of Resident #9's face sheet dated 08/30/23, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of encephalopathy (brain disease that alters brain function or structure), dementia (memory loss), pain, and anxiety.<BR/>Record review of Resident #9's quarterly MDS assessment dated [DATE], indicated she rarely/never understood or understood others. The MDS indicated Resident #9's staff assessment for mental status indicated Resident #9 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #9 was totally dependent on staff for bed mobility, dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #9 did not receive any opioid medications within the last 7 days of the look back period.<BR/>Record review of Resident #9's order summary report dated 08/30/23, indicated the following orders:<BR/>*Acetaminophen-codeine 300-60mg: give 1 tablet via gastrostomy tube (tube inserted through the belly) four times a day for chronic pain with a start date of 12/23/21.<BR/>*Acetaminophen-codeine 300-60mg: give 1 tablet via gastrostomy tube every 4 hours as needed for pain with a start date of 12/23/21.<BR/>Record review of Resident #9's undated comprehensive care plan indicated she had a potential for pain related to diagnoses of diabetes (group of diseases that result in too much sugar in the blood), osteoporosis (condition in which bones become weak and brittle), and chest pain. The care plan also indicated Resident #9 received pain medications as needed. The care plan interventions indicated to administer analgesia (pain reliever) as per orders and to monitor/document for side effects of pain medications. <BR/>During an observation and interview at 08:59 AM, ADON K and LVN V were counting the narcotic medications for the medication cart for hall 300 rooms 316-331 as ADON K was ending her shift. During the count, Resident #9's controlled administration record for acetaminophen-codeine tablet indicated Resident #9 had 31 tablets left. The medication card for acetaminophen-codeine tablet indicated she had 30 tablets left. This indicated 1 tablet of acetaminophen-codeine was missing. ADON K said she told LVN AA she had dropped Resident #9's acetaminophen-codeine tablet last night and needed her to come and sign as a witness. ADON K said Resident #9's medication was given crushed, so she had to obtain another tablet because it had spilled on the floor. ADON K said she did not get LVN AA to sign the controlled medication records, as she had been busy all night and forgot when LVN AA arrived at the floor. <BR/>Record review of Resident #9's controlled administration record for acetaminophen-codeine 300-60mg tablet dated 08/15/23-08/29/23, indicated ADON K signed out one tablet at 0200 (2 AM) on 08/29/23 with 31 tablets remaining. The controlled administration record did not indicate any medication was wasted or witnessed. <BR/>During an interview on 08/29/23 at 11:03 AM, the DON said she would expect the nurses to notify her of any narcotic medication discrepancies immediately. The DON said ADON K was coming to talk to her about what had happened. The DON said ADON K should have had another nurse sign as a witness that the medication had been wasted at the time the incident occurred. The DON said ADON K was responsible for notifying her of the wasted medication.<BR/>During an interview on 08/29/23 at 6:10 PM, LVN AA said she was not called by ADON K last night to sign as a witness for a medication that had been wasted and did not witness a medication being wasted by ADON K. <BR/>During an interview on 08/29/23 at 6:21 PM, the DON said she was aware of LVN AA not witnessing ADON K wasting Resident # 9's acetaminophen-codeine tablet. The DON said she had started her investigation as per the facility's policy.<BR/>2. Record review of Resident #68's face sheet dated 08/30/23, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included seizures, anxiety, gastro-esophageal reflux disorder (digestive disease in which stomach acid or bile irritates the food pipe lining), and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). <BR/>Record review of Resident #68's comprehensive care plan revised on 01/09/23, indicated she required psychotropic medications for diagnoses of affective mood disorder, anxiety, and depression. The care plan interventions indicated to administer medications as ordered and to monitor side effects and effectiveness. <BR/>Record review of Resident #68's quarterly MDS assessment dated [DATE], indicated she usually made herself understood and understood others. The MDS indicated Resident #68 had a BIMS score of 13, indicating her cognition was intact. The MDS indicated #68 required supervision with all ADLs. The MDS indicated Resident #68 had received antianxiety medications 6 days of the 7 day look back period.<BR/>Record review of Resident #68's order summary report dated 08/30/23, indicated she had an order for lorazepam 1 mg give one tablet by mouth in the evening for anxiety disorder with a start date of 04/20/23.<BR/>During an observation and interview on 08/29/23 at 10:24AM, the middle hall short cart was reviewed for accuracy for reconciliation of narcotic medications and was noted Resident #68's Lorazepam 1mg medication card indicated she had 14 tablets left. The controlled drug administration record for Lorazepam 1mg indicated she had 13 tablets remaining. LVN R and LVN G corrected the count by making a line through the administration dated for 08/28/23 at 8:00 PM making the count correct. LVN R said it appeared Resident #68 did not receive her Lorazepam on 08/28/23 at 8:00 PM as Resident #68 had an extra tablet. LVN R said she counted the cart with the LVN U that morning and she did not know how that was missed. <BR/>Record review of Resident #68's controlled drug administration record for lorazepam 1 mg tablet dated 08/12/23-08/28/23, indicated LVN U signed out she administered one tablet on 08/28/23 at 8:00 PM with 13 tablets remaining.<BR/>Record review of Resident #68's MAR for August 2023, indicated Lorazepam 1mg was administered at 8:00 PM on 08/28/23 by LVN U.<BR/>During an interview on 08/29/23 at 11:03 AM, the DON said if there was an extra tablet in the packet then it was considered as the medication was not given. <BR/>During an interview on 08/30/23 at 1:40 PM, LVN U said she remembered popping the blister pack and said she must have popped the wrong hole. LVN U said she thought she had given Resident #68 her Lorazepam 1mg tablet. LVN U said since there was an extra tablet in the medication card she probably did not administer the Lorazepam to Resident #68 as she was the only one that gave her the Lorazepam. LVN U said was unsure who she counted the medication cart with, but remembers the count being correct when she left. <BR/>During an interview on 08/30/23 at 04:19 PM, ADON O said she expected the DON, medical director, and family to be notified as soon as a medication discrepancy was identified. ADON O said there should be a witness when a nurse wastes a narcotic medication. ADON O said she expected the nurse to find a witness as there was never just one nurse in the building. ADON O said the nurse was responsible for counting the narcotic medications prior to obtaining responsibility of that cart and ensuring the count was correct. <BR/>During an interview on 08/30/23 at 4:50 PM, the Administrator said with a narcotic medication discrepancy he expected the DON to be notified. The Administrator said he expected the nurse to have a witness when wasting a narcotic medication. The Administrator said failure to do so would cause the employee to be suspended pending investigation, notifying HHSC, notifying the medical director, and calling the local authorities. The Administrator said the charge nurse was responsible for counting the medication cart before and at end of shift with the oncoming nurse or the nurse that was leaving. The Administrator said if the narcotic count indicated there was an extra tablet, then the medication was considered as not administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or For excessive duration; or Without adequate monitoring; or Without adequate indication for its use; or In the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 1 of 5 residents (Resident #21) reviewed for unnecessary medications in that: <BR/>The facility failed to ensure Resident #21 had documented diagnoses for the use of Atorvastatin (is used together with a proper diet to lower cholesterol and triglyceride (fats) levels in the blood), Furosemide (is a strong diuretic ('water pill')), Lasix (is a loop diuretic (water pill) that prevents your body from absorbing too much salt, causing it to be passed in your urine), Gabapentin (is a medicine used to treat partial seizures, nerve pain from shingles and restless leg syndrome), Melatonin (is used to combat jet lag and ease sleep problems like insomnia), and Allopurinol (is commonly used to treat gout, which is a form of arthritis caused by too much uric acid in your blood and joints) in her medical records. Atorvastatin was prescribed for hyperlipidemia, Furosemide for heart failure, Gabapentin for neuropathy, Lasix for congestive heart failure, Melatonin for insomnia and Allopurinol for gout. <BR/>This failure could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the use of medicines) and receiving unnecessary medications.<BR/>Findings include:<BR/>Record review of Resident #21's face sheet dared 10/14/24 indicated Resident #21 was a 69-years-old female admitted on [DATE] with diagnoses including need for assistance with personal care, chronic kidney disease (is a long-term condition that occurs when the kidneys are damaged and can't filter blood properly), weakness, pain in right and left shoulder, diabetes mellitus (a group of diseases that affect how the body uses blood sugar (glucose)), and hidradenitis suppurativa (is a painful, long-term skin condition that causes skin abscesses and scarring on the skin). Resident #21 face sheet did not reflect diagnoses of hyperlipidemia, (congestive) heart failure, neuropathy, insomnia, or gout.<BR/>Record review of Resident #21's quarterly MDS assessment dated [DATE] indicated Resident #21 was understood and understood others. Resident #21 had clear speech, adequate hearing, and adequate vision. Resident #21 a BIMS score of 12 which indicated moderate cognitive impairment. Resident #21's MDS assessment did not reflect diagnoses of hyperlipidemia, (congestive) heart failure, neuropathy, insomnia, or gout.<BR/>Record review of Resident #21's undated care plan indicated Resident #21 was on diuretic therapy related to hypertension. Intervention included may cause dizziness, postural hypotension, fatigue, and an increased risk for falls. Observe for possible side effects every shift. Resident #21's care plan did not reflect diagnoses of hyperlipidemia, (congestive) heart failure, neuropathy, insomnia, or gout or being on a medication to treat those diagnoses. <BR/>Record review of Resident #21's consolidated physician order active as of 10/16/24 indicated:<BR/>*Allopurinol Tablet 100mg, give 1 tablet by mouth two times a day for Gout. Ordered date 12/03/22. <BR/>*Atorvastatin Calcium Tablet 20mg, give 1 tablet by mouth at bedtime for Hyperlipidemia. Ordered date 12/03/22.<BR/>*Furosemide Tablet 40mg, give 1 tablet by mouth one time a day for Heart Failure. Ordered date 12/03/22. <BR/>*Gabapentin Capsule 100mg, give 1 capsule by mouth two times a day for Neuropathy. Ordered date 12/17/22. <BR/>*Gabapentin Capsule 400mg, give 1 capsule by mouth at bedtime for Neuropathy pain. Ordered date 12/03/22. <BR/>*Lasix Oral Tablet 20mg (Furosemide), give 1 tablet by mouth in the evening for Congestive Heart Failure. Ordered date 03/09/24.<BR/>*Melatonin Tablet 3mg, give 2 tablets by mouth at bedtime for Insomnia. Ordered date 12/03/22. <BR/>Record review of Resident #21's MAR dated 10/01/24-10/31/24 indicated:<BR/>*Allopurinol Tablet 100mg, give 1 tablet by mouth two times a day for Gout. Ordered date 12/03/22. Resident #21 had received scheduled doses.<BR/>*Atorvastatin Calcium Tablet 20mg, give 1 tablet by mouth at bedtime for Hyperlipidemia. Ordered date 12/03/22. Resident #21 had received scheduled doses.<BR/>*Furosemide Tablet 40mg, give 1 tablet by mouth one time a day for Heart Failure. Ordered date 12/03/22. Resident #21 had received scheduled doses.<BR/>*Gabapentin Capsule 100mg, give 1 capsule by mouth two times a day for Neuropathy. Ordered date 12/17/22. Resident #21 had received scheduled doses.<BR/>*Gabapentin Capsule 400mg, give 1 capsule by mouth at bedtime for Neuropathy pain. Ordered date 12/03/22. Resident #21 had received scheduled doses.<BR/>*Lasix Oral Tablet 20mg (Furosemide), give 1 tablet by mouth in the evening for Congestive Heart Failure. Ordered date 03/09/24. Resident #21 had received scheduled doses. <BR/>*Melatonin Tablet 3mg, give 2 tablets by mouth at bedtime for Insomnia. Ordered date 12/03/22. Resident #21 had received scheduled doses.<BR/>During an interview on 10/17/24 at 9:49 a.m., LVN K said the MDS Coordinator added diagnoses to the resident's medical record. She said when a nurse received an order from the physician, the nurse added the diagnosis the physician said the medication was for. She said the nurse added the diagnosis to the order from what diagnoses were available in the computer system. She said the nurse should notify the MDS Coordinator when a diagnosis needed to be added to the resident's medical records. She said she did not know who was responsible for ensuring the resident's medication had an appropriate or documented diagnosis. She said it was important the resident's medication had a documented or appropriate diagnosis, so staff knew why the resident was taken the medication. She said the residents should only take medications they need. She said Resident #21 had neuropathy from her diabetes. She said she did not know about the other diagnoses not listed on her diagnoses list. <BR/>During an interview on 10/17/24 at 10:28 a.m., ADON A said Resident #51's neuropathy was related to her Type 2 diabetes. She said the facility found an old progress note with the new diagnosis listed. <BR/>During an interview on 10/17/24 at 10:37 a.m., ADON N said he had only been in the ADON position for one week. She said when a resident had a medication with a diagnosis not listed on their profile, staff should review the discharge records or call the NP/ MD to get a diagnosis. She said the staff could also get with the MDS Coordinator if the diagnosis was not on the resident's profile the MD gave the order for. She said it was important to know what the ordered medication was treating. She said certain medications needed lab monitoring and staff could potential not be watching for the desired effect of the medication. She said the ADONs should be monitoring this by doing chart audits. She said the MDS Coordinator was also responsible. She said if it was not clear why a resident was receiving a medication, the resident could be taking an unnecessary medication. <BR/>During an interview on 10/17/24 at 10:45 a.m., the MDS Coordinator V said the MDS Coordinator added diagnoses to the resident's profile upon admission. She said if a resident received a new or missed diagnosis, the nurse needed to notify the MDS Coordinator to add it. She said sometimes the MDS Coordinator meet with the MD to discuss resident's diagnoses that may need to be added. She said a LVN could added an indication for use to a physician order but not a diagnosis. She said she had talked to nursing staff about notify the MDS Coordinator of new diagnoses that needed to add to the resident's diagnosis list. She said it was important for the resident's diagnosis and medication to be correct, so the physician knew what they were treating. She said the diagnosis and medication needed to be accurate because the information was placed on the MDS assessment. She said it was important to make sure the resident was not getting unnecessary medications.<BR/>During an interview on 10/17/24 at 2:05 p.m., Regional RN FF said the MDS Coordinator put in documented diagnoses and got orders from the physician to add new diagnoses. She said the MDS Coordinator and nurse managers were responsible for ensuring a medication had an appropriate or ordered diagnosis. She said the resident's medication and diagnosis had to match because it could lead to an inaccurate assessment. She said if there was no appropriate diagnosis, it could be considered an unnecessary medication. She said the IDT should be reviewing orders daily and during weekly standard of care meetings. <BR/>During an interview on 10/17/24 at 2:58 p.m., the Interim ADM said the MDS Coordinator was responsible for ensuring resident had appropriate diagnoses for medications. She said physician orders were monitored during morning meetings. She said if there was not an appropriate or listed diagnosis for a medication, it could be considered an unnecessary medication. <BR/>Record review of a facility's Ordering and Receiving Non-Controlled Medications revised date 08/2020 indicated .medications orders .or entered into the facility's EMR system and transmitted to the pharmacy .the written entry includes .indication for use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 14.81%, based on 4 errors out of 27 opportunities, which involved 2 of 5 residents (Resident #39, Resident #90) reviewed for medication administration. <BR/>1. <BR/>The facility failed to administer Resident # 39's [NAME] vitamin B-complex (contains essential vitamins such as B-complex, vitamin C, and folic acid, which help manage or prevent deficiencies common in individuals with compromised renal function.) and administered incorrect dose of Vitamin D3 25 mcg (a nutrient your body needs for building and maintaining healthy bones) on 10/15/2024. <BR/>2. <BR/>The facility failed to administer Resident # 90's Oxybutynin (to treat an overactive bladder) and Protonix (a medication used to decrease the amount of acid produced in the stomach as ordered on 10/15/2024. <BR/>These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. <BR/>Findings included:<BR/>Error #1 and #2<BR/>1. Record review of Resident #39's face sheet, dated 10/16/2024, indicated she was an [AGE] year-old female, who was readmitted to the facility on [DATE] , with the diagnoses which cerebral infarction (An ischemic stroke occurs when the blood supply to part of the brain is blocked or reduced ), type II diabetes (refers to a group of diseases that affect how the body uses blood sugar (glucose) , dysphagia (difficulty swallowing) and GERD (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach, called the esophagus).<BR/>Record review of Resident #39's quarterly MDS, dated [DATE], indicated she was rarely or never understood, and no BIMS score indicated. <BR/>Record review of Resident #39's MAR dated 10/1/2024-10/31/2024 indicated Resident #39 was prescribed [NAME]-vitamin to be administered one time daily for supplement. Resident # 39's medication record indicated she was to have Vitamin D3 25 mcg 1000IU administered via PEG tube one time daily for supplement. <BR/>During observation of medication pass on 10/15/2024 at 7:59 AM, RN Y said Resident #39 was out of her [NAME] Vitamin and she administered Vitamin D3 1000 IU via PEG tube with Resident # 39's scheduled medications. RN Y said she was going to reorder the medication and was not sure why it was not reordered. <BR/>Error #3 and #4<BR/>2 Record review of Resident #90's face sheet, dated 10/16/2024, indicated he was a [AGE] year-old male, who was admitted to the facility on [DATE], with the diagnoses which fracture of fifth lumbar vertebra (a fracture of the lumbar spine located in the lower part of the back), muscle weakness, cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech deficit.), and intellectual disabilities (a learning disability characterized by below average intelligence.)<BR/>Record review of Resident #90's quarterly MDS, dated [DATE], indicated he was rarely or never understood by others and BIM score was not completed. <BR/>Record review of Resident #90's MAR dated 10/1/2024-10/31/2024 indicated resident was prescribed oxybutynin chloride Extended release 10 mg, 1 tablet by mouth one time daily for history of traumatic brain injury and protonix delayed release 40 mg, 1 tablet by mouth one time daily for GERD. <BR/>Record review of Resident # 90's undated care plan, indicated the resident had bowel and bladder incontinence and was on a routine medication for overactive bladder. The care plan indicated Resident #90 had GERD with interventions in place for medication to be given as ordered and monitored and document side effects and effectiveness. <BR/>During an interview on 10/17/2024 at 9:30 AM, LVN AA said Resident #39 was prescribed Vitamin D3 (25 mcg) 1000 Units. LVN AA said there were different doses of Vitamin D3 on the cart. LVN AA said the facility was currently out of the [NAME]-Vit B complex vitamin. LVN AA said Resident #39 did not receive her B complex on 10/15/2024 or 10/16/2024. LVN AA said the night shift nurse stocks the cart. LVN AA said she was not sure who was responsible for restocking the vitamins. LVN AA said a resident not receiving the proper dose or vitamin supplement depended on what diagnosis a resident had. She said if a resident missed their supplements, it may delay healing, not get better. <BR/>During an interview on 10/17/2024 at 9:59 AM, ADON N said vitamins and supplements are ordered by central supply and the facility makes sure the nurses have what they need and order. ADON N said the nurses were responsible for verbally notifying and writing it down on a sheet and handing it to central supply. The ADON N said central supply would order or go to the store and pick up supplement, so the residents do not go without vitamins. ADON N said she considered it a med error if a medication was not administered due to being out of the medication. She said if the facility has the medication on the pyxis, the nurse will get it from there. ADON N said the nurses would contact the physician for an alternative. ADON N said the facility would try to get alternative meds. ADON N said it could cause harm, or a resident could get worse if they did not receive a medication that was ordered for them. <BR/>Attempted to contact Central supply but unavailable during interview due to transporting a resident for a Physician appointment. <BR/>During an interview on 10/17/2024 at 11:43 AM, Regional Nurse FF said she expected medications to be ordered in a timely manner. She said she considered the observed medication pass errors if not given or incorrect dose administered. Regional Nurse FF said the central supply is responsible for reordering OTC and supplements. Regional Nurse FF said the floor nurses were responsible for reordering prescribed medications. She said there was a reason why a resident is on the medication. Regional Nurse FF said not taking Protonix could cause GI issues. And Oxybutynin could cause urinary issues. <BR/>During an interview on 10/17/2024 at 12:06 PM, the ADM said the central supply is responsible for ordering the OTC and supplements. She said the nurses were responsible for reordering the prescription medications. Regional Nurse FF said if a resident does not receive medication, they could die or have a change in condition. The ADM said she expected the nurses and central supply to reorder medication prior to a resident running out. <BR/>Record review of the facility's policy Medication Administration undated stated: .To provide practice standards for safe administration of medication for residents in the facility. Medication must be given to the resident by the Licensed Nurse preparing the medication, or as consistent with state law . The licensed nurse must know the following information about any medication they are administering A: The drug name .B. the drug's route of administration . C The drug's action .D. The drug's indication for use and desired outcome .E. The drug's usual dosage .F. The drug's side effects .G. Any precautions and special considerations. VIII. Medication will not be left at the bedside. VIII. Compare the Licensed Practitioner's prescription and order with the MAR. XVII. Holding medications .A. Whenever a medication is held for any reason, the Licensed Nurse will initial the appropriate area on the MAR and circle his/her initials. The Licensed Nurse will document the reason the medication was help on the back of the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 10 residents (Residents #51) reviewed for pharmacy services. <BR/>The facility failed to ensure Resident #51 received Acetaminophen-Codeine Oral Tablet 300-60mg (is used to help relieve mild to moderate pain; Tylenol #4 contains 60 mg of Codeine) as scheduled on 10/13/24 (8am and 3pm) and 10/14/24 (8am). <BR/>This failure could place residents at risk of discomfort and pain.<BR/>Findings included:<BR/>Record review of Resident #51's face sheet dated 10/15/24 indicated Resident #51 was a [AGE] year-old female admitted on [DATE] and 12/08/20 with diagnoses including metabolic encephalopathy (is a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), muscle wasting and atrophy (shortening), pain in left leg and hip, anxiety (is a mental illness that causes excessive and uncontrollable feelings of fear or anxiety that can significantly impair a person's daily life), and bipolar disorder (is a mental illness that causes extreme shifts in mood, energy, and activity levels).<BR/>Record review of Resident #51's quarterly MDS assessment dated [DATE] indicated Resident #51 was usually understood and usually understood others. Resident #51 had a BIMS score of 04 which indicated severe cognitive impairment. Resident #51 had fluctuating behaviors of inattention and altered level of consciousness. Resident #51 was dependent for ADL care. Resident #51 received scheduled pain medication regimen.<BR/>Record review of Resident #51's undated care plan indicated Resident #51 required pain management chronic pain related to disease process. Intervention included anticipate need for pain relief and respond immediately to any complaint of pain. <BR/>Record review of Resident #51's consolidated physician order active as of 10/15/24 indicated Acetaminophen-Codeine Oral Tablet 300-60mg, give 2 tablets by mouth three times a day for pain. Ordered date 11/05/23. <BR/>Record review of Resident #51's MAR dated 10/01/24-10/31/24 indicated:<BR/>*Acetaminophen-Codeine Oral Tablet 300-60mg, give 2 tablets by mouth three times a day for pain. Ordered date 11/05/23. Resident #51's MAR indicated other/see nurse notes on 10/13/24 (8am and 3pm) by MA U and 10/14/24 (8am) by MA U. <BR/>*Pain Assessment every shift using PAINAD /Verbal Scale 0-10 for chronic pain. Resident #51's MAR indicated on 10/13/24 (0 for day and night shift) by RN Y and LVN Z and 10/14/24 (0 for day shift) by RN Y. <BR/>Record review of Resident #51's progress note dated 09/14/24-10/15/24 indicated:<BR/>*On 10/13/24 at 10:33 a.m. by MA U. Acetaminophen-Codeine Oral Tablet 300-60mg, give 2 tablets by mouth three times a day for PAIN, on order (not given). <BR/>*On 10/13/24 at 2:11 p.m., by MA U. Acetaminophen-Codeine Oral Tablet 300-60mg, give 2 tablets by mouth three times a day for pain, on order (not given).<BR/>*On 10/14/24 at 8:17 a.m., by MA U. Acetaminophen-Codeine Oral Tablet 300-60mg, give 2 tablets by mouth three times a day for pain, on order (not given).<BR/>During an interview on 10/17/24 at 9:25 a.m., MA U said she had been employed at the facility for one week. She said she was assigned the 300 hall. She said she passed medication to Resident #51. She said medications were documented on the MAR when administered. She said if a medication was unavailable on the medication cart, she notified the nurse to get it out of the emergency kit. She said then an order would be placed for the medication if the facility did not have it. She said when she passed medication on 10/13/24 and 10/14/24 to Resident #51, Resident #51's blister packet said Tylenol #4, but the EMR order said Tylenol #3, 300-60 mg. She said she did not give Resident #51 three scheduled doses because she thought the blister pack order did not match the EMR order. She said hospice came to visit Resident #51 on 10/13/24 and said the medication in the blister pack was correct. She said Resident #51 missed three doses of Acetaminophen-Codeine but received her Lorazepam (antianxiety). She said a nurse knew about the missed doses, but she could not remember who it was. She said the nurse knew she did not administer Resident #51's pain medication because the medication order seemed wrong, and it was not given. She said when Resident #51 missed three doses, she seemed more anxious. She said Resident #51 was cussing and threw water at her. She said her pain medication was not for her anxiety, but it would have helped controlled her temper and anxiety as well. <BR/>During an interview on 10/17/24 at 10:37 a.m., ADON N said she worked the 300 hall on either Sunday or Monday. She said MA U did not report to her she had not given Resident #51 her pain medication. She said she thought MA U reported to the 6pm-6am shift the issue. She said she still did not know why MA U did not give Resident #51 her schedule Acetaminophen-Codeine 300-60mg, which was considered Tylenol #4. She said Resident #51 needed her medication for pain management. She said MA U not giving Resident #51 her pain medication could have increased her behaviors and pain. She said Resident #51 had behaviors, but she also had a urinary tract infection and GDR (tapering residents antipsychotic and psychotropic medication) done on an antipsychotic medication that week. She said MA U should have told a nurse immediately she held Resident #51's pain medication.<BR/>During an interview on 10/17/24 at 2:05 p.m., Regional RN FF, acting DON, said MA U should have notified the LVN to clarify the medication order. She said she expected nursing staff to give medication as scheduled. She said Resident #51 not receiving her pain medication could have increased her pain if she did not have PRN pain medication available. She said competencies and skill checks were done to ensure nursing staff administrated medication correctly. She said the nurse should have checked the MAR and log to ensure the resident's medications were being administered. She said the ADON and DON should be monitoring resident's MAR/TARs for accurate administration. <BR/>During an interview on 10/17/24 at 2:58 p.m., the Interim ADM said she expected the MAs to administer medication as scheduled. She said she expected MAs to ask the LVN or DON for assistance with medication orders. She said when pain medication was not administered, a resident's blood pressure could be elevated due to the pain. She said the DON was responsible for ensuring the nursing staff administered medication as scheduled. She said the DON should be ensuring it was happening with training, auditing MARS and controlled substance logs. <BR/>Record review of an undated facility's Medication-Administration policy indicated .medication must be given to the resident by the Licensed Nurse preparing the medication, or as consistent with state law .compare the Licensed Practitioner's prescription/order with the MAR (first check) .compare the Licensed Practitioner's order with the pharmacy label on the medication package (second check) .compare the pharmacy label and MAR (third check) .any discrepancies identified during the first, second, and/or third check must be resolved prior to administration of any medication .administer the medication to the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 6 medication carts and 3 of 27 residents reviewed in sample (Resident #319, Resident #13 and Resident #81 ).<BR/>The facility failed to have Resident #319's Arthritis hot pain cream stored and locked in an area not accessible to other staff, residents, or visitors. <BR/>The facility failed to ensure Resident #13 did not have prescribed and OTC medications at bedside. <BR/>ADON K failed to ensure the medication cart for hall 300 rooms 316-331 was locked when it was left unattended while giving Resident #81's medication.<BR/>ADON K and LVN V failed to ensure the medication cart for hall 300 rooms 316-331 was locked when it was left unattended.<BR/>These failures could place residents at risk of injury.<BR/>Findings included:<BR/>1.Record review of Resident #319's face sheet dated 08/30/23 indicated she was a [AGE] year-old female that admitted to the facility on [DATE] with the diagnoses of diabetes, kidney disease, and chronic pain. <BR/>Record review of Resident #319's MDS assessment dated [DATE] indicated she had a BIMS score of 11 which means she had moderately impaired cognition. The MDS also indicated she required extensive assistance of 2 staff for bed mobility and extensive assistance of 1 staff for transfers, bathing, toileting, and dressing, and supervision for eating. <BR/>Record review of Resident #319's order summary report dated 08/30/23 indicated she did not have an order for arthritis hot pain cream. <BR/>During an observation and interview on 08/29/23 at 08:53 AM Resident #319 had a container of arthritis hot pain cream on dresser beside her bed. Resident said she used the cream on her hands and her knees when she needs to, and it really helped her. She said her family member brought it for her a couple days ago, but 08/29/23 was her first day to try it. <BR/>During an observation on 08/30/23 at 08:35 AM Resident #319 was sitting in her room in her wheelchair. The container of arthritis hot pain cream continues to lay on her dresser. She said she needed to use it because she had been having some issues with her knees and back, but her nurse had just given her medications to help.<BR/>During an observation and interview on 08/30/23 at 04:40 PM LVN N said no residents were allowed to have medications kept in their rooms. LVN N went to Resident #319's room and removed the arthritis hot pain cream and said she was going to contact the physician and obtain an order for the cream for the staffed nurses to give to Resident #319 as needed. LVN N said that she did not see the cream on Resident #319's dresser, but all staff were responsible for ensuring medications were not in resident's rooms. She said medications left in resident's rooms placed a risk for wandering residents to get the medication and overdose or possibly use in their eyes. <BR/>During an interview on 08/30/23 at 04:51 PM the ADON said medications were not supposed to be at any resident's bedside. She said nurses, as well as any staff who went into Resident #319's room was responsible for ensuring no medications were in the room. The ADON said with medications being left in Resident #319's room, it placed a risk for the medications to be used in the wrong way, overdosing, and allowing other residents to pick the medicine up and use.<BR/>During an interview on 08/30/23 at 05:09 PM the DON said no residents were to have medications at bedside. She said she expected residents and families to give any medications they get outside of the facility to the staffed nurse to handle properly. The DON said all staff were responsible for ensuring there are no medications in resident rooms and should have been more observant. The DON said with medications being left at Resident #319's bedside it placed a risk for anyone picking the medication up and ingesting, using the medication in an unproper way, or could have had an allergy to the medication. <BR/>During an interview on 08/31/23 at 09:49 AM the Administrator said all medications should be stored in nurse carts or medication room with lock and key. He said all staff are responsible for ensuring residents do not have medications at the bedside. The Administrator said having medications in resident rooms placed a risk for not having physician orders and not safely administering medications to residents. <BR/>2.Record review of Resident #13's face sheet dated 08/30/23, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dysphagia (difficulty swallowing), anxiety and depression (disorder characterized by persistently depressed mood or loss of interest in activities).<BR/>Record review of Resident #13's order summary report dated 08/30/23, indicated the following orders:<BR/>*Aspirin 81mg give one tablet by mouth one time a day for supplement with a start date of 01/03/21.<BR/>*B complex vitamin give one tablet by mouth one time a day for supplement with a start date of 01/03/21.<BR/>*Calcium 500+D3 tablet give one tablet by mouth one time a day for supplement with a start date of 09/17/20.<BR/>*Centrum Adults tablet give one tablet by mouth one time a day for supplement with a start date of 09/17/20.<BR/>*Coenzyme Q10 (acts as an antioxidant, which protects cells from damage and plays an important part in your metabolism) give one capsule by mouth in the morning for hyperlipidemia with a start date of 09/17/20.<BR/>*Coreg 25 mg give one tablet by mouth in the morning for essential hypertension (high blood pressure) with a start date of 08/25/22.<BR/>*Digoxin 125 mcg give one tablet by mouth one time day for atrial fibrillation (irregular heartbeat) with a start date of 04/12/23.<BR/>*Diltiazem 120 mg give one capsule by mouth in the morning for atrial fibrillation with a start date of 09/16/20.<BR/>*Furosemide 20 mg give three tablets by mouth in the morning for fluid retention with a start date of 09/17/20.<BR/>*Glimepiride 1 mg give one tablet by mouth one time a day for diabetes with a start date of 09/17/20<BR/>*Magnesium 400 mg give one tablet by mouth two times a day for supplement with a start date of 07/17/23.<BR/>*Oxybutynin 10 mg give one tablet by mouth one time a day for overactive bladder with a start date of 12/11/20.<BR/>*Pepcid 20 mg give one tablet by mouth two times a day for supplement with a start date of 01/03/21. <BR/>*Potassium 20 MEQ give one tablet by mouth one time a day for supplement with a start date of 12/10/20.<BR/>*Prilosec 20 mg give one tablet by mouth two times a day for GERD (digestive disease in which stomach acid or bile irritates the food pipe lining) with a start date of 12/14/20.<BR/>*Tramadol 50 mg give two tablets by mouth three times a day for chronic pain with a start date of 07/16/22.<BR/>*Venlafaxine 75 mg give one tablet by mouth two times a day for depression with a start date of 01/20/23.<BR/>*Vitamin C 1000 mg give one tablet by mouth two times a day for supplement with a start date of 01/03/21.<BR/>*Vitamin D3 125 mcg give two capsules by mouth one time a day for supplement with a start ate of 01/03/21.<BR/>*Zinc 50 mg give 2 tablets by mouth one time a day for supplement with a start date of 01/03/21. <BR/>Record review of Resident #13's quarterly MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS indicated Resident #13 had a BIMS score of 15, which indicated her cognition was intact. The MDS indicated Resident #13 required supervision with bed mobility, transfer, walking, locomotion, dressing, eating, toileting, and personal hygiene. <BR/>Record review of Resident #13's undated comprehensive care plan indicated she had diagnoses of overactive bladder, stroke, diabetes, hyperlipidemia, hypertension, fluid retention, anxiety, renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys caused by renal artery disease), depression and was at risk for pain. The care plan interventions indicated to administer medications as ordered. <BR/>During an observation and interview on 08/28/23 at 10:03 AM, Resident #13 was sitting up in her wheelchair in her room. A bottle of lubricating eye drops was on her bed. Resident #13 said she had the eye drops due to her dry eyes. Resident #13 also had a bottle of cranberry 500 mg tablets in a white basket that was on top of the seat of the recliner. Inside the white basket were also 2 medicine cups with pills. Resident #13 said the pills were her pills of the day that LVN CC had left for her to take as she knows she will take them. Resident #13 said the nurse comes back and checks to see if I took them. <BR/>During an observation and interview on 08/28/23 at 10:12 AM, LVN CC entered Resident #13's room and obtained the bottle of cranberry tablets, the lubricating eye drops and the 2 medicine cups with pills. LVN CC said she had given Resident #13 her medications to take that morning, turned her back, and then administered Resident #13's roommate her medications. LVN CC said she figured Resident #13 had taken the medications. LVN CC said the pills in the medication cups were Resident #13's morning medications. One medicine cup had 12 unidentified pills and the other had 6 unidentified pills which were left from her morning medications. LVN CC said Resident #13 liked her prescription medications in one cup and her OTC medications in another cup. LVN CC said the risk of Resident #13 having medications at bedside was someone could go in and take them or Resident #13 could take them whenever she wanted. LVN CC said she was responsible for ensuring Resident #13 took her medications. LVN CC said she was unaware Resident #13 had a bottle of cranberry tablets or the lubricating eye drops. LVN CC said the family tends to bring OTC medications and place them wherever they want. LVN CC said the risks of having OTC medications at bedside was someone could come in and take them. LVN CC said she was responsible for ensuring the residents did not have OTC medications at bedside. LVN CC said if medications were kept at beside there should be a physician's order indicating this and a self-administration assessment completed. LVN CC said she had not completed a self-administration assessment on Resident #13. <BR/>During an interview on 08/30/23 at 4:19 PM, ADON O said she expected the nurse to ensure medications were taken unless the resident had an order for self-administration. ADON O said by not ensuring medications were taken could cause a resident to miss a dose, resident could forget to take them, or other residents could take them. ADON O said the nurse who was administering the medications was responsible for ensuring medications were taken and not left at bedside. ADON O said OTC medications were not to be at bedside unless the resident had an order and an assessment that they could have at bedside. ADON O said by not knowing if a resident had OTC medications at bedside could cause medication to interfere with medications they were currently taking. ADON O said everyone was responsible for ensuring OTC medications were not at bedside.<BR/>During an interview on 08/30/23 at 4:50 PM, the Administrator said he expected the nurse to ensure medications were taken by the resident. The Administrator said OTC medications should be kept under lock and key to ensure proper administration. The Administrator said residents could have medications at bedside if they had a physician's order for self-administration. The Administrator said by having medications at bedside, anyone could go in the room and ingest them.<BR/>During an interview on 08/30/23 at 5:22 PM, the DON said she expected medications not to be left at bedside and expected the nurse to ensure the resident took them as it was their responsibility. The DON said she expected the family and resident to notify them if they bring or order OTC medications to the facility. The DON said having medications at bedside could cause an adverse event.<BR/>3. Record review of Resident #81's face sheet dated 08/30/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis that affects all four limbs, plus torso), diabetes mellitus (a group of diseases that result in too much sugar in the blood), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety. <BR/>Record review of Resident #81's order summary report dated 08/30/23, indicated he had the following orders:<BR/>*insulin glargine (long-acting type of insulin that works slowly) 100unit/ml inject 15 units subcutaneously (under the skin) in the morning for diabetes with a start date of 03/06/23.<BR/>*Novolog flex pen (fast-acting insulin) 100unit/ml inject per sliding scale subcutaneously before meals and at bedtime for diabetes with a start date of 02/24/23.<BR/>Record review of Resident #81's comprehensive care plan revised on 04/03/23, indicated he had a diagnoses of diabetes mellitus with interventions to administer diabetic medications as ordered. <BR/>Record review of Resident #81's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS indicated Resident #81 had a BIMS score of 15, indicating his cognition was intact. The MDS indicated he was totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated he received insulin injections 7 out of the 7 days of the look back period. <BR/>During an observation on 08/29/23 at 08:30 AM, ADON K entered Resident #81's room to obtain a blood sugar check. ADON K left the medication cart unlocked. A staff member came and stood next to the medication cart waiting on ADON K. Multiple staff members were observed passing down the hallway.<BR/>During an interview on 08/29/23 at 08:59 AM, ADON K said it was the nurse's responsibility to keep the cart locked when not present. ADON K said someone could have opened the cart and obtained medications.<BR/>4. During an observation and interview on 08/29/23 at 09:17 AM, the 316-331 medication cart was parked outside room [ROOM NUMBER], a supply room. The medication cart was noted to be unlocked. There was not a staff member present. LVN V came out of the supply room, and said she was the one responsible for leaving the cart unlocked. LVN V said she went to the supply room to obtain a syringe. LVN V said she was responsible for ensuring the medication cart was kept locked when left unattended. LVN V said by not locking the medication cart, someone could take the medications. <BR/>During an interview on 08/30/23 at 4:19 PM, ADON O said the medication carts should be kept locked when unattended for safety. ADON O said the nurse was responsible for ensuring the cart was kept locked.<BR/>During an interview on 08/30/23 at 4:50 PM, the Administrator said he expected the medication carts to be always locked when left unattended. The Administrator said leaving the cart unlocked could cause medications to be taken. The Administrator said the charge nurse was responsible for locking the cart. <BR/>During an interview on 08/30/23 at 5:22 PM, the DON said the nurses were responsible for locking their medication carts. The DON said not locking the medication carts someone could get into the medications inside the cart.<BR/>Record review of the facility's policy General Guidelines for Medication Administration revised on 08/2020, indicated .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer .15. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide .<BR/>Record review of the facility's policy Storage of Medications revised on 08/2020 indicated . Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .3. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 2 of 3 residents reviewed for personal food safety. (Resident #16 and Resident #34)<BR/>The facility did not implement the personal food policy related to personal refrigerators for Resident's #16 and Resident #34. <BR/>These failures could place the residents at risk for food borne illness.<BR/>The findings included:<BR/>1. Record review of Resident #16's face sheet dated 8/30/23 indicated she was a 100year old female who admitted to the facility on [DATE] with the diagnoses of high blood pressure, breast cancer, heart failure, and need for assistance with personal care. <BR/>Record review of Resident #16's MDS assessment dated [DATE] indicated that she had a BIMS score of 12 which meant she had moderately impaired cognition. The MDS also indicated that resident required extensive assistance of 2 staff for bed mobility, extensive assistance of 1 staff for transfers, toileting, dressing, and eating, and total assistance of 1 staff for bathing. <BR/>During an observation on 8/28/23 at 10:07 AM, Resident #16's refrigerator was in her room with temperature check sheet located on the outside of the refrigerator dated July 2023 with no temperatures on the sheet. There was no thermometer located in the refrigerator. <BR/>During an observation on 8/29/23 at 09:15 AM, Resident #16's refrigerator continued to have a July 2023 dated paper on the front of the refrigerator with no temperatures and no thermometer inside. <BR/>During an observation on 8/30/23 at 08:42 AM, Resident #16's refrigerator had a new undated temperature sheet on the outside of the refrigerator that was blank. There was no thermometer found inside. <BR/>During an observation on 8/30/23 at 04:36 PM, Resident #16's refrigerator had an undated sheet on the outside of the refrigerator with a date written in as 8/30/23 and a temperature of 40 degrees signed by Housekeeper L. <BR/>During an interview on 8/30/23 at 04:34 PM, CNA M said the housekeeping department was responsible for checking resident refrigerators. She said she had not noticed them being checked but she knew a housekeeper checked Resident #16's refrigerator on 8/30/23. <BR/>During an interview on 8/30/23 at 04:51 PM, ADON O said housekeeping was responsible for checking refrigerator temperatures daily. She said there should have been a thermometer in the refrigerator. ADON O said the failure could have caused Resident #16 to consume spoiled food. <BR/>During an interview on 8/30/23 at 05:09 PM, the DON said the temperature checks on Resident #16's refrigerator was assigned to the housekeepers. She said they should be checked daily. The DON said with the refrigerators not being checked, it could cause bacteria growth if temperatures are not within range and if resident consumes items in their refrigerator there could be adverse effects. <BR/>During an interview on 8/31/23 at 09:52 AM, the Administrator said he expected the resident refrigerators to be checked daily. He said the housekeepers and housekeeping supervisor were responsible for ensuring the refrigerator temperatures for all residents were completed daily. He said the risk for Resident #16 is that the refrigerator not cooling properly, and resident ingesting spoiled or expired food. <BR/>2. Record review of Resident #34's face sheet, dated 8/29/23, indicated Resident #34 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of heart failure, shortness of breath, high blood pressure, diabetes (high blood sugar), weakness, and abnormality of gait, and anxiety (nervousness).<BR/>Record review of Resident #34's quarterly MDS assessment, dated 7/07/23, indicated Resident #34 had clear speech and was understood by staff. The MDS indicated Resident #34 was able to understand others. The MDS indicated Resident #34 had a BIMS of 12, which indicated moderate cognitive function impairment. <BR/>During an observation and interview on 8/28/23 at 10:15 AM, Resident #34 had a temperature log on her personal refrigerator dated July at the top of log, but there were no temperatures recorded on the July temperature log and there was no log for August posted. Resident's refrigerator was packed full of food and unable to determine if there was a thermometer in it. Resident #34 said she did not know when the last time anyone had checked her refrigerator.<BR/>During an observation and interview on 8/29/23 at 9:35 AM, Resident #34's personal refrigerator July temperature log was removed, and an August temperature log was posted on the front of the refrigerator. There were no temperatures documented 8/01/23-8/29/23. There was a thermometer in the refrigerator door and surveyor observed the temperature to be 49 degrees and there was significantly less food in the refrigerator than observed on 8/28/23. Resident #34 said the staff had come in that morning and cleaned the refrigerator out and placed a new temperature log for August on the refrigerator.<BR/>During an interview on 8/30/23 at 8:36 AM, the ADON H said she had worked at the facility for three years and was responsible for ensuring everything was going smoothly on Hall 200 and ensuring everyone was doing what they were supposed to do. ADON H said the personal refrigerators should be checked by housekeeping when they cleaned the resident's room and document the temperature on the temperature log. ADON H said monitoring personal refrigerators was important to ensure food is stored at proper temperature to prevent food from spoiling and making residents sick.<BR/>During an interview on 8/30/23 at 2:37 PM, the Housekeeping Supervisor said she had worked at the facility since December 2022 in housekeeping, but she had been the Housekeeping Supervisor for about a month. The Housekeeping Supervisor said all of housekeeping was responsible for the personal refrigerators. The Housekeeping Supervisor said housekeeping should be checking the refrigerators weekly, along with cleaning it, removing expired food out of it, checking the temperature, and documenting it on the temperature log on the front of the refrigerator. The Housekeeping Supervisor said she was responsible for ensuring the personal refrigerators were being monitored and temperature logs were being completed. The Housekeeping Supervisor said it was important to ensure refrigerated items were checked and temperature logs were completed appropriately to ensure refrigerators were functioning properly to keep food from spoiling and removing expired food, so residents do not get sick. The Housekeeping Supervisor said there had been a high turnover of housekeeping staff and she may not have checked behind the staff to ensure the personal refrigerators were being monitored and temperatures checked and logged for Resident #34.<BR/>During an interview on 8/30/23 at 4:37 PM, the DON said she had worked at the facility for three years. The DON said it was the responsibility of housekeeping for monitoring the personal refrigerators for expired foods, checking, and documenting the temperatures of the personal refrigerators. The DON said it was important to monitor the refrigerators for expired foods and check the temperature of the refrigerator to ensure it was functioning properly, so food did not spoil and grow bacteria that could make residents sick.<BR/>During an interview on 8/30/23 at 5:34 PM, the Administrator said he would expect the personal refrigerators to be checked weekly and temperatures checked and documented on the temperature log, to ensure the food was kept at an appropriate temperature to prevent food spoiling and potentially causing the resident to get sick, and ensure the refrigerator was functioning properly. <BR/>Record review of the facility's policy, titled Refrigerator-Personal dated 5/2017, indicated . the resident's refrigerators would be checked weekly for cleanliness and remaining sanitary . Housekeeping Supervisor/designee would monitor resident's refrigerator weekly . clean and remove expired food as needed . keep thermometer in refrigerator and maintain at 41 degrees or below . log temperature weekly when checked .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 20 residents reviewed for incontinent care and catheter care infection control practices. (Resident #'s 35 and 76).<BR/>CNA E cleaned Resident #76's buttock using the same two wipes for multiple wiping motions.<BR/>CNA F used contaminated wipes for Resident #35's catheter care.<BR/>CNA F touched the package of wipes and the clean brief for Resident #35 without removing her gloves and sanitizing of her hands. <BR/>These failures could place residents with foley catheter care or incontinent care at risk for urinary tract infections.<BR/>Findings included: <BR/>1. Record review of a face sheet dated 7/13/2022 indicated Resident #76 was an [AGE] year-old-female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's dementia and difficulty swallowing.<BR/>Record review of the most recent Quarterly MDS dated [DATE] indicated Resident #76 sometimes understood and sometimes understood others. The MDS indicated Resident #76's brief interview memory score was a 2 indicating a severe cognitive deficit. The MDs indicated Resident #76 required total assistance of two staff with toileting . The MDS indicated Resident #76 was always incontinent of urine and bowel.<BR/>Record review of the comprehensive care plan dated 4/11/2019 indicated Resident #76 had a self-care deficit with a goal of her needs would be met daily. The care plan indicated Resident #76 required one staff for incontinent care. <BR/>During an observation on 7/12/2022 at 8:59 a.m. revealed CNA's E and F provided incontinent care to Resident #76. CNA F opened Resident #76's current brief and repositioned her in the bed. Resident #76's brief was visibly soiled with urine. Then CNA F touched the package of wipes and the clean brief without removing her gloves and sanitation of her hands. CNA E took 2 wipes from the wipe package and cleansed Resident #76's buttock making several wiping strokes, not turning the wipes nor obtaining new ones before discarding the wipes. CNA F removed the dirty brief and the draw sheet then touched the clean brief without changing her gloves . CAN F then touched the bed side table before removing her gloves and using hand sanitizer. <BR/>2.Record review of a face sheet dated 7/14/2022 indicated Resident #35 was a [AGE] year-old-male who admitted to the facility on [DATE] with the diagnoses of neuromuscular dysfunction (muscle weakness, muscle loss)of the bladder, morbid obesity, and low back pain. <BR/>Record review of the most recent Annual assessment dated [DATE] indicated Resident #35 understood others and was understood by others. Resident #35's brief interview for memory score was a 12 indicating moderate cognitive impairment. The MDS section H0100 Appliances indicated Resident #35 had an indwelling catheter and H0300 Urinary Continence indicated Resident #35 had a catheter. <BR/>Record review of the comprehensive care plan dated 10/18/2021 indicated Resident #35 had an indwelling catheter. The goal would be no signs or symptoms of a urinary infection. The care plan intervention was to change the catheter per orders, and catheter care with care daily and as needed.<BR/>Record review of consolidated physician's orders dated 7/14/2022 indicated Resident #35 had a Foley Catheter 16 french to bedside drainage bag for the diagnosis of dysfunction of the bladder.<BR/>Record review of consolidated physician's orders dated 07/14/2022 indicated Resident #35 had an order for Foley catheter care every shift and as needed.<BR/>During an observation and interview on 7/13/2022 at 11:59 a.m. revealed CNA's F and G provided catheter care for Resident #35. CNA F obtained a wipe from the bag of wipes lying at the foot of the bed. CNA F made one wipe down the inner thigh of Resident #35. CNA F then discarded the one wipe in the bag of clean wipes. CNA F continued to provide catheter care using the contaminated wipes. CNA F wiped the penis, scrotum and inner thighs using the contaminated wipes. During an interview with CNA's F and G, they indicated the incontinent care was appropriately done. CNA's F and G were asked about the discarding of the used wipe in with the clean wipes and they both indicated the discarding of the dirty wipe with the clean wipes and continuing to provide catheter care could place Resident #35 at risk for infection . The CNAs indicated they had been trained on catheter care. <BR/>During an interview on 7/14/2022 at 10:41 a.m., LVN D indicated she expected the CNA's to use a different wipe with each wiping motion. She indicated a resident was at risk for infection and skin issues when catheter care or incontinent care was not provided effectively. LVN D indicated the DON provided check offs for the CNAs to ensure effective catheter and incontinent care. <BR/>Record review of a CNA proficiency audit dated 7/7/2022 for CNAs E, F and G indicated they had been checked off as satisfactory in the performance of female perineal care and male foley catheter care.<BR/>During an interview on 7/14/2022 at 12:13 p.m., the DON indicated she expected incontinent care and catheter care to be provided according to the policy. The DON indicated failure to provide ineffective foley and catheter care was an opportunity for bacteria and illness. The DON said residents with catheters were at a greater risk of infection.<BR/>During an interview on 7/14/2022 at 1:05 p.m., the ADM indicated he expected incontinent care and catheter care to be provided as needed and indicated. The ADM indicated the nursing staff were responsible for ensuring the incontinent care and catheter care were provided accurately. The ADM indicated the provision of incorrect incontinent care and catheter care was an infection control issue.<BR/>Record review of an Infection Control-Prevention and Control Program dated May 2017 indicated the intent of this program was to assure that the home developed, implemented, and maintained an Infection Prevention and Control Program to prevent, recognize, the onset and spread of infection within the facility. The program will: 2. Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions. Procedure: 1. Policies, procedures, and practices which promote consistent adherence to evidence-based infection control practices; 5. Education, including training in infection prevention and control practices, to ensure compliance with facility requirements as well as State and Federal regulations.<BR/>According to the CDC Epidemiology and Prevention of UTI dated 7/2018 a component of prevention of a Urinary Tract Infection was to provide good perineal hygiene and UTIs are common and a significant cause of harm in long term care facilities. Accessed at Epidemiology and Prevention of UTI (cdc.gov) accessed on 7/18/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure residents were free from abuse for 1 of 8 residents (Resident #1) reviewed for resident abuse. <BR/>The facility did not ensure Resident # 1 was free from abuse on 2/20/25 when he was slapped on the top of his hand. <BR/>The noncompliance was identified as PNC. The noncompliance began on 2/20/25 and ended on 2/20/25. The facility had corrected the noncompliance before the investigation began.<BR/>This failure could place residents at risk of physical harm, mental anguish, or emotional distress.<BR/>The findings included: <BR/>Record Review of Resident #1's face sheet dated 11/20/24 indicated Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Dysphagia (Difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage), Cognitive Communication Deficit (Cognitive communication is the mental skills used to process information and communicate with others), Mild Cognitive Impairment (a condition characterized by a subtle decline in cognitive abilities, such as memory, attention, and reasoning, that is not severe enough to interfere with daily functioning). <BR/>Record Review of Resident #1's MDS assessment dated [DATE] indicated, Resident #1 usually understood others and usually made himself understood. The MDS assessment indicated Resident #1 had a BIMS score of 03, which indicated Resident #1 had severe cognitive impairment. Indicated that Resident #1 never rejected care. <BR/>Record Review of Resident #1's care plan, dated on 3/03/25, indicated Resident #1 requires tube feeding, is non-compliant with feeding and will eat other resident's food. Resident #1 has impaired cognitive function and has impaired thought processes. Resident #1 has a behavior he will open up his percutaneous endoscopic gastrostomy tube and suck the contents from his stomach. <BR/>During an interview on 3/3/25 at 3:31 p.m. CNA B said that on 2/20/25 that morning when she was passing breakfast trays, she could hear LVN A being loud in the room with Resident #1. She said she was curious of what was going on and that was when she heard LVN A hit the top of the hands of Resident #1. She said you could hear the skin-on-skin contact. She said she did not lightly tap the hands of Resident #1 but hit them hard like a slap. She said that Resident #1 was not crying and did not appear to be in any distress. She said she asked LVN A what was going on and she said she was trying to get Resident #1 to move his hands so she could feed him. She said that CNA C entered the room also to see what was going on. She said she told CNA C to go report what happened to their supervisor who then told the Administrator what happened. She said she never left Resident #1's side until after management got involved. She said she was trained on abuse and neglect, the timeframes and requirements for reporting abuse and neglect. She said that was how she knew to report and stay with the resident. She said she was then trained again in abuse and neglect after the incident.<BR/>During an interview on 3/3/25 at 3:40 p.m., the Administrator said that she did not witness the incident, but it was reported that CNA B witnessed LVN A hit the top of the hands of Resident #1 and that CNA C heard the skin on skin contact as well. She said that LVN A did speak loudly but she has never verbally abused anyone. She said LVN A speaks loudly because she was hearing impaired. She said that after the incident LVN A was suspended, a report was made to the Texas Health and Human Services Commission, and Resident #1 was assessed for any physical injury. She said that there was no physical injury, so he was evaluated by a counseling agency to determine if he had any trauma. Resident #1 who has a BIMS of 3 did not recall the incident, said the incident did not happen, and was not in any distress due to the incident. She said that after the incident occurred an investigation was started, and staff were re-trained on abuse and neglect.<BR/>During an interview on 3/3/25 at 3:54 p.m. Resident #1 was asked questions in an answer question format as he was unable to give full responses. Question: Resident #1 did you know LVN A? Answer: Yes. Question: Did LVN A hit you on the hand? Answer: No. Question: Resident #1 do you feel safe here? Answer: Yes.<BR/>During an interview on 3/3/25 at 4:05 p.m., CNA C said that on 2/20/25 while breakfast trays were being passed out, she heard a commotion in Resident #1's room. She said before she entered the room, she heard two loud slapping sounds. She said it sounded like skin-on-skin contact. She said when she entered the room CNA B was already inside and she said, She just hit him. She said she saw LVN A sitting with Resident #1 who was being fed. She said LVN A was being loud with the resident saying, Don't do that. She said CNA B said she needed to go get a supervisor. She said she then left the room and told a supervisor. She said she had been trained in abuse and neglect and was trained again after the incident. She said that when abuse or neglect occurs she should report to a supervisor or the Administrator what happened, ensure the resident is safe, and not allow the alleged perpetrator to stay with the resident. <BR/>During an interview on 3/4/25 at 8:50 a.m., LVN A said that on 2/20/25 she was feeding Resident #1. She said that Resident #1 has a history of interfering when he was being fed and pulling at his Gtube (a feeding tube). She said that on this day he was also pulling at his Gtube. She said she said to him in a loud voice, Stop and Don't do that. She said she did touch Resident #1's hands but it was to move them to his side. She said she did not tap or hit the hands of Resident #1. She said she was only trying to keep him from removing his Gtube. She said that CNA B and CNA C did not see what happened and they were both lying. She said they were both outside in the hallway and neither of them saw or heard her hit Resident #1. <BR/>During an interview and observation on 3/4/25 at 9:05 a.m. CNA B was asked to demonstrate the force used when she witnessed LVN A hit the top of Resident #1's hands. CNA B demonstrated what she witnessed, and the force used was very strong making aloud slapping noise on the table. She said that LVN A hit the top of Resident #1's hands very hard and it was not a light tap as if a child was being scolded. <BR/>During multiple staff interviews on 3/4/25 staff were able to identify the elements of abuse and neglect, timeframes for reporting abuse and neglect, who to report to, and that the resident involved should be made safe. Staff were also able to say that the alleged perpetrator should not have access to the alleged victim.<BR/>During an interview on 3/4/25 at 11:50 a.m., the Director of Nurses said that all newly hired staff and on occasion staff were trained in their abuse and neglect policy. She said staff were trained on when to report, who to report to, and how to protect residents that were suspected of being abused or neglected. She said she expects all her staff to follow facility policy regarding abuse and neglect. She said that a resident was placed at risk of harm if a staff abused them. <BR/>During an interview on 3/4/25 at 11:55 a.m., the Administrator said that the facility has developed abuse and neglect policies. She said that either herself or the Director of Nurses was to conduct the training. She said that their abuse and neglect policy teach on when to report abuse, who to report abuse to, and how to protect the resident if abuse was suspected or occurred. She said she expects that her staff would intervene if they see or suspect that abuse or neglect occurs. <BR/>Record review of the facility's provider investigation report dated 2/20/25 revealed that the facility conducted an investigation into the allegations that LVN A physically abused Resident #1 when CNA A observed LVN A hit Resident #1 on the top of his hands while LVN A was feeding the resident. The report showed that the time and date of the incident was 2/20/25 at 8:15 a.m. and that Resident #1 was physically assessed on 2/20/25 at 9:43 a.m. Further review showed that the incident was reported to the Texas Health and Human Services Commission on 2/20/25 at 10:01 a.m.<BR/>Record review of a skin assessment for Resident #1 dated 2/20/25, indicated that there were no skin impairments. Skin assessment was completed after the incident. <BR/>Record review of a trauma assessment for Resident #1 dated 2/20/25, indicated that there was no present trauma. Resident # 1 indicated no to the following questions: Has the event caused you to felt very scared, helpless, or horrified Has the event caused you to be constantly on guard, watchful, or easily startled Has the event caused you to feel numb, detached from others, actives, or your surroundings. <BR/>Record review of facility in-service dated 2/20/25 titled, Abuse and Neglect conducted by the Director of Nurses. In-service training reviewed the facilities abuse and neglect prohibition policy. Policy identified elements of abuse and timeframes for reporting abuse. <BR/>Record review of LVN A's personnel file on 03/4/25 indicated hire date of 1/15/19. The facility had performed background check and employee misconduct search. No concerns were identified.<BR/>Record review of LVN A's Corrective Action Memo, dated 2/25/25, indicated she was terminated for misconduct regarding allegations of Abuse.<BR/>The noncompliance began on 02/20/25 and ended on 02/20/25. The facility had corrected the noncompliance before the investigation began.<BR/>The surveyor confirmed PNC had been implemented sufficiently to remove the deficiency by:<BR/>Facility notification of abuse incident to responsible party, MD, Ombudsman and HHSC. <BR/>Completion of in-services on abuse. <BR/>Staff and management recognizing the steps to report abuse and neglect. <BR/>Termination of confirmed perpetrator.<BR/>Record Review of facility policy titled, Abuse Prevention and Prohibition dated 8/2020. Policy indicated, To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for 1 of 7 residents (Resident #1) reviewed for neglect.<BR/>Resident #1 was identified as confused and a wanderer and had increased confusion but was not monitored more closely. <BR/>The facility did not report to HHSC when Resident #1 was discovered in traffic on a busy street on 7/27/24. <BR/>This failure placed the resident at risk for harm. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 7/30/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were cognitive communication deficit, muscle weakness, unsteadiness on feet, lack of coordination, and stroke.<BR/>Record review of Resident #1's quarterly MDS dated [DATE] indicated a BIMS score of 3 (severely cognitively impaired.) The MDS did not indicate any memory problems, mood issues or behavioral symptoms. The resident required partial to moderate assist with the helper doing less than half the effort for transfers and sit to stand. <BR/>Record review of Resident #1's care plan dated 2/28/24 and last revised on 5/28/24 indicated a Focus area of impaired cognitive function or impaired thought process related to a stroke. He wandered into other resident rooms and used the bathroom. He urinated on his jacket and would not allow it to be cleaned. One of the interventions was to redirect the resident when he wandered into other rooms. A Focused area dated 7/27/24 and last revised 7/30/24 indicated Resident #1 was at risk for elopement related to Elopement Risk sore. He had a wander guard in place. Some of the interventions were engage the resident in activities of his choice. Report to MD factors for potential elopement such as wandering, repeated request to leave the facility, and attempts to leave. Ensure the wander guard was in place. <BR/>Record review of Resident #1's Elopement Risk Evaluation dated 5/19/24 indicated a score of 1 with no risk of elopement. The form indicated if there was a yes to question 1 or 2 then the form was complete. Question one indicated the resident was able to make decisions regarding task of daily living and decisions were consistent and reasonable. The question was answered yes. However, additional information indicated the resident was at risk for elopement related to Elopement Evaluation risk score, the goals were he would remain safe within the facility unless accompanied by staff or authorized persons. The intervention was to engage the resident in actives of his choice. <BR/>Record review of Resident #1's Elopement Risk Evaluation dated 7/27/24 indicated a score of 15 (imminent Risk for elopement.) The form indicated Resident #1 was unable to make decisions regarding task of daily living, and he was unable to ambulate. The patient was cognitively impaired and had a history of leaving the community without informing staff. Additional information the resident is an elopement risk related to Elopement Evaluation risk score. <BR/>Record review of Resident #1's nursing note dated 7/27/24 at 12:37 a.m. indicated the resident continued day 10 of 10 of an antibiotic for UTI. He was pleasantly confused and was out of bed and self-propelling using his lower extremities about the facility. He had his clothes piled up in his wheelchair and was sitting on them as if they were a cushion. It was difficult to re-direct the resident, and he did not know what time it was. He was also redirected due to the fact that he would stand and attempt to walk and it looked like he was having balance issues. He was frequently reminded to sit in his wheelchair. Will continue to monitor. <BR/>Record review of Resident #1's History for Police Event (#242090341) indicated on 7/27/24 at 4:18 p.m. they received a call a resident had rolled away from the nursing home. At 4:19 p.m. the caller said the resident is in the middle of the street and they are trying to get him out of the roadway. They have blocked traffic to get him moved. At 4:31 the patent was rolled back to the location by staff who did not know he had even left. At 4:33 p.m. Resident #1 said he was out to see a friend at the apartments next door. He was advised that it was dangerous out on the roadway with vehicles. He was assisted back to facility. The resident said he would never do that again and that it was scary. <BR/>Record review of an incident report dated 7/27/24 at 4:28 p.m. indicated Resident #1 was reported by and off duty staff member to be outside in the area adjacent to the facility in his wheelchair rolling himself with his feet. The resident was returned to the facility by law enforcement and wheeled to his room. The resident was asked how he was able to leave the facility and he stated he just went out the door himself. When the resident was asked how he opened the door he said you do not need a code to open the door from the inside. When the resident was asked what door, he went out. He said he went out the front door. When the resident was asked how he got down the stairs he said he did not go down any starts he was on the ground floor, the resident was confused and not aware of the current situation. The form indicated the resident was oriented to person, impulsive with a lack of safety awareness. Predisposing environmental factors were recent illness, confusion, and impaired memory. Predisposing situational factors where the resident was a wanderer. <BR/>Record review of statements dated 7/27/24 from CNA I and CNA L that placed the resident in and around the 200 hall about 4:15 p.m. The facility provided a timeline for their investigation 8/1/24 at 12:30 p.m. with no date. The typed form indicated on 7/27/24 at 4:15 CNA I noted Resident #1 self-propelling self in wheelchair in hallway. At 4:18 p.m. CNA L noted Resident #1 sitting at the dining room table. Between 4:10 p.m. and 4:20 p.m. the family of another resident was noted in and out of the 300-hall door moving a resident belongings. At 4:26 p.m. Resident #1 was brought back to the facility by the police. With no signature.<BR/>Record review of TULIP ( HHSC system for reporting abuse) indicated no facility report was located for 7/27/24 for Resident #1. <BR/>During an interview on 7/30/24 at 9:28 a.m. the ADON P said Resident #1 was the resident that the police bought back on 7/27/24 and he was just on the side of the building. She said to the best of what they could figure out there was a family in the building picking up a resident's belonging, she said they felt like Resident #1 had gone out the door by kitchen/ nurses' station with those family members on 300 hall. She said Resident #1 was not considered at risk for wandering until 7/27/24. She said Resident #1 was confused at times but had never tried to leave. She said the nurse on duty LVN A said the police brought the resident back and only waved at her. The nurse said the floor tech brought Resident #1 back into to the facility. <BR/>During an interview on 7/30/24 at 9:45 a.m. Resident #1 said he did not remember leaving the facility on 7/27/24. He could not say where he lived now or where he used to live. He only said, I live here. He did say he used to go fishing every day and told fish stories. He was confused.<BR/>During an interview on 7/30/24 at 9:55 a.m. LVN B said Resident #1 was confused. She said she had never heard him say he was going to leave. She said a while back he thought his family was coming to take him home. He would pack his clothes and say he was waiting on his family to come and get him. She said he would place his clothes in the chair behind him. However recently he had not said anything about leaving. <BR/>During a telephone interview on 7/30/24 at 10:47 a.m. LVN A said on 7/27/24 around 4:00 p.m. LVN A said she was doing last med pass. She saw Resident # 1, he had been up and down the hallway all day, and she kept an eye on him due to his increased confusion. LVN A said Resident #1 had a UTI and had just finished antibiotics. She said he was wandering up and down the halls more than usual. LVN A said a group of family came to get another resident's belonging. She said Resident #1 had gone to the common area and the several members of a family walked in from the 300 hall. The LVN said she did not hear any alarms going off. She said the family members had been in and out of the facility multiple times. She said the doors were all locked and it was not easy to get out of the facility. She said another nurse called and said Resident #1 was outside about 4:28 p.m. She said she left by the side door of the 200-hall floor. LVN A said when she saw Resident #1 he was between the building parking lot and the apartment building across the street. She said when she saw him he was being wheeled up the ramp by Floor Tech C. LVN A said the Police had him and the floor tech went and got him. She said the police did not ask her name or speak to her, they only waved and left. She said she had tried to complete a skin assessment on Resident #1 but as soon as she removed one piece of clothing, he was putting another piece of clothes on. She said Resident #1 did not complain of any pain to her. She said Resident #1 told her he went out the ground floor. However, he could not because there were steps down to the ground level on the first floor. She said he exit to parking lot on the 300-hall looked like it is at the ground level. She said the family removed a lot of stuff, gave two big boxes and a couple of trash bags, and their hands were full. LVN A said they may not have seen the resident exit the facility with them. She said that was the way the staff pieced together Resident #1's possible exit. LVN A said she had texted ADON P to let her know the family had come to get the resident things at 4:17 right before the family left. She said she received a call on 7/27/24 at 4:28 p.m. and was notified Resident #1 was missing and outside with the police. She said that either way he went out the door would have been downhill. She said she had never seen him stand or walk. <BR/>During an interview on 7/30/24 at 12:25 p.m. the Administrator said he knew Resident #1 had left the faciity on 7/27/24. He said they had come to the conclusion he was not trying to elope. He said no staff he interviewed had seen him exit the building, but they felt he had got caught up in the traffic of the family leaving the facility. The Administrator said they did not think Resident #1 was trying to elope, and he was found by the apartments across the street. He said the staff did not know he was gone. He said he was not aware of the police saying anything about where he was found but they believed from what the nurse said he was just across the street and not on the main street in front of the facility. The Administrator said he was the abuse coordinator. He said they deliberated calling Resident #1's elopement, but Resident #1 did not have an intent to leave and he was only gone a short time. He said Resident #1 was only gone about 10 minutes as best they could determine with staff interviews. So he had not reported the incident to the State agency. He said he had not talked to Floor Tech C.<BR/>During a telephone interview on 7/30/24 at 12:35 p.m. Floor Tech C said he was upstairs on the second floor on 7/27/24. He said he was not sure of the time, but he was looking out the patio doors and he saw several police cars. He said a female officer was approaching the front door and he went down to answer the door. He said there were 3 police cars and one emergency vehicle parked by the corner of the facility. He said the officer wanted to know if Resident #1 was their resident. He said they wanted someone to escort Resident #1 back in the building. He said when he saw Resident #1, he was on the major street by the facility. Floor Tech C said Resident #1 said he hurt his hand because he could not stop his wheelchair from going down the hill so fast. He said the resident had passed the facility, crossed the street on the same side of the street, and had rolled down to almost the next street. He said he had turned around somehow but he was in the street because there was no sidewalk. Floor Tech C said Resident #1 said he was glad he did not get by car. He said Resident #1 said he was glad they had come to get him because he was scared a car was going to hit him. The Floor Tech said Resident # 1 was trying to figure out why so many police were there. He said he had wheeled Resident #1 back into the facility from the wheelchair access on the side of the building. He said no one had asked him where the resident was located when he got him from the police. <BR/>During an interview on 7/31/24 at 10:58 a.m. the Administrator said he had done an investigation regarding Resident # 1 leaving the facility. He said that he had interviewed staff on duty, and they were very direct on the time that they had last seen the resident. He said he did not interview the Floor Tech C, no one had told him was really involved with the incident. He was told a Floor Tech brought Resident # 1 back into the facility. He said CNA I said that she had last seen the resident between 4:10 p.m. and 4:15 p.m. He said LVN A said that she had gotten a call at 4:28 saying that the police had the resident outside. The Administrator said he said that he had not attempted to contact the family because they had just lost a relative. He said that he felt that Resident #1 had got caught up in the door when the family was leaving. He said the family should not have had a code and he does not know who let them in and who let them out or who let the resident out of the facility.<BR/>During an interview on 7/31/24 at 11:20 a.m. the DON said Resident #1 was more confused since he had a UTI. <BR/>During an interview on 8/1/24 at 12:30 p.m. the Administrator he had not called the incident in regarding Resident #1, but he realized it should have been called into the state. He said he realized also that he did not take all the steps to complete a thorough investigation. He said from his initial reports it appeared the resident only made it across the street to the apartments and did not get to the stop sign on the main street. <BR/>Record review of the facility Abuse Prevention and Prohibition Program policy last revised 8/2020 indicated Physical Neglect was inadequate provision of care, leaving someone unattended who needed supervision. An investigation consisted of the facility promptly and thoroughly investigating reports of resident neglect. The facility would interview any witnesses. Reportable events that did not result in serious bodily injury the Administrator would make a telephone report in 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 7 residents reviewed for care plans. (Resident #72, Resident #98)<BR/>The facility failed to implement the care plan intervention to document Resident #72 and Resident #98's meal intake. <BR/>The facility failed to implement the care plan intervention for Resident #98 to receive his Frozen Nutritional Treats with meals. <BR/>These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services<BR/>Findings included:<BR/>1. Record review of a face sheet dated 08/30/23 indicated Resident #72 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses including Parkinson's (is a movement disorder. It causes tremors, stiffness, and slow movement), Alzheimer's (a progressive disease that destroys memory and other important mental functions), and fracture of left femur (is a break in the thighbone). <BR/>Record review of an admission MDS assessment dated [DATE] indicated Resident #72 was understood and understood others. The MDS indicated Resident #72 had a BIMS score of 12 which indicated moderately impaired cognition and required supervision for eating, extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated Resident #72 had nutritional malnutrition. <BR/>Record review a care plan dated 06/06/23 indicated Resident #72 had potential nutritional problem/malnutrition related to Alzheimer's, Parkinson's, poor dental health, and admission to nursing facility. Intervention included provide, serve diet as ordered. Monitor intake and record every meal. <BR/>Record review of Resident #72's Amount Eaten report dated 08/30/23 indicated no meal intake amount for:<BR/>*08/28/23: 9:00 am, 1:00 pm<BR/>*08/29/23: 9:00 am, 1:00 pm <BR/>*08/30/23: 9:00 am, 1:00 pm<BR/>2. Record review of a face sheet dated 08/28/23 indicated Resident #98 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Asperger's syndrome (a developmental disorder affecting ability to effectively socialize and communicate), muscle wasting and atrophy (is the wasting (thinning) or loss of muscle tissue), muscle weakness, need for assistance with personal care, dysphagia (difficulty swallowing foods or liquids), Type 2 diabetes (is a disease in which your blood glucose, or blood sugar, levels are too high), and protein calorie malnutrition (is the state of inadequate intake of food). <BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #98 was sometimes understood and usually understood others. The MDS indicated Resident #98 had adequate hearing, unclear speech, and highly impaired vision. The MDS indicated Resident #98 had a BIMS score of 05 which indicated severe cognitive impairment and required limited assistance for bathing and extensive assistance for bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident #98 had weight loss and was not on a physician prescribed weight-loss regimen. <BR/>Record review of a care plan dated 05/03/23 indicated Resident #98 had potential for pressure ulcer development. Intervention included monitor nutritional status. Serve diet as ordered, monitor intake and record.<BR/>Record review of a care plan revised on 08/07/23 indicated Resident #98 had potential nutritional problem related to Asperger's Syndrome. Intervention included 06/27/23 RD recommendations: 1. Frozen Nutritional Treat TID meals.<BR/>Record review of Resident #98's consolidated physician's order dated 06/22/23 indicated Frozen Nutritional Treat with meals for significant weight loss. <BR/>Record review of Resident #98's Amount Eaten report dated 08/30/23 indicated no meal intake amount for:<BR/>*08/28/23: 9:00 am, 1:00 pm<BR/>*08/29/23: 9:00 am, 1:00 pm <BR/>*08/30/23: 9:00 am, 1:00 pm<BR/>During an observation on 08/29/23 at 9:06 a.m., revealed Resident #98's breakfast tray had only one bite of ground sausage missing. No frozen treat was noted on Resident #98's tray or bedside table. Resident #98's meal ticket indicated frozen nutritional treat with meals. The observation revealed further that Resident #72's breakfast tray had one glass of milk drank and one bite of oatmeal. <BR/>During an observation on 08/29/23 at 1:25 p.m., revealed Resident #72 only ate his dessert, and his roommate gave him another dessert. Resident #72 did not eat his 2 chopped beef sandwiches. Resident #98's ate 50-75% of lunch. No frozen treat was noted on Resident #98's tray or bedside table.<BR/>During an observation on 08/29/23 at 6:36 p.m., revealed Resident #72 only drank his milk for dinner. Resident #98's ate 0-25% for dinner. No frozen treat was noted on Resident #98's tray or bedside table. <BR/>During an observation on 08/29/23 at 6:38 p.m., at the end of 300 hall, revealed a bucket with ice had frozen treats and house shakes. <BR/>During an observation on 08/30/23 at 8:56 a.m., revealed Resident #98 did not eat breakfast but drank a house shake. No frozen treat was noted on Resident #98's tray or bedside table.<BR/>During an interview on 08/30/23 at 9:03 a.m., CNA A said Resident #98 normally drank house shakes and today was the first time to hear he was supposed to have frozen treats with his meals. She said dietary was responsible for providing the frozen treats. CNA A said she had not gotten into the facility's electronic charting system and charted Resident #72 or Resident #98's meal intakes for the last 3 days. She said she had not looked at Resident #72 and Resident #98's care plan recently. She said Resident #98 and Resident #72 did not eat much the last three days. CNA A said maybe one day Resident #98 and Resident #72 ate 25-50% of their food. She said she was responsible for documenting meal intake and LVNs ensured it was inputted and correct. CNA A said it was important to document meal intake so the dietician would know if she needed to make changes. She said it was important to follow the care plan intervention to offer frozen treats to Resident #98 to help with weight loss and let the dietician know if the interventions worked. <BR/>During an interview on 08/30/23 at 2:07 p.m., LVN D said Resident #72 and Resident #98 were being monitored for weight loss. She said both residents were getting prescribed nutritional supplements by the nurses. LVN D said CNAs and LVNs should chart residents meal intakes. She said LVNs should make sure the meal intakes were documented at the end of the shift as the care plan intervention indicated. LVN D said the kitchen placed the house shakes and frozen treats on ice in a bucket on each hall. She said the CNAs should hand the nutrition frozen treats out to each resident. LVN D said the DON looked at the meal intake report to determine which resident needed to be seen by the dietician or dietary manager. She said dietary recommendations on the care plan should be followed to prevent further weight loss and improve nutritional status. LVN D said if recommendations were not followed, or meal intakes not documented residents were at risk for dehydration or illnesses. <BR/>During an interview on 08/31/23 at 8:20 a.m., LVN C said CNAs were responsible for documenting meal intakes. She said Resident #72 and Resident #98 were being monitored for weight loss. LVN C said Resident #72 normally ate 50% and Resident #98 75-100%. She said LVNs should make sure CNAs were documenting meal intakes. LVN C said it was important to document meal intakes to monitor for change of condition and know if a resident needed a supplement. She said dietary recommendation should be followed to prevent decline, skin breakdown, and improve nutrition. <BR/>During an interview on 08/31/23 at 9:45 a.m., the DON said CNAs and LVNs should document resident's meal intake in the facility's computer system. She said nursing staff were responsible for providing resident frozen treats per the doctor's orders and meal tickets. The DON said it was important to document meal intake and give dietary recommendations so dietary interventions could be planned, and new interventions developed, or revisions made to the care plan to prevent further weight loss. The DON said all nursing staff had access to resident's care plans on the facility's electronic charting system and should be followed. She said managers should review residents' charts to ensure it was being done and the dietician would also look at the information documented. <BR/>During an interview on 08/31/23 at 10:41 a.m., the ADM said CNAs should document meal intake amounts. He said nursing staff and dietary were responsible for dietary recommendations. The ADM said it was important to document and follow recommendation, to know if the resident received proper nutrition and prevent further weight loss. He said nursing administration should oversee this process. <BR/>Record review of a facility Care Planning policy revised 10/24/22 indicated .each resident's comprehensive care plan will describe the following .services that are to be furnished to attain or maintain the resident's highest practicable physical .well-being <BR/>Record review of a facility Nutrition/Hydration Management policy revised 06/20 indicated .to ensure that each resident maintains acceptable parameters of nutritional status .implementing the nutritional/hydration program .a comprehensive care plan is developed .that addresses nutrition/hydration and an individualized .management program based on individualized assessed needs

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision, for 2 of 2 smoking areas (West balcony, and East ground floor).<BR/> and eliminate accident and hazards for 3 of 19 residents (Residents #6, #62 and #39) reviewed for accidents and supervision. <BR/>1. The facility failed to provide supervision for Resident #6 and Resident #62 while smoking.<BR/>2. The facility failed to identify side rails and eliminate accident and hazards for Resident #39 's environment. <BR/>These failures could place residents at risk of injuries and burns.<BR/>Findings include:<BR/>1. Record review of Resident #6's face sheet, dated 07/14/22 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included encephalopathy (a disease that damages your brain), anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), HIV (human immunodeficiency virus) is a virus that attacks the body's immune system), cerebral edema (brain swelling). <BR/>Record review of Resident # 6's MDS, dated [DATE] indicated Resident # 6 made himself understood and understood others. Resident # 6 had a BIMS score of 15 which indicated he was cognitively intact. The MDS indicated Resident # 6 required supervision with bed mobility, dressing, toileting, personal hygiene, bathing and eating.<BR/>Record review of Resident #6 's care plan, dated 09/10/21, revealed Resident # 6 was a smoker. Interventions indicated: for smoking material to be maintained by staff and distributed during smoking times. Would smoke in designated smoking area and smoking breaks. <BR/>Record review of Resident #6's Smoking evaluation, dated 06/10/22, revealed Resident # 6 required direct supervision while smoking, all smoking material would be kept at the nurses' station and evaluation had been discussed with resident.<BR/>During an observation and interview on 07/14/22 at 9:30 a.m., ADON H and the surveyor saw Resident #6 with a cigarette and lighter in his hand while sitting on the balcony unattended by any staff member. ADON H talked with Resident #6 about the smoking policy and confiscated his paraphernalia. ADON H said it is hard to watch every resident because sometimes they go out on pass or have family and friends bring them cigarettes and staff were not aware. The ADON H said they have caught some residents with paraphernalia on them before and confiscated it. ADON H said the ADM talked to all residents that smoke this week about their cigarettes and the smoking policy. ADON H said all residents should follow the rules to keep it fair and to keep residents safe from burning themselves or starting a fire.<BR/>During an interview on 07/14/22 at 9:33 a.m., Resident #6 stated he was aware of the smoking policy but does not like it. Resident #6 said he feels he was safe and did not need anyone to watch him smoke. <BR/>2. Record review of Resident #62' s face sheet, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included dementia, tachycardia (a condition that makes your heartbeat more than 100 times per minute), atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), and hypertension (high blood pressure).<BR/>Record review of Resident #62's MDS, dated [DATE] indicated Resident #62 made himself understood and understood others. Resident #62 had a BIMS score of 15 which indicated he was cognitively intact. The MDS indicated Resident #62 required supervision with bed mobility, dressing, toileting, personal hygiene, and eating, independent in bathing.<BR/>Record review of Resident #62 's care plan, dated 01/06/22, revealed Resident #62 uses tobacco products: smoking, chewing or snuff. Interventions indicated: for smoking/tobacco supplies to be kept in the smoking supply box at the nurse's station. Will smoke only during the designated times determined by facility when supervision will be provided and will smoke in designated smoking area. <BR/>Record review of Resident # 62's Smoking evaluation, dated 05/18/22, revealed Resident #62 was a safe smoker with minimal supervision.<BR/>During an observation and interview on 07/11/22 at 3:48 p.m., revealed Resident #62 was outside on the smoking balcony with a lighter and smoking a cigarette. Resident #62 stated, he keeps his lighter, but that man referring to floor tech P lit my cigarette. I like to smoke on time, they set a time but never on time. Resident #62 walked away and would not answer any more questions.<BR/>During an interview on 07/11/22 at 3:50 p.m., CNA N looked out the door and verified that Resident #62 was indeed outside with a lighter and a lit cigarette. CNA N stated Resident #62 does what he wants to, he has 3 clocks set in his room and demands to smoke at smoke times. CNA N said residents are supposed to be supervised, to prevent them from burning themselves. <BR/>During an interview on 07/11/22 at 3:51 p.m., Floor tech P stated he lit Resident #62's cigarette and then left to go gather the other smokers. Floor tech P said the resident was very demanding when it came to smoke times and the DON and ADM was aware of his behavior. Floor tech P said he was not supposed to leave any resident unsupervised because they could burn themselves. <BR/>During an interview on 07/14/22 at 9:29 a.m., LVN L said to her knowledge all lighters and cigarettes are to be kept in a lock box that floor techs have for the safety of the residents.<BR/>During an interview on 07/13/22 at 3:30 p.m., Floor tech A said all residents who smoke are to keep their cigarettes and lighters in the lock box. He said they have about fifteen smokers. Floor Tech A said he supervises the residents who smoke for their safety.<BR/>During an interview on 07/14/22 at 1:29 p.m., the ADM said he talked with Resident # 6 with the Social Worker and gave him a final warning and Resident # 6 signed the notice. The ADM showed the signed form to the surveyor. The ADM said they have reviewed the policy with every resident who smokes starting on 7/11/22. The ADM said floor techs are the keepers of the lock box with cigarettes and lighters and he is supposed to follow up to make sure they are keeping the box locked and secure. The ADM said he instructed all staff if they see any resident with cigarettes or lighters to confiscate and report to him immediately. The ADM said the smoking policy states all cigarettes and lighters should be kept locked and his goals for the smoking residents are from them and their families to be compliant with the smoking policy so that they can be supervised and safe.<BR/>During an interview on 07/14/22 at 2:02 p.m., the DON said her expectation for smoking residents is to follow the policy and not try to sneak cigarettes and lighters. The DON said some residents have called their family to bring cigarettes, but they have directed staff if they see any paraphernalia to confiscate them. The ADM and Social Worker talked with residents and had them to sign an agreement this week and they need to abide by the agreement. The DON said she was told the ADM was also going to send a letter out to families about the smoking policy. The DON said ADM and Social Worker are the overseers of residents who smoke but failure to follow the policy could potentially cause injury to themselves such as burns.<BR/>Record review of policy Smoking by Residents dated March 2022, indicated, To respect the residents' choice and to maintain a safe healthy environment for both smokers and non-smokers. Smokers will be identified on admission and given a copy of smoking policy, IDT will create a care plan .Resident will be allowed to smoke in designated area only All smoking material will be stored in a secure area to ensure they are kept safe .All smoking sessions will be supervised by facility staff members.<BR/>Record review of smoking violation policy given by the DON on 07/13/22 indicated, Smoking by residents is only permitted in designated facility areas at designated times regulated by staff .It may be necessary to counsel patients or responsible parties who violate the smoking policy. Violation of this policy may compromise the safety of all residents and staff due to potential negative consequences that may occur.<BR/>3.Record review of Resident #39's face sheet dated 07/14/22 indicated Resident #39 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), dyspepsia (indigestion) and intellectual disabilities (a term used when there are limits to a person's ability to learn at an expected level and function in daily life). <BR/>Record review of Resident #39's most recent comprehensive MDS, dated [DATE], indicated Resident #39 rarely made herself understood and was rarely understood by others. Resident #39's brief interview for mental status score was not completed. The MDS indicated Resident #39 required total assist with bed mobility, dressing, eating, toileting, personal hygiene, and bathing. <BR/>Record review of the care plan dated 11/20/18 for Resident #39 indicated the resident was a risk for falls. Resident #39 was unaware of safety needs. Interventions indicated: anticipate and meet the resident's needs, bolster mattress to set safe bed boundaries, fall mat at bedside, low bed, keep in lowest position while in bed. <BR/>Record review of care plan dated 05/29/19 indicated Resident #39 has Cerebral Palsy, her muscles were spastic, and she was unable to control her body movements. Interventions indicated: required a low bed with a safety mat due to the possibility of falls from bed secondary to Cerebral Palsy with spastic movement.<BR/>During an observation on 07/11/22 at 3:47 p.m. revealed Resident #39 was in her bed with all 4 side rails up.<BR/>During an observation and interview on 07/12/22 at 3:10 p.m. revealed Resident #39 was in bed with all 4 side rails up. CNA G stated the resident's family member bought the current bed some months ago and they have been putting up all 4 side rails. CNA G said the DON and ADM were aware Resident #39 had the bed with side rails. CNA G said resident #39 has not had a fall and did not feel she was at risk for falling out of this bed.<BR/>During an observation on 07/13/22 at 9:27 a.m. revealed Resident #39 was in her bed with all 4 side rails up and fall mat on floor.<BR/>During an interview on 07/13/22 12:03 p.m., LVN L said she knew Resident # 39's bed had side rails but were not aware they were up. LVN L looked at the MAR to check the orders and said the orders indicated a low bed with a scoop mattress and a fall mat on the floor. LVN L said the bed was in the hallway for a while and when she came back to work from her off days the bed was in the room. LVN L said she thought the DON and ADM were aware of the bed, so she never questioned the bed. LVN L said they keep a close watch on Resident #39, but it could be a potential for her legs or head to be caught in between the rails but she never saw it and no staff ever reported it. LVN L stated Resident #39 mostly grinded her heels in bed, not thrashing. LVN L stated the only thing she did see was a potential to fall out of bed because it did not go down low to the ground. <BR/>During an interview on 07/14/22 at 9:30 a.m., ADON H said she knew Resident # 39 had the bed with rails, but her understanding was the ADM told maintenance to put the bed in Resident #39's room so she never questioned it. ADON H said she felt like the proper monitoring and tools were in place and Resident #39 was safe. ADON H said she could see the potential for Resident # 39 to bump her legs against side rails and cause bruises.<BR/>During an interview on 07/13/22 at 12:05 p.m., the ADM said from what he remember, the family was doing a Medicare spend down when they purchased the bed. The ADM said they placed a call to the family to let them know they were going to replace Residents # 39's bed with a low bed and a scoop mattress and were awaiting a return call. The ADM said he was not aware of siderails on the bed until today and he is getting the maintenance supervisor to place a zip tie on the side rails to prevent anyone from using them. In a subsequent interview at 12:20 p.m., the ADM said after looking at the bed for Resident #39, they are going to move the existing bed out and place a low bed with a scoop mattress in room. The ADM said he can see the risk of Resident #39 potentially getting caught in or in-between the rails and that could cause harm to any part of her body.<BR/>During an observation on 07/14/22 at 8:01 a.m., revealed Resident #39 was in a low bed with a scoop mattress and a fall mat. The bed with side rails had been removed from room.<BR/>During an interview on 07/14/22 at 8:06 a.m., CNA N said she thought Resident # 39's family member brought the bed and then someone put it in the room. CNA N said she liked the bed and did not believe Resident #39 was in any harm because she never saw her legs or head go through the rails.<BR/>During an interview on 07/14/22 at 8:09 a.m., CNA O said she never saw Resident # 39's legs or arms in between rails but it was a potential that it could.<BR/>During an interview on 07/14/22at 08:31 a.m., CNA G said resident # 39 could have fallen out of bed because it was not low enough, maybe get hurt or bruised related to side rails.<BR/>During an interview on 07/14/22 at 10:02 a.m., the Maintenance Supervisor said he was not aware of Resident # 39's bed until yesterday (07/13/2022), when he was instructed to move the bed out of room. The Maintenance Supervisor said he was not employed when that bed was placed in Resident # 39's room. The Maintenance Supervisor said after identifying the bed, he did believe it could have been a hazard if an emergency arose because the bed could not fit through the door. <BR/>During an interview on 07/14/22 at 2:02 p.m., the DON said she was told, the resident's family member had to do a spend down and bought the bed. The DON talked with Resident # 39's family member and he agreed to remove the bed, apply the low bed and scoop mattress. The DON said the bed was already in Resident # 39's room when she returned as DON. The DON said she had mention something to ADM while she was the MDS nurse about the bed but was informed by staff that the ADM instructed staff to put the bed in the room. The DON said they should use the least restrictive form of restraints. The DON said the low bed, fat mat and scoop mattress for Resident #39 was the least restrictive form of restraint. The DON said because of Resident #39's diagnosis of Cerebral Palsy with uncontrolled spasms she had the potential for body injury. <BR/>Record review of Restraints policy dated June 2020 indicated, Residents shall be provided an environment that is restraint free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measure shall be used. If facility is utilizing bed rail, the assessment bed rails entrapment risk assessment or other electronic documentation in PCC will be complete .prior to installation of bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for 1 of 7 residents (Resident #1) reviewed for neglect.<BR/>Resident #1 was identified as confused and a wanderer and had increased confusion but was not monitored more closely. <BR/>The facility did not report to HHSC when Resident #1 was discovered in traffic on a busy street on 7/27/24. <BR/>This failure placed the resident at risk for harm. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 7/30/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were cognitive communication deficit, muscle weakness, unsteadiness on feet, lack of coordination, and stroke.<BR/>Record review of Resident #1's quarterly MDS dated [DATE] indicated a BIMS score of 3 (severely cognitively impaired.) The MDS did not indicate any memory problems, mood issues or behavioral symptoms. The resident required partial to moderate assist with the helper doing less than half the effort for transfers and sit to stand. <BR/>Record review of Resident #1's care plan dated 2/28/24 and last revised on 5/28/24 indicated a Focus area of impaired cognitive function or impaired thought process related to a stroke. He wandered into other resident rooms and used the bathroom. He urinated on his jacket and would not allow it to be cleaned. One of the interventions was to redirect the resident when he wandered into other rooms. A Focused area dated 7/27/24 and last revised 7/30/24 indicated Resident #1 was at risk for elopement related to Elopement Risk sore. He had a wander guard in place. Some of the interventions were engage the resident in activities of his choice. Report to MD factors for potential elopement such as wandering, repeated request to leave the facility, and attempts to leave. Ensure the wander guard was in place. <BR/>Record review of Resident #1's Elopement Risk Evaluation dated 5/19/24 indicated a score of 1 with no risk of elopement. The form indicated if there was a yes to question 1 or 2 then the form was complete. Question one indicated the resident was able to make decisions regarding task of daily living and decisions were consistent and reasonable. The question was answered yes. However, additional information indicated the resident was at risk for elopement related to Elopement Evaluation risk score, the goals were he would remain safe within the facility unless accompanied by staff or authorized persons. The intervention was to engage the resident in actives of his choice. <BR/>Record review of Resident #1's Elopement Risk Evaluation dated 7/27/24 indicated a score of 15 (imminent Risk for elopement.) The form indicated Resident #1 was unable to make decisions regarding task of daily living, and he was unable to ambulate. The patient was cognitively impaired and had a history of leaving the community without informing staff. Additional information the resident is an elopement risk related to Elopement Evaluation risk score. <BR/>Record review of Resident #1's nursing note dated 7/27/24 at 12:37 a.m. indicated the resident continued day 10 of 10 of an antibiotic for UTI. He was pleasantly confused and was out of bed and self-propelling using his lower extremities about the facility. He had his clothes piled up in his wheelchair and was sitting on them as if they were a cushion. It was difficult to re-direct the resident, and he did not know what time it was. He was also redirected due to the fact that he would stand and attempt to walk and it looked like he was having balance issues. He was frequently reminded to sit in his wheelchair. Will continue to monitor. <BR/>Record review of Resident #1's History for Police Event (#242090341) indicated on 7/27/24 at 4:18 p.m. they received a call a resident had rolled away from the nursing home. At 4:19 p.m. the caller said the resident is in the middle of the street and they are trying to get him out of the roadway. They have blocked traffic to get him moved. At 4:31 the patent was rolled back to the location by staff who did not know he had even left. At 4:33 p.m. Resident #1 said he was out to see a friend at the apartments next door. He was advised that it was dangerous out on the roadway with vehicles. He was assisted back to facility. The resident said he would never do that again and that it was scary. <BR/>Record review of an incident report dated 7/27/24 at 4:28 p.m. indicated Resident #1 was reported by and off duty staff member to be outside in the area adjacent to the facility in his wheelchair rolling himself with his feet. The resident was returned to the facility by law enforcement and wheeled to his room. The resident was asked how he was able to leave the facility and he stated he just went out the door himself. When the resident was asked how he opened the door he said you do not need a code to open the door from the inside. When the resident was asked what door, he went out. He said he went out the front door. When the resident was asked how he got down the stairs he said he did not go down any starts he was on the ground floor, the resident was confused and not aware of the current situation. The form indicated the resident was oriented to person, impulsive with a lack of safety awareness. Predisposing environmental factors were recent illness, confusion, and impaired memory. Predisposing situational factors where the resident was a wanderer. <BR/>Record review of statements dated 7/27/24 from CNA I and CNA L that placed the resident in and around the 200 hall about 4:15 p.m. The facility provided a timeline for their investigation 8/1/24 at 12:30 p.m. with no date. The typed form indicated on 7/27/24 at 4:15 CNA I noted Resident #1 self-propelling self in wheelchair in hallway. At 4:18 p.m. CNA L noted Resident #1 sitting at the dining room table. Between 4:10 p.m. and 4:20 p.m. the family of another resident was noted in and out of the 300-hall door moving a resident belongings. At 4:26 p.m. Resident #1 was brought back to the facility by the police. With no signature.<BR/>Record review of TULIP ( HHSC system for reporting abuse) indicated no facility report was located for 7/27/24 for Resident #1. <BR/>During an interview on 7/30/24 at 9:28 a.m. the ADON P said Resident #1 was the resident that the police bought back on 7/27/24 and he was just on the side of the building. She said to the best of what they could figure out there was a family in the building picking up a resident's belonging, she said they felt like Resident #1 had gone out the door by kitchen/ nurses' station with those family members on 300 hall. She said Resident #1 was not considered at risk for wandering until 7/27/24. She said Resident #1 was confused at times but had never tried to leave. She said the nurse on duty LVN A said the police brought the resident back and only waved at her. The nurse said the floor tech brought Resident #1 back into to the facility. <BR/>During an interview on 7/30/24 at 9:45 a.m. Resident #1 said he did not remember leaving the facility on 7/27/24. He could not say where he lived now or where he used to live. He only said, I live here. He did say he used to go fishing every day and told fish stories. He was confused.<BR/>During an interview on 7/30/24 at 9:55 a.m. LVN B said Resident #1 was confused. She said she had never heard him say he was going to leave. She said a while back he thought his family was coming to take him home. He would pack his clothes and say he was waiting on his family to come and get him. She said he would place his clothes in the chair behind him. However recently he had not said anything about leaving. <BR/>During a telephone interview on 7/30/24 at 10:47 a.m. LVN A said on 7/27/24 around 4:00 p.m. LVN A said she was doing last med pass. She saw Resident # 1, he had been up and down the hallway all day, and she kept an eye on him due to his increased confusion. LVN A said Resident #1 had a UTI and had just finished antibiotics. She said he was wandering up and down the halls more than usual. LVN A said a group of family came to get another resident's belonging. She said Resident #1 had gone to the common area and the several members of a family walked in from the 300 hall. The LVN said she did not hear any alarms going off. She said the family members had been in and out of the facility multiple times. She said the doors were all locked and it was not easy to get out of the facility. She said another nurse called and said Resident #1 was outside about 4:28 p.m. She said she left by the side door of the 200-hall floor. LVN A said when she saw Resident #1 he was between the building parking lot and the apartment building across the street. She said when she saw him he was being wheeled up the ramp by Floor Tech C. LVN A said the Police had him and the floor tech went and got him. She said the police did not ask her name or speak to her, they only waved and left. She said she had tried to complete a skin assessment on Resident #1 but as soon as she removed one piece of clothing, he was putting another piece of clothes on. She said Resident #1 did not complain of any pain to her. She said Resident #1 told her he went out the ground floor. However, he could not because there were steps down to the ground level on the first floor. She said he exit to parking lot on the 300-hall looked like it is at the ground level. She said the family removed a lot of stuff, gave two big boxes and a couple of trash bags, and their hands were full. LVN A said they may not have seen the resident exit the facility with them. She said that was the way the staff pieced together Resident #1's possible exit. LVN A said she had texted ADON P to let her know the family had come to get the resident things at 4:17 right before the family left. She said she received a call on 7/27/24 at 4:28 p.m. and was notified Resident #1 was missing and outside with the police. She said that either way he went out the door would have been downhill. She said she had never seen him stand or walk. <BR/>During an interview on 7/30/24 at 12:25 p.m. the Administrator said he knew Resident #1 had left the faciity on 7/27/24. He said they had come to the conclusion he was not trying to elope. He said no staff he interviewed had seen him exit the building, but they felt he had got caught up in the traffic of the family leaving the facility. The Administrator said they did not think Resident #1 was trying to elope, and he was found by the apartments across the street. He said the staff did not know he was gone. He said he was not aware of the police saying anything about where he was found but they believed from what the nurse said he was just across the street and not on the main street in front of the facility. The Administrator said he was the abuse coordinator. He said they deliberated calling Resident #1's elopement, but Resident #1 did not have an intent to leave and he was only gone a short time. He said Resident #1 was only gone about 10 minutes as best they could determine with staff interviews. So he had not reported the incident to the State agency. He said he had not talked to Floor Tech C.<BR/>During a telephone interview on 7/30/24 at 12:35 p.m. Floor Tech C said he was upstairs on the second floor on 7/27/24. He said he was not sure of the time, but he was looking out the patio doors and he saw several police cars. He said a female officer was approaching the front door and he went down to answer the door. He said there were 3 police cars and one emergency vehicle parked by the corner of the facility. He said the officer wanted to know if Resident #1 was their resident. He said they wanted someone to escort Resident #1 back in the building. He said when he saw Resident #1, he was on the major street by the facility. Floor Tech C said Resident #1 said he hurt his hand because he could not stop his wheelchair from going down the hill so fast. He said the resident had passed the facility, crossed the street on the same side of the street, and had rolled down to almost the next street. He said he had turned around somehow but he was in the street because there was no sidewalk. Floor Tech C said Resident #1 said he was glad he did not get by car. He said Resident #1 said he was glad they had come to get him because he was scared a car was going to hit him. The Floor Tech said Resident # 1 was trying to figure out why so many police were there. He said he had wheeled Resident #1 back into the facility from the wheelchair access on the side of the building. He said no one had asked him where the resident was located when he got him from the police. <BR/>During an interview on 7/31/24 at 10:58 a.m. the Administrator said he had done an investigation regarding Resident # 1 leaving the facility. He said that he had interviewed staff on duty, and they were very direct on the time that they had last seen the resident. He said he did not interview the Floor Tech C, no one had told him was really involved with the incident. He was told a Floor Tech brought Resident # 1 back into the facility. He said CNA I said that she had last seen the resident between 4:10 p.m. and 4:15 p.m. He said LVN A said that she had gotten a call at 4:28 saying that the police had the resident outside. The Administrator said he said that he had not attempted to contact the family because they had just lost a relative. He said that he felt that Resident #1 had got caught up in the door when the family was leaving. He said the family should not have had a code and he does not know who let them in and who let them out or who let the resident out of the facility.<BR/>During an interview on 7/31/24 at 11:20 a.m. the DON said Resident #1 was more confused since he had a UTI. <BR/>During an interview on 8/1/24 at 12:30 p.m. the Administrator he had not called the incident in regarding Resident #1, but he realized it should have been called into the state. He said he realized also that he did not take all the steps to complete a thorough investigation. He said from his initial reports it appeared the resident only made it across the street to the apartments and did not get to the stop sign on the main street. <BR/>Record review of the facility Abuse Prevention and Prohibition Program policy last revised 8/2020 indicated Physical Neglect was inadequate provision of care, leaving someone unattended who needed supervision. An investigation consisted of the facility promptly and thoroughly investigating reports of resident neglect. The facility would interview any witnesses. Reportable events that did not result in serious bodily injury the Administrator would make a telephone report in 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision, for 2 of 2 smoking areas (West balcony, and East ground floor).<BR/> and eliminate accident and hazards for 3 of 19 residents (Residents #6, #62 and #39) reviewed for accidents and supervision. <BR/>1. The facility failed to provide supervision for Resident #6 and Resident #62 while smoking.<BR/>2. The facility failed to identify side rails and eliminate accident and hazards for Resident #39 's environment. <BR/>These failures could place residents at risk of injuries and burns.<BR/>Findings include:<BR/>1. Record review of Resident #6's face sheet, dated 07/14/22 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included encephalopathy (a disease that damages your brain), anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), HIV (human immunodeficiency virus) is a virus that attacks the body's immune system), cerebral edema (brain swelling). <BR/>Record review of Resident # 6's MDS, dated [DATE] indicated Resident # 6 made himself understood and understood others. Resident # 6 had a BIMS score of 15 which indicated he was cognitively intact. The MDS indicated Resident # 6 required supervision with bed mobility, dressing, toileting, personal hygiene, bathing and eating.<BR/>Record review of Resident #6 's care plan, dated 09/10/21, revealed Resident # 6 was a smoker. Interventions indicated: for smoking material to be maintained by staff and distributed during smoking times. Would smoke in designated smoking area and smoking breaks. <BR/>Record review of Resident #6's Smoking evaluation, dated 06/10/22, revealed Resident # 6 required direct supervision while smoking, all smoking material would be kept at the nurses' station and evaluation had been discussed with resident.<BR/>During an observation and interview on 07/14/22 at 9:30 a.m., ADON H and the surveyor saw Resident #6 with a cigarette and lighter in his hand while sitting on the balcony unattended by any staff member. ADON H talked with Resident #6 about the smoking policy and confiscated his paraphernalia. ADON H said it is hard to watch every resident because sometimes they go out on pass or have family and friends bring them cigarettes and staff were not aware. The ADON H said they have caught some residents with paraphernalia on them before and confiscated it. ADON H said the ADM talked to all residents that smoke this week about their cigarettes and the smoking policy. ADON H said all residents should follow the rules to keep it fair and to keep residents safe from burning themselves or starting a fire.<BR/>During an interview on 07/14/22 at 9:33 a.m., Resident #6 stated he was aware of the smoking policy but does not like it. Resident #6 said he feels he was safe and did not need anyone to watch him smoke. <BR/>2. Record review of Resident #62' s face sheet, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included dementia, tachycardia (a condition that makes your heartbeat more than 100 times per minute), atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), and hypertension (high blood pressure).<BR/>Record review of Resident #62's MDS, dated [DATE] indicated Resident #62 made himself understood and understood others. Resident #62 had a BIMS score of 15 which indicated he was cognitively intact. The MDS indicated Resident #62 required supervision with bed mobility, dressing, toileting, personal hygiene, and eating, independent in bathing.<BR/>Record review of Resident #62 's care plan, dated 01/06/22, revealed Resident #62 uses tobacco products: smoking, chewing or snuff. Interventions indicated: for smoking/tobacco supplies to be kept in the smoking supply box at the nurse's station. Will smoke only during the designated times determined by facility when supervision will be provided and will smoke in designated smoking area. <BR/>Record review of Resident # 62's Smoking evaluation, dated 05/18/22, revealed Resident #62 was a safe smoker with minimal supervision.<BR/>During an observation and interview on 07/11/22 at 3:48 p.m., revealed Resident #62 was outside on the smoking balcony with a lighter and smoking a cigarette. Resident #62 stated, he keeps his lighter, but that man referring to floor tech P lit my cigarette. I like to smoke on time, they set a time but never on time. Resident #62 walked away and would not answer any more questions.<BR/>During an interview on 07/11/22 at 3:50 p.m., CNA N looked out the door and verified that Resident #62 was indeed outside with a lighter and a lit cigarette. CNA N stated Resident #62 does what he wants to, he has 3 clocks set in his room and demands to smoke at smoke times. CNA N said residents are supposed to be supervised, to prevent them from burning themselves. <BR/>During an interview on 07/11/22 at 3:51 p.m., Floor tech P stated he lit Resident #62's cigarette and then left to go gather the other smokers. Floor tech P said the resident was very demanding when it came to smoke times and the DON and ADM was aware of his behavior. Floor tech P said he was not supposed to leave any resident unsupervised because they could burn themselves. <BR/>During an interview on 07/14/22 at 9:29 a.m., LVN L said to her knowledge all lighters and cigarettes are to be kept in a lock box that floor techs have for the safety of the residents.<BR/>During an interview on 07/13/22 at 3:30 p.m., Floor tech A said all residents who smoke are to keep their cigarettes and lighters in the lock box. He said they have about fifteen smokers. Floor Tech A said he supervises the residents who smoke for their safety.<BR/>During an interview on 07/14/22 at 1:29 p.m., the ADM said he talked with Resident # 6 with the Social Worker and gave him a final warning and Resident # 6 signed the notice. The ADM showed the signed form to the surveyor. The ADM said they have reviewed the policy with every resident who smokes starting on 7/11/22. The ADM said floor techs are the keepers of the lock box with cigarettes and lighters and he is supposed to follow up to make sure they are keeping the box locked and secure. The ADM said he instructed all staff if they see any resident with cigarettes or lighters to confiscate and report to him immediately. The ADM said the smoking policy states all cigarettes and lighters should be kept locked and his goals for the smoking residents are from them and their families to be compliant with the smoking policy so that they can be supervised and safe.<BR/>During an interview on 07/14/22 at 2:02 p.m., the DON said her expectation for smoking residents is to follow the policy and not try to sneak cigarettes and lighters. The DON said some residents have called their family to bring cigarettes, but they have directed staff if they see any paraphernalia to confiscate them. The ADM and Social Worker talked with residents and had them to sign an agreement this week and they need to abide by the agreement. The DON said she was told the ADM was also going to send a letter out to families about the smoking policy. The DON said ADM and Social Worker are the overseers of residents who smoke but failure to follow the policy could potentially cause injury to themselves such as burns.<BR/>Record review of policy Smoking by Residents dated March 2022, indicated, To respect the residents' choice and to maintain a safe healthy environment for both smokers and non-smokers. Smokers will be identified on admission and given a copy of smoking policy, IDT will create a care plan .Resident will be allowed to smoke in designated area only All smoking material will be stored in a secure area to ensure they are kept safe .All smoking sessions will be supervised by facility staff members.<BR/>Record review of smoking violation policy given by the DON on 07/13/22 indicated, Smoking by residents is only permitted in designated facility areas at designated times regulated by staff .It may be necessary to counsel patients or responsible parties who violate the smoking policy. Violation of this policy may compromise the safety of all residents and staff due to potential negative consequences that may occur.<BR/>3.Record review of Resident #39's face sheet dated 07/14/22 indicated Resident #39 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), dyspepsia (indigestion) and intellectual disabilities (a term used when there are limits to a person's ability to learn at an expected level and function in daily life). <BR/>Record review of Resident #39's most recent comprehensive MDS, dated [DATE], indicated Resident #39 rarely made herself understood and was rarely understood by others. Resident #39's brief interview for mental status score was not completed. The MDS indicated Resident #39 required total assist with bed mobility, dressing, eating, toileting, personal hygiene, and bathing. <BR/>Record review of the care plan dated 11/20/18 for Resident #39 indicated the resident was a risk for falls. Resident #39 was unaware of safety needs. Interventions indicated: anticipate and meet the resident's needs, bolster mattress to set safe bed boundaries, fall mat at bedside, low bed, keep in lowest position while in bed. <BR/>Record review of care plan dated 05/29/19 indicated Resident #39 has Cerebral Palsy, her muscles were spastic, and she was unable to control her body movements. Interventions indicated: required a low bed with a safety mat due to the possibility of falls from bed secondary to Cerebral Palsy with spastic movement.<BR/>During an observation on 07/11/22 at 3:47 p.m. revealed Resident #39 was in her bed with all 4 side rails up.<BR/>During an observation and interview on 07/12/22 at 3:10 p.m. revealed Resident #39 was in bed with all 4 side rails up. CNA G stated the resident's family member bought the current bed some months ago and they have been putting up all 4 side rails. CNA G said the DON and ADM were aware Resident #39 had the bed with side rails. CNA G said resident #39 has not had a fall and did not feel she was at risk for falling out of this bed.<BR/>During an observation on 07/13/22 at 9:27 a.m. revealed Resident #39 was in her bed with all 4 side rails up and fall mat on floor.<BR/>During an interview on 07/13/22 12:03 p.m., LVN L said she knew Resident # 39's bed had side rails but were not aware they were up. LVN L looked at the MAR to check the orders and said the orders indicated a low bed with a scoop mattress and a fall mat on the floor. LVN L said the bed was in the hallway for a while and when she came back to work from her off days the bed was in the room. LVN L said she thought the DON and ADM were aware of the bed, so she never questioned the bed. LVN L said they keep a close watch on Resident #39, but it could be a potential for her legs or head to be caught in between the rails but she never saw it and no staff ever reported it. LVN L stated Resident #39 mostly grinded her heels in bed, not thrashing. LVN L stated the only thing she did see was a potential to fall out of bed because it did not go down low to the ground. <BR/>During an interview on 07/14/22 at 9:30 a.m., ADON H said she knew Resident # 39 had the bed with rails, but her understanding was the ADM told maintenance to put the bed in Resident #39's room so she never questioned it. ADON H said she felt like the proper monitoring and tools were in place and Resident #39 was safe. ADON H said she could see the potential for Resident # 39 to bump her legs against side rails and cause bruises.<BR/>During an interview on 07/13/22 at 12:05 p.m., the ADM said from what he remember, the family was doing a Medicare spend down when they purchased the bed. The ADM said they placed a call to the family to let them know they were going to replace Residents # 39's bed with a low bed and a scoop mattress and were awaiting a return call. The ADM said he was not aware of siderails on the bed until today and he is getting the maintenance supervisor to place a zip tie on the side rails to prevent anyone from using them. In a subsequent interview at 12:20 p.m., the ADM said after looking at the bed for Resident #39, they are going to move the existing bed out and place a low bed with a scoop mattress in room. The ADM said he can see the risk of Resident #39 potentially getting caught in or in-between the rails and that could cause harm to any part of her body.<BR/>During an observation on 07/14/22 at 8:01 a.m., revealed Resident #39 was in a low bed with a scoop mattress and a fall mat. The bed with side rails had been removed from room.<BR/>During an interview on 07/14/22 at 8:06 a.m., CNA N said she thought Resident # 39's family member brought the bed and then someone put it in the room. CNA N said she liked the bed and did not believe Resident #39 was in any harm because she never saw her legs or head go through the rails.<BR/>During an interview on 07/14/22 at 8:09 a.m., CNA O said she never saw Resident # 39's legs or arms in between rails but it was a potential that it could.<BR/>During an interview on 07/14/22at 08:31 a.m., CNA G said resident # 39 could have fallen out of bed because it was not low enough, maybe get hurt or bruised related to side rails.<BR/>During an interview on 07/14/22 at 10:02 a.m., the Maintenance Supervisor said he was not aware of Resident # 39's bed until yesterday (07/13/2022), when he was instructed to move the bed out of room. The Maintenance Supervisor said he was not employed when that bed was placed in Resident # 39's room. The Maintenance Supervisor said after identifying the bed, he did believe it could have been a hazard if an emergency arose because the bed could not fit through the door. <BR/>During an interview on 07/14/22 at 2:02 p.m., the DON said she was told, the resident's family member had to do a spend down and bought the bed. The DON talked with Resident # 39's family member and he agreed to remove the bed, apply the low bed and scoop mattress. The DON said the bed was already in Resident # 39's room when she returned as DON. The DON said she had mention something to ADM while she was the MDS nurse about the bed but was informed by staff that the ADM instructed staff to put the bed in the room. The DON said they should use the least restrictive form of restraints. The DON said the low bed, fat mat and scoop mattress for Resident #39 was the least restrictive form of restraint. The DON said because of Resident #39's diagnosis of Cerebral Palsy with uncontrolled spasms she had the potential for body injury. <BR/>Record review of Restraints policy dated June 2020 indicated, Residents shall be provided an environment that is restraint free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measure shall be used. If facility is utilizing bed rail, the assessment bed rails entrapment risk assessment or other electronic documentation in PCC will be complete .prior to installation of bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 3 residents (Resident #98, Resident #267) reviewed for reasonable accommodations.<BR/>The facility failed to ensure Resident #98 and Resident#267 call lights were within reach.<BR/>The facility failed to ensure Resident #98, and Resident #267 had been assessed for the appropriate type of call light.<BR/>These failures could place residents at risk for unmet needs.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 08/28/23 indicated Resident #98 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses including Asperger's syndrome (a developmental disorder affecting ability to effectively socialize and communicate), muscle wasting and atrophy (is the wasting (thinning) or loss of muscle tissue), muscle weakness, slowness and poor responsiveness, limitation of activities due to disability, and need for assistance with personal care.<BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #98 was sometimes understood and usually understood others. The MDS indicated Resident #98 had adequate hearing, unclear speech, and highly impaired vision. The MDS indicated Resident #98 had a BIMS score of 05 which indicated severe cognitive impairment and required limited assistance for bathing and extensive assistance for bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident #98 had limited range of motion to his upper and lower extremities on one side. The MDS indicated Resident #98's mobility device was a wheelchair. The MDS indicated Resident #98 had an indwelling catheter and always incontinent for bowel continence. <BR/>Record review of the care plan dated 05/03/23 indicated Resident #98 was at high risk for falls. Intervention included be sure the resident's call light was within reach and encourage use for assistance as needed. <BR/>During an observation on 08/28/23 at 9:43 a.m., revealed Resident #98 was in the bed and his call light was on the floor. <BR/>During an observation on 08/29/23 at 8:30 a.m., revealed Resident #98 was in the bed and his call light was hanging off the side of the bed, not within reach. <BR/>During an observation on 08/29/23 at 10:34 a.m., revealed Resident #98 was in the bed and his call light was placed near his contracted right hand. <BR/>During an observation on 08/29/23 at 6:36 p.m., revealed Resident #98 was in the bed and his call light was on the floor.<BR/>During an observation on 08/30/23 at 8:56 a.m., revealed Resident #98 was in the bed and his call light was on the floor.<BR/>During an observation on 08/31/23 at 8:00 a.m., revealed Resident #98 was in the bed and his call light was hanging off the side of the bed, not within reach.<BR/>During an observation on 08/31/23 at 9:20 a.m., revealed Resident #98 was in the bed and his call light was hanging off the side of the bed, not within reach.<BR/>2. Record review of a face sheet dated 08/28/23 indicated Resident #267 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses including contractures (is a fixed tightening of muscle, tendons, ligaments, or skin) of right and left shoulder, right and left elbow, right and left hand, left and right knee, limitation of activities due to disability, muscle wasting and atrophy (is the wasting (thinning) or loss of muscle tissue), contracture of muscle of left and right hand, and hypoxic ischemic encephalopathy (is a condition that happens when there is a loss of oxygen and/or reduced blood flow to the brain). <BR/>Record review of an annual MDS assessment dated [DATE] indicated Resident #267 was rarely/never understood and rarely/understood others. The MDS indicated Resident #267 had adequate hearing and no speech. The MDS indicated Resident #267 was unable to complete the BIMS assessment due to being rarely/never understood. The MDS indicated Resident #267 had short-and-long term memory problems with severely impaired cognitive skills for daily decision making. The MDS indicated Resident #267 required extensive assistance for personal hygiene and total dependence for bed mobility, dressing, eating, toilet use, and bathing. The MDS indicated Resident #267 had bilateral (both sides) upper and lower extremities limited range of motion. The MDS indicated Resident #267 was always incontinent for urinary and bowel. <BR/>Record review of a care plan dated 11/19/20 indicated Resident #267 was low risk for falls related to no independent movement. Intervention included be sure the resident's call light was within reach and encourage use for assistance as needed.<BR/>Record review of a care plan dated 02/21/22 indicated Resident #267 had alteration in musculoskeletal status related to bilateral hand contractures due to immobility and disease process. Intervention included apply hand rolls to bilateral hands as recommended. <BR/>During an observation on 08/28/23 at 9:49 a.m., revealed Resident #267 was in the bed with a push call light clipped to his sheet, not within reach of his hands. In Resident #267's hands were rolled washcloths. <BR/>During an observation on 08/28/23 at 3:19 p.m., revealed Resident #267 was in the bed with a push call light clipped to his sheet, not within reach of his hands. In Resident #267's hands were rolled washcloths.<BR/>During an observation on 08/29/23 at 8:34 a.m., revealed Resident #267 was in the bed with a push call light clipped to his sheet, not within reach of his hands. In Resident #267's hands were rolled washcloths.<BR/>During an observation on 08/29/23 at 10:36 a.m., revealed Resident #267 was in the bed with a push call light clipped to his sheet, not within reach of his hands. In Resident #267's hands were rolled washcloths.<BR/>During an observation on 08/29/23 at 3:05 p.m., revealed Resident #267 was in the bed with a push call light clipped to his sheet, not within reach of his hands. In Resident #267's hands were rolled washcloths.<BR/>During an interview on 08/30/23 at 9:03 a.m., CNA A said call lights should be within reach of the residents. She said Resident #98 and Resident #267 should have a touch pad call light instead of the push button. CNA A said the call lights were important for residents to get assistance or call for help. She said all nursing staff was responsible for ensuring call lights were within reach. CNA A said she did not know how residents were assessed to determine if they needed a different type if light. <BR/>During an interview on 08/30/23 at 2:07 p.m., LVN D said everyone was responsible for making sure call lights were within reach. She said call lights were used so the resident could get help, let staff know if they were in pain or needed incontinence care. LVN D said a touch pad call light would be good for Resident #98, but she did not know if Resident #267 could use a call light. She said the DON should be notified if a resident needed a different type of call light. LVN D said the appropriate type of call lights were important to accommodate the needs of the resident.<BR/>During an interview on 08/30/23 at 5:36 p.m., the OT Director said she went to evaluate Resident #98 and Resident #267, and they both could push the call light button. <BR/>During an interview on 08/31/23 at 8:20 a.m., LVN C said everybody was responsible for making sure call lights were within reach. She said nurses were responsible for making sure the resident had the appropriate type of call light. LVN C said Resident #98 and Resident #267 could use the push button call lights. She said she had notified therapy to evaluate Resident #267 to make sure he had the right call light, but she could not remember when. LVN C said the facility recently had a new company take over the therapy department so she could not remember who she told. She said Resident #267 normally had hand rolls and were taken out every 2 hours or so. LVN C said she could see when Resident #267 had hands rolls in place, a push button call light would not work for him. She said call lights were used to call for assistance or when in distress. LVN C said when call lights were not within reach, falls could happen. <BR/>During an observation on 08/31/23 at 9:16 a.m., revealed Resident #267 was in the bed with a push call light clipped to his sheet, not within reach of his hands. In Resident #267's hands were rolled washcloths.<BR/>During an interview on 08/31/23 at 9:45 a.m., the DON said all staff were responsible for making sure call lights were within reach. She said a resident admitted with contractures should be evaluated by therapy for call light appropriateness. The DON said after admission, it was a team effort to assess the resident to make sure they had the right type of call light. She said without personally evaluating Resident #98 and Resident #267, she could not say which call light was appropriate for them. The DON said call lights were important to take care of the resident's needs. She said all staff should oversee each other to ensure call lights were placed within reach. The DON said when call lights were not within reach or not the right type of call light, needs cannot be met timely. <BR/>During an interview on 08/31/23 at 10:41 a.m., the ADM said facility staff were responsible for placing call lights within reach and ensure they were appropriate for the resident. He said call lights were important because residents used them to call for help. The ADM said charge nurses, managers, and facility ambassadors should be overseeing by making rounds. He said call lights not being in reach placed residents at risk for falls or needs not being met.<BR/>Record review of a facility Resident Rights-Accommodation of Needs policy date revised 08/20 indicated to ensure that the facility provided an environment and services that meet residents' individual needs

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to consult with the resident physician when there was a need to alter treatment for 1 out of 3 residents (Resident #61) reviewed for notification of changes. <BR/>The facility failed to notify and consult with the physician about the changes in Resident #61's high blood sugar readings.<BR/>This failure could place residents at the risk of not receiving appropriate medical interventions, which could result in severe illness or hospitalization.<BR/>Findings included:<BR/>Record review of Resident #61's face sheet, dated 09/05/23 indicated Resident #61 was an [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included stroke (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), diabetes (a condition that happens when your blood sugar (glucose) is too high) and seizures (when too many of your brain cells become excited at the same time).<BR/>Record review of Resident #61's quarterly MDS assessment, dated 08/04/23, indicated Resident #61 was understood and understood others. Resident #61's BIMs score was 14, which indicated he was cognitively intact. Resident #61 required extensive assist with bathing, and limited assist with eating and independent with toileting, personal hygiene, transfer, dressing, and bed mobility. The MDS indicated Resident #61 received insulin during the 7-day look back period.<BR/>Record review of Resident #61's comprehensive care plan, dated 04/12/23 indicated <BR/>Resident #61 required insulin products related to diagnosis of diabetes. The interventions of the care plan were for staff to provide Resident #61 with medications as ordered, check blood sugars as ordered and monitor for any signs or symptoms of low or high blood sugars due to new diagnosis and use of insulin.<BR/>Record review of Resident #61's physician's orders dated 04/10/23 indicated, Humalog injection solution 100units/ml(lispro). Inject 10 units subcutaneously with meals for diagnosis of diabetes with blood sugar checks before meals<BR/>Record review of Resident #61's physician's orders dated 04/17/23 revealed, Lantus Solostar subcutaneous injection 100units/ml. Inject 20 units subcutaneously in the morning for diagnosis of diabetes.<BR/>Record review of Resident #61's physician's orders dated 04/17/23 revealed, Lantus Solostar subcutaneous injection 100units/ml. Inject 15 units subcutaneously in the evening for diagnosis of diabetes.<BR/>Record review of Resident #61's MAR dated August 2023 documented by LVN S revealed a high blood sugar over 400 on the following days and times: 417 on 8/22/23 at 12:00pm, 410 on 8/26/23 at 12:00pm, 510 on 08/27/23 at 12:00pm and 404 on 08/28/23 at 12:00pm and documented by LVN T 400 on 08/26/23 at 7:00am.<BR/>Record review of Resident #61's progress notes dated August 2023 did not reveal any notes regarding blood sugars over 400 were reported to the physician or NP. <BR/>During an interview on 08/30/23 at 11:10 a.m., Resident #61 said staff did let him know about his blood sugars but he did not understand why some of his blood sugar readings were high.<BR/>During an observation and interview on 08/30/23 at 2:41 p.m., LVN R said if Resident #61's blood sugar was over 401 she would notify the doctor. She looked on his MAR and saw some of his recent blood sugars were over 400 and then looked at his nurses notes and did not see any notification to the physician. LVN R said she would notify the physician about Resident #61's high blood sugar readings. She said it was important to notify the physician of high blood sugar results to prevent any further damage to his kidneys or other organs of his body. <BR/>During a phone interview on 08/30/23 at 2:53 p.m., the facility NP said he was just informed by LVN R of Resident #61's blood sugar readings. He said he expected staff to notify him of blood sugar readings below 60 and above 400. He said he communicated to the primary physician about any changes provided for the facility. He said he amended Resident #61's insulin. He said untreated hyperglycemia over a period could lead to organ damage.<BR/>Record review of Resident #61's physician's orders dated 08/30/23 revealed, Lantus Solostar subcutaneous injection 100units/ml. Inject 30 units subcutaneously in the morning.<BR/>Record review of Resident #61's physician's orders dated 08/30/23 revealed, Lantus Solostar subcutaneous injection 100units/ml. Inject 20 units subcutaneously in the evening.<BR/>During a phone interview on 08/30/23 at 3:49 p.m., LVN S said if a resident's blood sugar reading was over 400, she would notify the physician or NP. She said she was Resident #61's primary nurse but did not remember Resident #61's blood sugars being high. She said she did not remember notifying the doctor about his blood sugars over the weekend (08/26/23-08/27/23) or on Monday (08/28/23). LVN S said it was important to notify the doctor or NP of high blood sugar reading because a resident could go into a diabetic coma. <BR/>During an interview on 08/30/23 at 4:41 p.m., ADON H said an order to notify the physician or NP of low or high blood sugars was usually in the orders. She said if they did not have an order, she would use best practice and notify the doctor of any blood sugar readings over 400. The ADON H said a high blood sugar reading could cause further issues with diabetes if not under control.<BR/>During an interview on 08/30/23 at 4:57 p.m., the DON said the physician or NP should be notified of blood sugars over 400. She said the unit managers should be monitoring MARS daily, and NP/physicians reviewed when making rounds. The DON said if blood sugars remain uncontrolled a resident could have adverse effects. <BR/>During an interview on 08/30/23 at 5:24 p.m., the Administrator said he was unaware when the physician should be notified of blood sugars, but he said nurses should be following the parameters set by the physician. He said nurse managers and the DON should be monitoring blood sugars readings. The Administrator said if a resident had a change in condition, then the nurses should be notifying the physician. <BR/>Record review of the facility policy for Blood Glucose Monitoring revised 06/2020, indicated, Purpose: to monitor blood glucose concentration as ordered by the attending physician. Policy: the attending physician will be notified of a blood sugar lower than 60 or higher than 400, unless otherwise indicated in the plan of care.<BR/>Record review of the facility policy for Notification of physician revised 06/2020, indicated, To ensure residents, family, legal representative, and physicians are informed of changes in the resident's condition in a timely manner. Definition: an acute change of condition was a sudden, deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. The facility will promptly inform the resident, consult with the resident's attending physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to a significant change in residents' physical cognitive behavior or functional status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 2 (Resident #81 and Resident #5) of 7 residents reviewed for privacy and confidentiality.<BR/>ADON K failed to ensure she closed the EMR of Resident #81 before entering his room to obtain a blood sugar check and administer medications. <BR/>LVN V failed to ensure she closed Resident #5's EMR before entering the supply room and leaving the cart unattended. <BR/>These failures could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others.<BR/>Findings included:<BR/>1. Record review of Resident #81's face sheet dated 08/30/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis that affects all four limbs, plus torso), diabetes mellitus (a group of diseases that result in too much sugar in the blood), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety. <BR/>Record review of Resident #81's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS indicated Resident #81 had a BIMS score of 15, indicating his cognition was intact. The MDS indicated he was totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated he received insulin injections 7 out of the 7 days of the look back period.<BR/>During an observation on 08/29/23 at 08:30 AM, revealed ADON K entered Resident #81's room to obtain a blood sugar check. ADON K left Resident #81's MAR screen open on her cart facing toward Resident #81's room but far enough someone could have stopped visualized it. ADON K came back to the cart and obtained Resident #81's medications. After obtaining Resident #81's medications, ADON K entered his room to administer the medications leaving the MAR screen open. A staff member came next to the cart waiting on ADON K. Multiple staff members were observed passing down the hallway.<BR/>During an interview on 08/29/23 at 08:59 AM, ADON K said it was the nurse's responsibility to keep EMR locked when not present. ADON K said she forgot to lock the screen and someone could have seen the resident's information.<BR/>2. Record review of Resident #5's face sheet dated 08/30/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (memory loss), neuromuscular dysfunction of bladder (bladder dysfunction caused by nervous system conditions), diabetes mellitus (a group of diseases that result in too much sugar in the blood) and essential hypertension (high blood pressure). <BR/>Record review of Resident #5's annual MDS assessment dated [DATE], indicated Resident #5 had unclear speech, was usually understood and usually understood others. The MDS indicated Resident #5 had a BIMS score of 5, which indicated her cognition was severely impaired. The MDS indicated Resident #5 required extensive assistance with bed mobility, dressing, eating, toileting, personal hygiene, and bathing. <BR/>During an observation and interview on 08/29/23 at 09:17 AM, the 316-331 medication cart was parked outside room [ROOM NUMBER], a supply room. The MAR for Resident #5 was open, turned toward the hall and visible with her information. There was not a staff member present. LVN V came out of the supply room, and said she was the one responsible for leaving the screen with the MAR open. LVN V said she quickly ran to the supply room to obtain a syringe and did not think about closing Resident #5's EMR. LVN V said she was responsible for ensuring the EMR screen was kept locked when not present. LVN V said by not locking the EMR screen the resident's personal information could be seen by others passing by .<BR/>During an interview on 08/30/23 at 4:50 PM, the ADM said he expected the MAR screen to be closed when the nurses entered the resident's room or if they left the cart unattended. The ADM said it was a HIPPA violation and breech of resident information leaving the screen with resident information up and visible to others. The ADM said everyone was responsible for ensuring resident information was kept confidential.<BR/>During an interview on 08/30/23 at 5:22 PM, the DON said she expected the EMR screen to be locked and the resident's information to be kept confidential. The DON said the nurse was responsible for ensuring the screen was kept locked when not in use. The DON said by not keeping the screen locked was a privacy and confidentially issue.<BR/>Record review of the facility's policy General Guidelines for Medication Administration revised on 08/2020, indicated . privacy is maintained for all resident information at all times by closing the MAR when not in use

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of a face sheet dated 8/30/23 indicated Resident #23 was [AGE] year-old female and admitted to the facility on [DATE] with diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), unsteadiness on feet, and need for assistance with personal care.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #23 was understood and understood others. The MDS indicated Resident #23 had adequate hearing, clear speech, and impaired vision. The MDS indicated Resident #23 had a BIMS score of 15 which indicated intact cognition and only required supervision for dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #23 was always continent for urinary and bowel. <BR/>Record review of a care plan with revision date of 6/19/23 indicated Resident #23 had an ADL self-care performance deficit related to impaired vision. Resident #23 was able to do most ADLs with supervision or setup assist. Intervention included toilet use: Resident #23 required 1 person assist for toileting. <BR/>During an observation and interview on 8/29/23 at 8:41 AM, Resident #23 said housekeepers cleaned the bare minimum when they did show up. She said no one has emptied her bathroom trash since Friday (8/25/23) and no one had cleaned the bathroom in a few weeks. Resident #23's toilet bowel had light brown streaks and the trash can was &frac34; full. <BR/>During an interview on 8/30/23 at 9:03 AM, CNA A said there was no housekeeping the past weekend, so she was not surprised Resident #23's bathroom was not cleaned. CNA A said an unclean bathroom had germs which was not good for residents. <BR/>During an interview on 8/30/23 at 2:07 PM, LVN D said Resident #23 complained about her bathroom not being cleaned regularly. <BR/>During an interview on 8/31/23 at 8:20 AM, LVN C said housekeeping should clean residents' bathrooms daily. She said it was important for residents to have a clean, homelike environment without germs. <BR/>4. Record review of a face sheet dated 8/28/23 indicated Resident #267 was a [AGE] year-old male and admitted on [DATE] with diagnoses including dysphasia (difficulty swallowing foods or liquids) following cerebral infarction (stroke) and protein calorie malnutrition (is the state of inadequate intake of food). <BR/>Record review of an annual MDS assessment dated [DATE] indicated Resident #267 was rarely/never understood and rarely/understood others. The MDS indicated Resident #267 had adequate hearing and no speech. The MDS indicated Resident #267 was unable to complete the BIMS assessment due to being rarely/never understood. The MDS indicated Resident #267 had short-and-long term memory problems with severely impaired cognitive skills for daily decision making. The MDS indicated Resident #267 required extensive assistance for personal hygiene and total dependence for bed mobility, dressing, eating, toilet use, and bathing. The MDS indicated Resident #267 had a feeding tube (is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) and received calories and fluid intake through it. <BR/>Record review of the care plan with revision date of 8/25/21 indicated Resident #267 required tube feeding related to respiratory failure (is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) with PEG (a percutaneous endoscopic gastrostomy (PEG) is a procedure to place a feeding tube) status secondary to anoxic brain injury (the brain is deprived of oxygen). <BR/>Record review of the Resident #267's consolidated physician's order dated 11/28/22 indicated Enteral feed order every shift continuous: Formula: Glucerna 1.5 at 65 ml/hr with H2O at 42 ml/hr x 22 hours. <BR/>During an observation on 8/28/23 at 9:49 AM, revealed Resident #267 had a feeding pump running with enteral formula. Resident #267 had a large amount of dried, beige substance on the floor, bottom of the IV pole, feeding pump plug, wall, and bed. <BR/>During an interview on 8/30/23 at 9:03 AM, CNA A said whoever initially spilled Resident #267's formula should have cleaned it up. She said housekeeping and CNAs should have also cleaned the spillage. She said wasted formula could draw pests and made the room look terrible. CNA A said Resident #267's room was not sanitized with dried formula everywhere.<BR/>During an interview on 8/30/23 at 10:45 AM, the Housekeeping Supervisor said one weekend day, there was no housekeeper working. She said the housekeepers should clean residents' rooms and bathrooms daily. The Housekeeping Supervisor said she had not seen the formula on Resident #267's floor. She said she was responsible for making sure her staff cleaned rooms and bathrooms daily. The Housekeeping Supervisor said she asked her staff if they cleaned daily and checked behind them. She said not cleaning residents' rooms and bathrooms could cause buildup of bacteria, mildew, and smells. The Housekeeping Supervisor said uncleanness placed resident at risk for infections. <BR/>During an interview on 8/30/23 at 2:07 PM, LVN D said she did not notice the formula on Resident #267's floor. She said the nurse who spilled the formula should have cleaned it and housekeeping. LVN D said spilled formula was unsanitary. <BR/>During an interview on 8/31/23 at 8:20 AM, LVN C said the nurses and housekeeping were responsible for cleaning the spilled formula. She said the spilled formula attracted pests and germs and could lead to a fall. <BR/>During an interview on 8/31/23 at 9:45 AM, the DON said Resident #267 had formula on the floor, IV pole, and walls. She said LVNs and aides should clean the formula up when it happened. The DON said the formula had become hardened, they had to replace the IV pole because it would not come off. She said it was important for the residents to have a clean environment. The DON said nursing administrators and housekeeping supervisors should oversee the cleanness of the facility by doing rounds. She said housekeeping was responsible for cleaning resident's toilets and emptying trash to promote cleanliness. The DON said the housekeeper should follow their cleaning schedule and the housekeeping supervisor should make rounds to ensure it was being done. <BR/>During an interview on 8/31/23 at 10:41 AM, the ADM said he expected the facility to be cleaned as indicated. He said all facility staff were responsible for a clean environment. The ADM said administration and housekeeping supervisor should ensure it happened. He said a clean environment was important for cleanliness, infection control, and to prevent accidents and hazards. <BR/>Review of a facility policy titled, Maintenance Services-Physical Environment with a revised date of August 2020 indicated . protect the health and safety of residents, visitors, and facility staff . maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . maintaining the heat/cooling system . maintaining all mechanical, electrical, and patient care equipment in safe operating condition . providing routinely scheduled maintenance service to all areas . Director of Maintenance was responsible for developing and maintaining a schedule of maintenance service to assure that buildings, grounds, and equipment were maintained in a safe and operable manner . responsible for conducting regular inspections that may include . resident . maintenance staff follow established safety regulations to ensure the safety and well-being of all concerned <BR/>Review of a facility policy titled, Resident Rooms and Environment with a revised date of August 2020 indicated . to provide residents with a safe, clean, comfortable and homelike environment . ensuring that residents could receive care and services safely and the physical layout of the facility maximizes resident independence and did not pose a safety risk . facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following . cleanliness and order . comfortable levels of ventilation <BR/> <BR/> <BR/> <BR/> <BR/> <BR/> <BR/>Based on observation, interview, and record review, the facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment 4 of 35 residents reviewed for environment. (Resident #34, Resident #73, Resident #23, and Resident #267)<BR/>1. <BR/>The facility failed to ensure Resident #34 and Resident #73's portable air conditioning unit/filter was free of gray fuzz and dust-like particles.<BR/>2. <BR/>The facility failed to ensure Resident #34's fan was free of gray fuzz and dust-like particles.<BR/>3. <BR/>The facility failed to ensure Resident #23's bathroom was cleaned daily.<BR/>4. <BR/>The facility failed to ensure Resident #267 did not have enteral feeding (also known as tube feeding, is a way of delivering nutrition directly to your stomach or small intestine) on the floor, IV pole, wall, and mattress. <BR/>These failures could place residents at risk of an unsafe, unsanitary, or uncomfortable environment and a decrease in quality of life and self-worth.<BR/>Findings included:<BR/>1.Record review of Resident #34's face sheet dated 8/29/23 revealed she was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #34 had diagnoses of shortness of breath, heart failure, reduced mobility, hypertension, diabetes, weakness, dependent on supplemental oxygen, obstructive sleep apnea (blockage in airway keeps air from moving through the windpipe during sleep), and chronic bronchitis (long-term inflammation of the airways).<BR/>Record review of Resident #34's quarterly MDS, dated [DATE], indicated Resident #34 had clear speech and was understood by staff. The MDS indicated Resident #34 was able to understand others. The MDS indicated Resident #34 had a BIMS of 12, which indicated moderate cognitive function impairment. The MDS revealed Resident #34 required extensive assistance of 1-2 persons for most ADLs. <BR/>Record review of Resident #34's undated care plan revealed she received oxygen therapy related to respiratory failure and chronic bronchitis and she had altered respiratory status/difficulty breathing related to sleep apnea.<BR/>During an observation and interview on 8/28/23 at 10:15 AM, revealed Resident #34 was sitting up in bed with oxygen on at 4 LPM by NC. Resident #34 had a black fan sitting on a desk at the end of her bed blowing directly at her and the fan casing and blades were covered in gray fuzz and dust-like particles. Resident #34 had a portable air conditioning unit in her room that she shared with Resident #73. The portable air conditioning unit was at the end of Resident #34's bed with a white flex tubing that vented out the window, and the unit was pointed to blow across the room. The portable air conditioning unit had significant dust-like particles on it and the filter on the back of the unit was heavily covered in gray fuzz and dust-like particles. Resident #34 said no one had cleaned the portable air conditioning unit or cleaned the filter to her knowledge. Resident #34 said she needed lots of air flow in her room because of her breathing problems.<BR/>During an observation on 8/29/23 at 9:35 AM revealed Resident #34's black fan that was blowing directly toward Resident #73 continued to be covered in gray fuzz and dust-like particles.<BR/>2. Record review of Resident #73's face sheet dated 8/29/23 revealed he was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #73 had diagnoses of COPD, shortness of breath, respiratory failure, weakness, heart failure, and pulmonary fibrosis (lung disease where lung tissue becomes damaged and scarred, thickened and stiff making it harder for lungs to work properly).<BR/>Record review of Resident #73's annual MDS dated [DATE] revealed he was understood and understood others. Resident #4 had a BIMS of 15, which indicated he was cognitively intact. Resident #73 required limited to extensive assistance of 1 person for most ADLs. Resident #73 had shortness of breath when lying flat and received oxygen therapy. <BR/>Record review of Resident #73's undated care plan revealed he had shortness of breath related to respiratory failure, altered respiratory status/difficulty breathing related to respiratory failure and COPD.<BR/>During an observation and interview on 8/28/23 at 10:28 AM, revealed Resident #73 was lying in bed with his oxygen on at 4 LPM by NC. Resident #73 shared a room with Resident #34 and there was a portable air conditioning unit was at the end of Resident #34's bed with a white flex tubing that vented out the window, and the unit was pointed to blow across the room. Resident #73's bed was located across the room closest to the door. The portable air conditioning unit had significant dust-like particles on it and the filter on the back of the unit was heavily covered in gray fuzz and dust-like particles. Resident #73 agreed that no one had cleaned the portable air conditioning unit or cleaned the filter to his knowledge.<BR/>During an observation on 8/29/23 at 9:35 AM revealed Resident #34 and Resident #73's portable air conditioning unit continued to have significant dust-like particles on it and the filter on the back of the unit was heavily covered in gray fuzz and dust-like particles.<BR/>During an interview on 8/30/23 at 8:17 AM, LVN G said she had worked at the facility for eight years and usually worked day shift on Hall 200. LVN G said staff would tell the Maintenance Supervisor if a resident's fan needed to be cleaned. She said maintenance would be responsible for cleaning the portable air conditioning unit and filters to ensure the unit was functioning properly. <BR/>During an interview on 8/30/23 at 8:36 AM, ADON H said she had worked at the facility for three years. ADON H said she was responsible for ensuring everything was going smoothly and everyone was doing what they were supposed to do. ADON H said she did not know who was responsible for cleaning the fans in the residents' rooms or the portable air conditioning unit/filter, but she said she would find out. ADON H said a dirty fan blowing towards a resident increased their risk of respiratory issues. ADON H said the dirty portable air conditioning unit and filter could affect how the unit worked and not be able to filter contaminates from the air in the resident's room.<BR/>During an interview on 8/30/23 at 9:07 AM, the Maintenance Supervisor said all staff were responsible for maintaining the portable air condition unit. The Maintenance Supervisor said the portable air conditioner unit filter should be cleaned at least monthly by housekeeping or the maintenance department. The Maintenance Supervisor said he did not have cleaning the portable air conditioning unit's filter on the maintenance schedule, but he would be adding it to the schedule to ensure the filter was cleaned monthly. The Maintenance Supervisor said a full dirty air conditioning filter would not allow the unit to work correctly and it could affect the resident's breathing due to the dust. The Surveyor showed the Maintenance Supervisor a picture of the portable air conditioning filter and he said it did not look like it had been cleaned in a month or longer. The Maintenance Supervisor said housekeeping or the maintenance department should be cleaning the fan shields and blades, but any staff member could do it. The Maintenance Supervisor said dirty fans could cause respiratory issues for the residents.<BR/>During an interview on 8/30/23 at 9:29 AM, ADON K said she had worked at the facility since November 2022. ADON K said the maintenance department was responsible for cleaning the residents' fans and the portable air conditioner/filters. ADON K said residents could get respiratory infections due to the dust and pollution.<BR/>During an interview on 8/30//23 at 2:37 PM, the Housekeeping Supervisor said she had worked at the facility since December 2022 in housekeeping, but she had been the Housekeeping Supervisor for about a month. The Housekeeping Supervisor said housekeeping was responsible for dusting the residents' fans daily with the housekeeping task. The Housekeeping Supervisor said she expected her housekeeping staff to do a deep clean of the residents' rooms daily to include changing the trash, wiping the bed frames and call lights down, dusting the light fixtures, wiping down the tabletops and walls, bathroom mirrors, cleaning the toilets, everything should be wiped down and clean. The Housekeeping Supervisor said housekeeping should include cleaning the air conditioning filter in the residents' rooms. The Housekeeping Supervisor said she was new to the supervisor role and was working on training staff and improving the housekeeping department.<BR/>During an interview on 8/30/23 at 4:37 PM, the DON said she had worked at the facility for three years. The DON said the maintenance department or housekeeping would be responsible for ensuring the resident's fan was clean and for cleaning the portable air conditioning unit/filter. The DON said dirty fans and dirty air conditioning filters could lead to a bacteria build up and could cause the residents respiratory issues.<BR/>During an interview on 8/30/23 at 5:34 PM, the Administrator said he would expect the staff to ensure the residents' fans and the portable air conditioning unit/filter to be clean and free of dust in the residents' room. The Administrator said the residents could have respiratory issues related to dirty fans and dirty portable air conditioning units/filters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 7 residents reviewed for care plans. (Resident #72, Resident #98)<BR/>The facility failed to implement the care plan intervention to document Resident #72 and Resident #98's meal intake. <BR/>The facility failed to implement the care plan intervention for Resident #98 to receive his Frozen Nutritional Treats with meals. <BR/>These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services<BR/>Findings included:<BR/>1. Record review of a face sheet dated 08/30/23 indicated Resident #72 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses including Parkinson's (is a movement disorder. It causes tremors, stiffness, and slow movement), Alzheimer's (a progressive disease that destroys memory and other important mental functions), and fracture of left femur (is a break in the thighbone). <BR/>Record review of an admission MDS assessment dated [DATE] indicated Resident #72 was understood and understood others. The MDS indicated Resident #72 had a BIMS score of 12 which indicated moderately impaired cognition and required supervision for eating, extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated Resident #72 had nutritional malnutrition. <BR/>Record review a care plan dated 06/06/23 indicated Resident #72 had potential nutritional problem/malnutrition related to Alzheimer's, Parkinson's, poor dental health, and admission to nursing facility. Intervention included provide, serve diet as ordered. Monitor intake and record every meal. <BR/>Record review of Resident #72's Amount Eaten report dated 08/30/23 indicated no meal intake amount for:<BR/>*08/28/23: 9:00 am, 1:00 pm<BR/>*08/29/23: 9:00 am, 1:00 pm <BR/>*08/30/23: 9:00 am, 1:00 pm<BR/>2. Record review of a face sheet dated 08/28/23 indicated Resident #98 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Asperger's syndrome (a developmental disorder affecting ability to effectively socialize and communicate), muscle wasting and atrophy (is the wasting (thinning) or loss of muscle tissue), muscle weakness, need for assistance with personal care, dysphagia (difficulty swallowing foods or liquids), Type 2 diabetes (is a disease in which your blood glucose, or blood sugar, levels are too high), and protein calorie malnutrition (is the state of inadequate intake of food). <BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #98 was sometimes understood and usually understood others. The MDS indicated Resident #98 had adequate hearing, unclear speech, and highly impaired vision. The MDS indicated Resident #98 had a BIMS score of 05 which indicated severe cognitive impairment and required limited assistance for bathing and extensive assistance for bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident #98 had weight loss and was not on a physician prescribed weight-loss regimen. <BR/>Record review of a care plan dated 05/03/23 indicated Resident #98 had potential for pressure ulcer development. Intervention included monitor nutritional status. Serve diet as ordered, monitor intake and record.<BR/>Record review of a care plan revised on 08/07/23 indicated Resident #98 had potential nutritional problem related to Asperger's Syndrome. Intervention included 06/27/23 RD recommendations: 1. Frozen Nutritional Treat TID meals.<BR/>Record review of Resident #98's consolidated physician's order dated 06/22/23 indicated Frozen Nutritional Treat with meals for significant weight loss. <BR/>Record review of Resident #98's Amount Eaten report dated 08/30/23 indicated no meal intake amount for:<BR/>*08/28/23: 9:00 am, 1:00 pm<BR/>*08/29/23: 9:00 am, 1:00 pm <BR/>*08/30/23: 9:00 am, 1:00 pm<BR/>During an observation on 08/29/23 at 9:06 a.m., revealed Resident #98's breakfast tray had only one bite of ground sausage missing. No frozen treat was noted on Resident #98's tray or bedside table. Resident #98's meal ticket indicated frozen nutritional treat with meals. The observation revealed further that Resident #72's breakfast tray had one glass of milk drank and one bite of oatmeal. <BR/>During an observation on 08/29/23 at 1:25 p.m., revealed Resident #72 only ate his dessert, and his roommate gave him another dessert. Resident #72 did not eat his 2 chopped beef sandwiches. Resident #98's ate 50-75% of lunch. No frozen treat was noted on Resident #98's tray or bedside table.<BR/>During an observation on 08/29/23 at 6:36 p.m., revealed Resident #72 only drank his milk for dinner. Resident #98's ate 0-25% for dinner. No frozen treat was noted on Resident #98's tray or bedside table. <BR/>During an observation on 08/29/23 at 6:38 p.m., at the end of 300 hall, revealed a bucket with ice had frozen treats and house shakes. <BR/>During an observation on 08/30/23 at 8:56 a.m., revealed Resident #98 did not eat breakfast but drank a house shake. No frozen treat was noted on Resident #98's tray or bedside table.<BR/>During an interview on 08/30/23 at 9:03 a.m., CNA A said Resident #98 normally drank house shakes and today was the first time to hear he was supposed to have frozen treats with his meals. She said dietary was responsible for providing the frozen treats. CNA A said she had not gotten into the facility's electronic charting system and charted Resident #72 or Resident #98's meal intakes for the last 3 days. She said she had not looked at Resident #72 and Resident #98's care plan recently. She said Resident #98 and Resident #72 did not eat much the last three days. CNA A said maybe one day Resident #98 and Resident #72 ate 25-50% of their food. She said she was responsible for documenting meal intake and LVNs ensured it was inputted and correct. CNA A said it was important to document meal intake so the dietician would know if she needed to make changes. She said it was important to follow the care plan intervention to offer frozen treats to Resident #98 to help with weight loss and let the dietician know if the interventions worked. <BR/>During an interview on 08/30/23 at 2:07 p.m., LVN D said Resident #72 and Resident #98 were being monitored for weight loss. She said both residents were getting prescribed nutritional supplements by the nurses. LVN D said CNAs and LVNs should chart residents meal intakes. She said LVNs should make sure the meal intakes were documented at the end of the shift as the care plan intervention indicated. LVN D said the kitchen placed the house shakes and frozen treats on ice in a bucket on each hall. She said the CNAs should hand the nutrition frozen treats out to each resident. LVN D said the DON looked at the meal intake report to determine which resident needed to be seen by the dietician or dietary manager. She said dietary recommendations on the care plan should be followed to prevent further weight loss and improve nutritional status. LVN D said if recommendations were not followed, or meal intakes not documented residents were at risk for dehydration or illnesses. <BR/>During an interview on 08/31/23 at 8:20 a.m., LVN C said CNAs were responsible for documenting meal intakes. She said Resident #72 and Resident #98 were being monitored for weight loss. LVN C said Resident #72 normally ate 50% and Resident #98 75-100%. She said LVNs should make sure CNAs were documenting meal intakes. LVN C said it was important to document meal intakes to monitor for change of condition and know if a resident needed a supplement. She said dietary recommendation should be followed to prevent decline, skin breakdown, and improve nutrition. <BR/>During an interview on 08/31/23 at 9:45 a.m., the DON said CNAs and LVNs should document resident's meal intake in the facility's computer system. She said nursing staff were responsible for providing resident frozen treats per the doctor's orders and meal tickets. The DON said it was important to document meal intake and give dietary recommendations so dietary interventions could be planned, and new interventions developed, or revisions made to the care plan to prevent further weight loss. The DON said all nursing staff had access to resident's care plans on the facility's electronic charting system and should be followed. She said managers should review residents' charts to ensure it was being done and the dietician would also look at the information documented. <BR/>During an interview on 08/31/23 at 10:41 a.m., the ADM said CNAs should document meal intake amounts. He said nursing staff and dietary were responsible for dietary recommendations. The ADM said it was important to document and follow recommendation, to know if the resident received proper nutrition and prevent further weight loss. He said nursing administration should oversee this process. <BR/>Record review of a facility Care Planning policy revised 10/24/22 indicated .each resident's comprehensive care plan will describe the following .services that are to be furnished to attain or maintain the resident's highest practicable physical .well-being <BR/>Record review of a facility Nutrition/Hydration Management policy revised 06/20 indicated .to ensure that each resident maintains acceptable parameters of nutritional status .implementing the nutritional/hydration program .a comprehensive care plan is developed .that addresses nutrition/hydration and an individualized .management program based on individualized assessed needs

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team and the participation of the resident for 1 of 2 residents (Resident #82) reviewed for care plan timing and revision.<BR/>The facility failed to ensure the IDT were in attendance to Resident #82's care plan meeting. <BR/>This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. <BR/>Findings included:<BR/>Record review of Resident #82's face sheet dated 08/30/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease (stroke), diabetes mellitus (a group of diseases that result in too much sugar in the blood), hypertension (high blood pressure), schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), and bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs). <BR/>Record review of Resident #82's annual MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS indicated Resident #82 had a BIMS score of 15, indicating his cognition was intact. The MDS did not indicate Resident #82 had any behaviors or refused care. The MDS indicated Resident #82 required extensive assistance with personal hygiene and dressing. Resident #82 required extensive assistance with bed mobility and toileting. <BR/>Record review of Resident #82's care plan conference dated 08/02/23, indicated Resident #82 and the MDS Coordinator attended the meeting. The care plan conference indicated Resident #82's family did not attend and had n/a marked under RN, nurse aide, food service staff, physician, activity director and social service director. <BR/>During an interview on 08/28/23 at 3:06 PM, Resident #82 said he had not attended a care plan meeting. Resident #82 said he would have liked to have gone to his care plan meetings. Resident #82 said the staff did not come to his room to have the meeting and he had not received an invitation to attend the care plan meetings. <BR/>During an interview on 08/30/23 at 08:35 AM, Resident #82 said he did not remember having a care plan meeting in the beginning of the month of August 2023. Resident #82 said he could not recall ever having a care plan meeting. Resident #82 said he would like to be invited and be able to attend so he could know about his care. <BR/>During an interview on 08/30/23 at 04:50 PM, the ADM said the policy indicated the care plan meeting was held with the IDT which consisted of the MDS Coordinator, dietary, activity director, and social services. The ADM said it was not a complete IDT meeting if only the MDS Coordinator and the resident attended the meeting.<BR/>During an interview on 08/30/23 at 05:22 PM, the DON said a care plan meeting was conducted with the IDT which included the social worker, rehab director, dietary, and activities. The DON said she did not consider the IDT care conference meeting if only the MDS Coordinator and the resident attended the meeting. The DON said the MDS Coordinator was responsible for coordinating the meeting with each department.<BR/>During an interview on 08/31/23 at 09:34 AM with MDS W and Corporate MDS, MDS W said she had the care plan meeting with Resident #82 on 08/02/23 and it was held in his room. MDS W said she probably did not say it was a meeting so Resident #82 probably did not think it was a meeting. The Corporate MDS said when the care plan meeting was held the dietary supervisor was in the hospital, there was not a social worker or activities director. Resident #82 was receiving therapy and when asked how come therapy was not invited, she said she did not know. <BR/>Record review of the facility's policy Care planning revised October 24, 2022, indicated .To ensure that a comprehensive person-centered Care plan is developed for each resident based on their individual assessed needs .XI The Comprehensive Care Plan must be prepared by the IDT team. The IDT team includes the following individuals: A. The Attending Physician; B. The Resident Assessment Coordinator; C. The Licensed nurse who is responsible for the resident; D. The Dietary Supervisor and/or registered dietician; E. Social Service staff member responsible for the resident; F. The Activity Director, G. Therapist as applicable; H Consultants (as appropriate); J. Certified Nursing Assistants and/or RNAs responsible for the resident's care; K. The resident and/or his/her family or legal representative; L. Other individuals as appropriate or necessary .IV. IDT meeting A. The Facility will invite the resident, if capable, and their family to care plan meetings and use its best effort to schedule care plan meetings at times convenient for the resident and family

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of a face sheet dated 08/30/23 indicated Resident #79 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves.), contracture (reduce joint mobility and restrict activities of daily living) left and right ankle, stiffness in right and left shoulder, and need for assistance with personal care. <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #79 was understood and understood others. The MDS indicated Resident #79 had minimal difficulty hearing, clear speech, and adequate vision. The MDS indicated Resident #79 had a BIMS score of 11 which indicated moderate cognitive impairment and did not reject care. The MDS indicated Resident #79 required extensive assistance for bed mobility and personal hygiene, and total dependence for dressing, toilet use and bathing. The MDS indicated Resident #79 had limited range of motion bilateral (both)<BR/>upper and lower extremities. The MDS indicated Resident #79 was always incontinent of urinary and bowel. <BR/>Record review of a care plan dated 04/06/23 indicated Resident #79 had an ADL self-care performance deficit related to weakness and nerve damage related to Guillain Barre Syndrome. Intervention included toilet use required 1 staff extensive to dependent participation for toileting.<BR/>Record review of a care plan dated 04/06/23 indicated Resident #79 had bowel and bladder incontinence. Intervention included check the resident as required for incontinence. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes. <BR/>During an interview on 08/28/23 at 12:27 p.m., Resident #79 said she was normally changed at 9:30 a.m. and 3:30 p.m. She said yesterday (08/27/23) she was changed at 4:30 p.m. and not changed again until 5:30 a.m. by CNA E. Resident #79 said when she pushed the call light to be changed, staff made excuses why they could not change you. Resident #79 said CNAs did not make rounds every 2 hours to see if we needed to be changed. She said she was changed around 9:30 a.m. and was currently wet. Resident #79 said she took a water pill in the morning, so she needed to be changed more often. <BR/>During an interview on 08/29/23 at 8:53 a.m., Resident #79 said the last time she was changed was at 8:00 p.m. (08/28/23). She said she did not know who her CNA was today, and she had soaked through her brief and drawsheet. <BR/>During an interview and observation on 08/29/23 at 10:41 a.m., Resident #79 said she still had not been changed. Resident #79's drawsheet she was sitting on was wet with urine. <BR/>During an interview on 08/29/23 at 6:12 p.m., Resident #79 said she had been changed last at 3:30 p.m.<BR/>3. Record review of a face sheet dated 08/30/23 indicated Resident #89 was a [AGE] year-old female and admitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia (is a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide), limitation of activities due to disability, and need for assistance with personal care. <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #89 was understood and understood others. The MDS indicated Resident #89 had clear speech, adequate hearing, and adequate vision. The MDS indicated Resident #89 had a BIMS score of 10 which indicated moderately impaired cognition and did not reject care. The MDS indicated Resident #89 required limited assistance for bed mobility and personal hygiene, extensive assistance for dressing, total dependence for toilet use, bathing, and transfers. The MDS indicated Resident #89 was always incontinent of urinary and bowel. <BR/>Record review of a care plan dated 09/08/22 indicated Resident #89 had ADL self-care performance deficit. Intervention included toilet use required 2 staff participation to use toilet, transfers, and bed mobility. <BR/>Record review of an in-service training report, Incontinent care, dated 08/09/23 at 7:00 p.m. by the DON indicated .are residents on the night shift being changed timely when they have incontinent episodes? . every resident should be checked for incontinent episodes . rounds should be made every 2 hours .check the resident and the linen .change as needed . assist residents with toileting .keep the call light in reach at all times . 12 staff members signed the training. <BR/>During an interview on 08/28/23 at 11:25 a.m., Resident #89 said she was changed one-time on night shift by CNA E. <BR/>During an interview on 08/29/23 at 6:15 p.m., Resident #89 said she was changed one-time on night shift at 5:15 a.m. by CNA E. <BR/>During an interview on 08/30/23 at 9:03 a.m., CNA A said she tried to make rounds every 2 hours to check resident for incontinent episodes. She said on Mondays and Tuesdays she did not get to work until 7:30 am or 8:00 am so her first rounds were after breakfast. CNA A said Resident #79 was extremely wet on 08/29/23 when she changed her. She said Resident #79 told her she had not been changed all night. CNA A said she had started her shift and resident had been wet. She said Resident #79 and Resident #89 had complained about not getting changed at night and I told them to report it to upper management. CNA A said timely incontinent care was important to prevent skin breakdown and odors. <BR/>During an interview on 08/30/23 at 2:07 p.m., LVN D said resident should be changed as needed and every 2 hours. She said CNAs and LVNs were responsible for incontinent care. LVN D said LVNs should ensure resident were getting changed timely. She said it was important to prevent skin breakdown, infection, and pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin). <BR/>During an interview on 08/30/23 at 5:34 p.m., CNA E said she did work Sunday (08/27/23) and Monday (08/28/23) night shift on the 300 hall. She said she provided incontinent care every 2 hours, as needed, or when the resident called. CNA E said she did her last rounds at 4:30 a.m. She said timely incontinent care was important to prevent skin irritation and breakdown. <BR/>During an interview on 08/31/23 at 8:20 a.m., LVN C said resident should be changed every 2 hours and as needed. She said CNAs and LVNs were responsible for changing residents. LVN C said LVNs should ensure CNAs changed residents timely. She said timely changing was important for infection control, notice skin issues, hygiene, and dignity. <BR/>During an interview on 08/31/23 at 9:45 a.m., the DON said resident should be rounded on every 2 hours and as needed to check for incontinent episodes. She said CNAs and LVNs were responsible for timely incontinent care. The DON said LVNs should ensure resident were changed timely. She said managers should oversee the process by checking ADL sheets and rounding daily. The DON said incontinence care was important for hygiene, cleanliness, and skin care.<BR/>During an interview on 08/31/23 at 10:41 a.m., the ADM said resident should be changed as needed and when requested by the CNAs. He said it was important for infection control and identifying skin breakdown. The ADM said charge nurses and mangers should ensure timely incontinent care happened when requested and as needed.<BR/>Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 3 of 4 resident (Resident #5, #79, and #89) reviewed for incontinence and urinary catheters.<BR/>The facility failed to ensure Resident #5 had a physician's order for her indwelling urinary catheter with appropriate diagnosis for use. <BR/>The facility failed to provide timely incontinence care to Resident #79 and Resident #89. <BR/>These failures could place residents at risk for not receiving appropriate care, infections, skin breakdown and decreased quality of life. <BR/>Findings included: <BR/>1. Record review of Resident #5's face sheet dated 08/30/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (memory loss), neuromuscular dysfunction of bladder (bladder dysfunction caused by nervous system conditions), diabetes mellitus (a group of diseases that result in too much sugar in the blood) and essential hypertension (high blood pressure).<BR/>Record review of Resident #5's order summary report dated 08/30/23, did not indicate resident had an order for her indwelling urinary catheter. <BR/>Record review of Resident #5's comprehensive care plan revised on 03/24/23, indicated she had an indwelling catheter related to neurogenic bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition). The care plan interventions included to position catheter bag and tubing below the level of the bladder. <BR/>Record review of Resident #5's Admission/readmission Evaluation dated 07/26/23, indicated Resident #5 had a 16 French 10ml catheter.<BR/>Record review of Resident #5's annual MDS assessment dated [DATE], indicated Resident #5 had unclear speech, was usually understood, and usually understood others. The MDS indicated Resident #5 had a BIMS score of 5, which indicated her cognition was severely impaired. The MDS indicated Resident #5 required extensive assistance with bed mobility, dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #5 had an indwelling catheter.<BR/>During an observation on 08/28/23 at 10:58 AM, Resident #5 was lying in her bed. Resident #5 had her foley catheter hanging on the right side of the bed and was covered. <BR/>During an interview on 08/30/23 at 4:19 PM, ADON O said if a resident had a foley catheter then they should have an order for care and maintenance. ADON O said the nurse was responsible for ensuring the order for the foley catheter was placed in the resident's EMR. <BR/>During an interview on 08/30/23 at 04:50 PM, the Administrator said he expected a resident that had a foley catheter to have an order in place to provide care. The Administrator said not having an order could cause an adverse reaction. The Administrator said the charge nurse was responsible for ensuring the order for the foley catheter was in place.<BR/>During an interview on 08/30/23 at 05:22 PM, the DON said she expected a resident who had a foley catheter to have an order in place for care. The DON said the nurses were responsible for ensuring the resident had an order in place. The DON said the administrative nurses reviewed orders on any new admissions, readmissions or if there was a change.<BR/>During an interview on 08/31/23 at 08:48 AM, LVN CC said Resident #5 should have had an order for her foley catheter indicating the reason for the catheter use and catheter size. LVN CC said she was the nurse who readmitted Resident #5 on 07/26/23 and Resident #5 had a catheter upon admission. LVN CC said she must have missed inputting the order for Resident #5's catheter. LVN CC said she was the person responsible for ensuring Resident #5 had an order for her catheter. LVN CC said Resident #5 not having an order for her catheter with appropriate diagnoses could have caused her to have a UTI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 3 of 4 resident (Resident #23, Resident #79, Resident #98) reviewed for hydration. <BR/>The facility failed to ensure Resident #23, and Resident #79 received adequate hydration. <BR/>The facility failed to ensure Resident #98 received thickened liquid for hydration between meals. <BR/>The facility failed to implement the care plan intervention for Resident #98 to receive his Frozen Nutritional Treats with meals.<BR/>These failures could place residents at risk for dehydration, electrolyte imbalance, and infections. <BR/>Findings included:<BR/>1. Record review of a face sheet dated 08/30/23 indicated Resident #23 was [AGE] year-old female and admitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), need for assistance with personal care, and abnormal weight loss. <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #23 was understood and understood others. The MDS indicated Resident #23 had adequate hearing, clear speech, and impaired vision. The MDS indicated Resident #23 had a BIMS score of 15 which indicated intact cognition and only required supervision for dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #23 was always continent for urinary and bowel. <BR/>Record review of a care plan dated 06/29/21 indicated Resident #23 had chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Intervention included give supplements if needed to maintain adequate nutrition. Encourage good fluid intake. <BR/>Record review of a care plan with revision date of 06/19/23 indicated Resident #23 had an ADL self-care performance deficit related to impaired vision. Resident #23 was able to do most ADLs with supervision or setup assist. Intervention included needs set up for meals. <BR/>Record review of Resident #23's Comprehensive Metabolic Panel (is a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working) dated 08/11/23 indicated Chloride (is a mineral that helps maintain the acid-base balance in your body.) was 110 which was elevated. <BR/>Record review of Medline Plus [Internet]. Bethesda (MD): National Library of Medicine (US); (April 04,2022), www.medlineplus.gov/lab-tests/chloride-blood-test was accessed 08/31/23 which indicated .Chloride is a mineral that helps maintain the acid-base balance in your body .normal range 96-109 .high levels of chloride may be a sign of: Dehydration. Kidney disease. Metabolic acidosis, a condition in which you have too much acid in your blood .<BR/>During an interview on 08/28/23 at 10:04 a.m., Resident #23 said the facility did not pass ice and water regularly. She said she had to get water out of her bathroom sink and at times you did not get the drink you ordered for meals. <BR/>During an interview on 08/29/23 at 8:41 a.m., Resident #23 said CNA A filled her water cup yesterday (08/28/23) before she left for the day around 6:30 p.m. She said that was the only time it was filled. <BR/>2. Record review of a face sheet dated 08/30/23 indicated Resident #79 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves.), contracture (reduce joint mobility and restrict activities of daily living) left and right ankle, stiffness in right and left shoulder, and need for assistance with personal care. <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #79 was understood and understood others. The MDS indicated Resident #79 had minimal difficulty hearing, clear speech, and adequate vision. The MDS indicated Resident #79 had a BIMS score of 11 which indicated moderate cognitive impairment and did not reject care. The MDS indicated Resident #79 required extensive assistance for bed mobility and personal hygiene, and total dependence for dressing, toilet use and bathing. The MDS indicated Resident #79 had limited range of motion bilateral (both) upper and lower extremities. The MDS indicated Resident #79 was always incontinent of urinary and bowel. <BR/>Record review of a care plan dated 04/06/23 indicated Resident #79 had an ADL self-care performance deficit related to weakness and nerve damage related to Guillain Barre Syndrome. Intervention included 1 staff extensive participation for meals. <BR/>Record review of Resident #79's CMP dated 03/29/23 indicated normal lab values. No recent lab work available to review. <BR/>During an interview on 08/28/23 at 12:27 p.m., Resident #79 said the facility did not pass out ice and water enough. She said staff probably passes ice and water once a shift. <BR/>During an interview on 08/29/23 at 2:52 p.m., Resident #79 said she got fresh ice and water today at 2:45 p.m. before LVN C left for the day. She said LVN C did not normally pass ice and water out. <BR/>3. Record review of a face sheet dated 08/28/23 indicated Resident #98 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Asperger's syndrome (a developmental disorder affecting ability to effectively socialize and communicate), muscle wasting and atrophy (is the wasting (thinning) or loss of muscle tissue), muscle weakness, slowness and poor responsiveness, limitation of activities due to disability, retention of urine, need for assistance with personal care, dysphagia (difficulty swallowing foods or liquids), Type 2 diabetes (is a disease in which your blood glucose, or blood sugar, levels are too high), and protein calorie malnutrition (is the state of inadequate intake of food).<BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #98 was sometimes understood and usually understood others. The MDS indicated Resident #98 had adequate hearing, unclear speech, and highly impaired vision. The MDS indicated Resident #98 had a BIMS score of 05 which indicated severe cognitive impairment and required limited assistance for bathing and extensive assistance for bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident #98 had an indwelling catheter and always incontinent for bowel continence.<BR/>Record review of a care plan dated 05/03/23 indicated Resident #98 had an ADL self-care deficit. Interventions included 1 staff participation to eat. <BR/>Record review of a care plan dated 08/07/23 indicated Resident #98 had urinary tract infection. Intervention included encourage adequate fluid intake. <BR/>Record review of a care plan revised on 08/07/23 indicated Resident #98 had potential nutritional problem related to Asperger's Syndrome. Intervention included 06/27/23 RD recommendations: 1. Frozen Nutritional Treat TID meals.<BR/>Record review of Resident #98's CMP dated 05/25/23 indicated all electrolytes within normal ranges except Creatinine (is a blood test used to check how well your kidneys are filtering your blood) was 1.4. No recent lab work available to review. <BR/>Record review of Mount [NAME] Creatinine blood test (last reviewed 07/21/21), www.mountsinai.org/health, was accessed on 08/31/23 which indicated .normal range 0.6-1.3 .high creatinine level may be a sign that the kidneys are not working like they should .<BR/>Record review of Resident #98's urinalysis (is a test of your urine. It is often done to check for a urinary tract infection, kidney problems, or diabetes) dated 08/28/23 indicated color (yellow-dark yellow): dark yellow urine (may indicate that a person is mildly dehydrated), clarity (normal range is clear): turbid (cloudy urine possible cause dehydration and infection), protein (normal range is negative: 2 plus (protein in your urine possible causes urinary tract infections, certain infection or illness, dehydration, stress). <BR/>Record review of Resident #98's weights indicated on 07/03/2023, the resident weighed 130.1 lbs. On 08/01/2023, the resident weighed 127 pounds which was a -2.38 % Loss.<BR/>During an observation and interview on 08/28/23 at 3:48 p.m., Resident #98 was sitting up in bed with dry, peeling lips and no hydration on bedside tray. Attempted to interview Resident #98 but unable understand because he was soft spoken and mumbled. Discontinued interview because Resident #98 started becoming agitated. <BR/>During an observation on 08/28/23 at 9:43 a.m.-1:02 p.m. and 2:33 p.m. -4:00 p.m., no ice water was passed to the residents. <BR/>During an observation on 08/29/23 at 8:30 a.m., Resident #98 had a full cup of red liquid from his breakfast on the bedside table. <BR/>During an observation on 08/29/23 at 9:06 a.m., revealed Resident #98's breakfast tray had only one bite of ground sausage missing. No frozen treat was noted on Resident #98's tray or bedside table. Resident #98's meal ticket indicated frozen nutritional treat with meals.<BR/>During an observation on 08/29/23 at 10:34 a.m., Resident #98 was asleep with dry lips and red stained sheet. No cup noted on bedside tray. <BR/>During an observation on 08/29/23 at 8:56 a.m., Resident #98 had dry lips and drank about 4 oz of a strawberry house shake. <BR/>During an observation on 08/29/23 at 6:36 p.m., revealed Resident #98's ate 0-25% for dinner. No frozen treat was noted on Resident #98's tray or bedside table.<BR/>During an interview on 08/30/23 at 9:03 a.m., CNA A said Resident #98 required thickened liquid for hydration. She said dietary made the drinks, but the CNAs were responsible for giving it to the resident. CNA A said hydration was passed out once yesterday (08/29/23). She said hydration was important to prevent urinary tract infections, dehydration, and dry skin. CNA A said Resident #98 normally drank house shakes and today was the first time to hear he was supposed to have frozen treats with his meals. She said dietary was responsible for providing the frozen treats. She said it was important to follow the care plan intervention to offer frozen treats to Resident #98 to help with weight loss and let the dietician know if the interventions worked. <BR/>During an interview on 08/30/23 at 2:07 p.m., LVN D said residents should be provided hydration every 2 hours or when they asked. She said she felt resident were getting proper hydration. LVN D said all staff were responsible to provide hydration to residents. She said proper hydration was important to prevent dehydration. LVN D said LVNs should ensure residents received thickened liquids only if ordered and the CNAs should give it to the resident to drink. LVN D said Resident #98 were being monitored for weight loss. She said Resident #98 was getting a prescribed nutritional supplement by the nurses. LVN D said the kitchen placed the house shakes and frozen treats on ice in a bucket on each hall. She said the CNAs should hand the nutrition frozen treats out to each resident.<BR/>During an interview on 08/31/23 at 8:20 a.m., LVN C said hydration should be provided to resident twice a shift and as needed. She said CNAs were responsible for passing it out and LVNs should ensure it happened twice a shift. LVN C said hydration was important for a resident's well-being, skin, and keep their immune system up. She said aides should provide Resident #98 his thickened liquid between meals. LVN C said she was responsible for ensuring aides only offered him thickened liquids. <BR/>During an interview on 08/31/23 at 9:45 a.m., the DON said all nursing staff should provide resident hydration in the morning, afternoon, and at bedtime. She said managers should make daily rounds to ensure hydration was provided to residents. She said nursing staff were responsible for providing resident frozen treats per the doctor's orders and meal tickets. The DON said it was important to give dietary recommendations so dietary interventions could be planned, and new interventions developed, or revisions made to the care plan to prevent further weight loss. The DON said hydration was important to a resident's health and prevent adverse effects. She said dietary provided the thickened hydration but CNAs and LVNs should offer it to the resident 3 times a day. <BR/>During an interview on 08/31/23 at 10:41 a.m., the ADM said resident should receive hydration as needed and when indicated. He said staff should check resident hydration status every 2 hours. He said nursing staff and dietary were responsible for dietary recommendations. The ADM said it was important to document and follow recommendation, to know if the resident received proper nutrition and prevent further weight loss. He said nursing administration should oversee this process. The ADM said CNAs were responsible for providing hydration and the charge nurse and nursing administration should ensure it happened. He said proper hydration prevented dehydration.<BR/>Record review of a facility Nutrition/Hydration Management policy revised on 06/20 indicated .to ensure that each resident maintains acceptable parameters of nutritional status .developing an individual nutrition/hydration program based on individual assessed needs .ongoing assessment, monitoring, and evaluation of the effectiveness of the nutrition/hydration program .the goal of any nutrition/hydration management process is to improve quality of life . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 19 residents reviewed for respiratory care. (Resident #18, Resident #53).<BR/>The facility failed to properly store suction device (oral suctioning tool to clear the airway) and date tubing for Resident #18.<BR/>The facility failed to properly store a handheld nebulizer (HHN) and date tubing for Resident #53.<BR/>These failures could place residents who required respiratory care at risk for respiratory infections. <BR/>Findings included: <BR/>1. Record review Resident #18's face sheet dated 07/13/22 indicated Resident #18 was an [AGE] years old male, admitted to the facility with diagnoses of CVA (a stroke- is an interruption in the flow of blood to cells in the brain), Dysphagia (difficulty swallowing), Diabetes Mellitus (group of diseases that affect how your body uses blood sugar), Atrial Fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), and hypertension (high blood pressure).<BR/>Record review of Resident #18's most recent comprehensive MDS, dated [DATE], indicated Resident #18 rarely made himself understood and was rarely understood by others. Resident #18's brief interview for mental status score was not completed. The MDS indicated Resident #18 required extensive assist with bed mobility, dressing, eating, toileting, personal hygiene, and bathing. <BR/>Record review of the care plan dated 07/14/22 for Resident #18 indicated he required the use of a suction device for oral care, to remove secretion from his mouth due to cognitive impairment. The goal was to use suction machine with suction device to remove oral secretions.<BR/>Record review of physician's ordered dated 07/13/22 for Resident #18 indicated: May use suction device to suction secretions from cheeks while performing oral care and change suction device and tubing to suction machine Q week on Sunday and PRN.<BR/>During an observation on 07/12/22 at 8:34 a.m., revealed Resident #18's suction canister with about 500ml of blueish white liquid substance in color and the suction device tubing with no date and not bagged.<BR/>During an observation on 07/12/22 at 12:35 p.m., revealed Resident #18's suction canister with about 550 ml of blueish white liquid substance and the suction device tubing with no date and not in bag.<BR/>During an observation and interview on 07/13/22 at 9:55 a.m., revealed Resident #18's suction device tubing in a drawer without a cover and remained with no date. LVN K was in the room at this time and looked to verify the suction device tubing in the drawer with no date and not bagged. LVN K said the suction device tubing should be dated and, in a bag, when not in use and the suction canister and tubing should be changed on Saturday or Sunday nights. LVN K said having the suction device tubing in a bag would reduce the risk of getting a respiratory infection. <BR/>During an interview on 07/14/22 at 8:47 a.m., LVN M said she suctioned Resident #18 at least daily on her 7am-7pm shift. LVN M said she changes the set up on her first assigned day to work but it was ordered to be changed every Sunday night. LVN M said the suction device tubing should be kept in a bag to prevent respiratory infection.<BR/>2. Record review of the resident #53's face sheet dated 07/14/22 indicated Resident #53 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses of Schizophrenia (a serious mental disorder in which people interpret reality abnormally), COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing), Hypertension (high blood pressure), and Diabetes Mellitus. <BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #53 made herself understood and could understand others. Resident #53 had a BIMS score of 12 which indicated he was cognitively intact. The MDS indicated Resident #53 required total assist with bathing; extensive assist with bed mobility, dressing, toileting, personal hygiene; and set up for eating.<BR/>Record review of a Physician's order dated 07/14/22 indicated to give Ipratropium-Albuterol Solution 0.5-2.5mg/3ml vial, inhale orally every 6 hours for shortness of breath. Change nebulizer mask and tubing every Friday night.<BR/>Record review of care plan dated 02/04/22 indicated that Resident #53 had shortness of breath and diagnosis of COPD and asthma. Staff approach indicated: give aerosol or bronchodilators as ordered.<BR/>During an observation on 07/11/22 at 11:47 a.m., revealed Residents #53's HHN with no date on the tubing and was not bagged.<BR/>During an observation on 07/12/22 at 2:47 p.m., revealed Residents #53's HHN with no date on the tubing.<BR/>During an observation and interview on 07/13/22 at 10:06 a.m., revealed Residents #53's HHN nebulizer tubing was out of the bag with no date and the on bedside table. LVN K came to the room and verified the tubing was not dated and on the bedside table. LVN K said if tubing was not bagged it could cause a respiratory infection.<BR/>During an observation and interview on 07/14/22 at 8:47 a.m., LVN M went into Resident #53's room and verified that the HHN nebulizer tubing was not dated. LVN M said they would date the tubing and place back in bag when they finished to prevent infection. <BR/>During an interview on 07/14/22 at 9:30 a.m., the ADON H said tubing should be changed weekly some are on Friday's and some are Sundays; they should have an order for which date to change them. Vents are different. The ADON H said nurses are supposed to date and placed in a bag to prevent bacteria and germs. <BR/>During an interview on 07/14/22 at 9:55 a.m., LVN L said tubing should be changed every Sunday night. LVN L said nurses should put the date on them and place in a bag to keep away germs.<BR/>During an interview on 07/14/22 at 2:02 p.m., the DON said all tubing are scheduled to be changed on the MAR for Sunday nights. The DON said they do not have a policy on suction device or HHN tubing, but she expects tubing to be dated and properly stored. The DON said they have department heads who do ambassador rounds daily and nurse managers are to follow up to make sure they are dated and properly stored. The DON said failure to keep the tubing in bags could lead to illness related to bacteria.<BR/>During an interview on 07/14/22 at 1:29 p.m., the ADM said all tubing should be in a bag and dated. The ADM said he expected the ADON and DON to follow the protocol and failure to follow could lead to infection control issues. <BR/>Record review of the suctioning policy dated May 2017 indicated, It is the policy of this home that oral suctioning of a resident's mouth, pharynx and nasopharynx will be provided to remove mucus, drainage or salvia away from the resident's airway.<BR/>Record review of the aerosol therapy (hand0held Nebulizer) policy dated 04/18/16 indicated, the respiratory therapist or licensed nurse will provide .hand-held nebulizer therapy as ordered by physician The order should include medication, dose and frequency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of a face sheet dated 08/30/23 indicated Resident #23 was [AGE] year-old female and admitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), hypertension (high blood pressure), atherosclerotic heart disease (is caused by plaque buildup in the wall of the arteries that supply blood to the heart), nonrheumatic mitral valve stenosis (is the heart valve that controls the flow of blood from the heart's left atrium to the left ventricle), congestive heart failure (occurs when the heart muscle doesn't pump blood as well as it should), and aortocoronary bypass graft (also called heart bypass surgery, is a medical procedure to improve blood flow to the heart).<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #23 was understood and understood others. The MDS indicated Resident #23 had adequate hearing, clear speech, and impaired vision. The MDS indicated Resident #23 had a BIMS score of 15 which indicated intact cognition and only required supervision for dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #23 was always continent for urinary and bowel. The MDS indicated Resident #23 received a diuretic during the last days of the assessment period. <BR/>Record review of a care plan dated 06/29/21 indicated Resident #23 had hypertension. Intervention included give anti-hypertensive medications as ordered. <BR/>Record review of a care plan dated 06/29/21 indicated Resident #23 had diabetes mellitus. Intervention included diabetes medication as ordered by doctor.<BR/>Record review of a care plan dated 06/29/21 indicated Resident #23 had altered cardiovascular (relating to the heart and blood vessels) status as evidence by recent coronary artery bypass graft x2 (heart bypass surgery) due to myocardial infarction (heart attack). <BR/>Record review of Resident #23's consolidated physician order dated 06/24/21 indicated Clopidogrel Bisulfate (is an antiplatelet medicine. This means it reduces the risk of blood clots forming) 75mg, give 1 tablet by mouth in the morning for cardiovascular disease.<BR/>Record review of Resident #23's consolidated physician order dated 08/02/21 indicated Metformin tablet (is used to treat high blood sugar levels that are caused by a type of diabetes mellitus or sugar diabetes called type 2 diabetes) 500mg, give 1 tablet by mouth one time a day related to type 2 diabetes.<BR/>Record review of Resident #23's consolidated physician order dated 09/08/21 indicated Entresto (is a brand-name oral tablet prescribed to treat certain types of heart failure) tablet 24-26 MG, give 1 tablet by mouth by mouth two times a day related to congestive heart failure.<BR/>Record review of Resident #23's consolidated physician order dated 10/10/22 indicated Furosemide (Lasix; is used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease) 20mg, give 1 tablet by mouth one time a day for edema.<BR/>Record review of Resident #23's consolidated physician order dated 03/24/23 indicated Metoprolol Succinate Extended Release (is a beta-blocker used to treat chest pain (angina), heart failure, and high blood pressure) 24-hour 25mg, give 0.5 tablet by mouth in the morning for hypertension. <BR/>Record review of Resident #23's Electronic MAR indicated Clopidogrel Bisulfate 75MG scheduled for 8:00 a.m. indicated the following late administrations:<BR/>*08/19/23 at 3:41 p.m. by LVN D<BR/>*08/21/23 at 9:37 a.m. by LVN D<BR/>*08/22/23 at 11:29 a.m. by LVN C<BR/>*08/23/23 at 10:33 a.m. by LVN C<BR/>*08/24/23 at 9:19 a.m. by LVN D<BR/>*08/25/23 at 9:13 a.m. by LVN D<BR/>*08/27/23 at 10:46 a.m. by LVN C<BR/>*08/28/23 at 9:30 a.m. by LVN C<BR/>Record review of Resident #23's Electronic MAR indicated Metformin tablet 500mg scheduled for 8:00 a.m. indicated the following late administrations: <BR/>*08/19/23 at 3:41 p.m. by LVN D<BR/>*08/21/23 at 9:37 a.m. by LVN D<BR/>*08/22/23 at 11:29 a.m. by LVN C<BR/>*08/23/23 at 10:33 a.m. by LVN C<BR/>*08/24/23 at 9:19 a.m. by LVN D<BR/>*08/25/23 at 9:13 a.m. by LVN D<BR/>*08/27/23 at 10:46 a.m. by LVN C<BR/>*08/28/23 at 9:30 a.m. by LVN C<BR/>Record review of Resident #23's Electronic MAR indicated Entresto 24-26mg scheduled for 8:00 a.m. and 7:00 p.m. indicated the following late administrations:<BR/>*08/19/23 at 3:41 p.m. by LVN D<BR/>*08/21/23 at 9:37 a.m. by LVN D<BR/>*08/22/23 at 11:29 a.m. by LVN C<BR/>*08/23/23 at 10:33 a.m. by LVN C<BR/>*08/24/23 at 9:19 a.m. by LVN D<BR/>*08/25/23 at 9:13 a.m. by LVN D<BR/>*08/27/23 at 10:46 a.m. by LVN C<BR/>*08/28/23 at 9:30 a.m. by LVN C<BR/>Record review of Resident #23's Electronic MAR indicated Furosemide 20mg scheduled for 9:00 a.m. indicated the following late administrations:<BR/>*08/19/23 at 3:41 p.m. by LVN D<BR/>*08/22/23 at 11:30 a.m. by LVN C<BR/>*08/23/23 at 10:34 a.m. by LVN C<BR/>*08/27/23 at 10:47 a.m. by LVN C<BR/>Record review of Resident #23's Electronic MAR indicated Metoprolol Succinate Extended Release 24-hour 25mg scheduled for 8:00 a.m. indicated the following late administrations:<BR/>*08/17/23 at 10:20 a.m. by LVN C<BR/>*08/18/23 at 11:31 a.m. by LVN C<BR/>*08/21/23 at 9:37 a.m. by LVN D<BR/>*08/22/23 at 11:29 a.m. by LVN C<BR/>*08/23/23 at 10:33 a.m. by LVN C<BR/>*08/24/23 at 9:19 a.m. by LVN D<BR/>*08/25/23 at 9:13 a.m. by LVN D<BR/>*08/27/23 at 10:46 a.m. by LVN C<BR/>*08/28/23 at 9:30 a.m. by LVN C<BR/>During an interview on 08/29/23 at 8:41 a.m., Resident #23 said her medication were given late sometimes. <BR/>4. Record review of a face sheet dated 08/30/23 indicated Resident #79 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves.), contracture (reduce joint mobility and restrict activities of daily living) left and right ankle, chronic pain syndrome (is a common problem that presents a major challenge to health-care providers because of its complex natural history, unclear etiology, and poor response to therapy), and mood affective disorder (is a mental health condition that primarily affects your emotional state).<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #79 was understood and understood others. The MDS indicated Resident #79 had minimal difficulty hearing, clear speech, and adequate vision. The MDS indicated Resident #79 had a BIMS score of 11 which indicated moderate cognitive impairment and did not reject care. The MDS indicated Resident #79 required extensive assistance for bed mobility and personal hygiene, and total dependence for dressing, toilet use and bathing. The MDS indicated Resident #79 was always incontinent of urinary and bowel. The MDS indicated Resident #79 received scheduled pain medication regimen. The MDS indicated Resident #79 received 7 days of an anticoagulant, antidepressant, and opioid during the assessment period. <BR/>Record review of a care plan dated 04/06/23 indicated Resident #79 had GERD (Gastroesophageal reflux disease; is a common condition in which the stomach contents move up into the esophagus). Intervention included give medications as ordered. <BR/>Record review of a care plan dated 04/06/23 indicated Resident #79 was on anticoagulant (are medicines that help prevent blood clots) therapy related to atrial fibrillation (is an irregular and often very rapid heart rhythm). Intervention included monitor/document/report to MD as needed signs and symptoms of complications. <BR/>Record review of a care plan dated 04/06/23 indicated Resident #79 required pain management related to neuropathy (refers to any condition that affects the nerves outside your brain or spinal cord) and chronic pain syndrome. Intervention included anticipate resident's need for pain relief and respond immediately to any complaint of pain. <BR/>Record review of a care plan dated 04/06/23 indicated Resident #79 required antidepressant medication for diagnosis of depression. Intervention included give antidepressant medications ordered by physician.<BR/>Record review of Resident #79's consolidated physician order dated 03/21/23 indicated Eliquis (is used to lower the risk of stroke or a blood clot in people with a heart rhythm disorder called atrial fibrillation) Oral Tablet 5mg (Apixaban), give 1 tablet by mouth two times a day for AFIB. <BR/>Record review of Resident #79's consolidated physician order dated 04/04/23 indicated Hydrocodone-Acetaminophen (combine to treat moderate pain) Oral Tablet 10-325mg, give 1 tablet by mouth three times a day for chronic pain. <BR/>Record review of Resident #79's consolidated physician order dated 06/12/23 indicated Metoclopramide (is a medication that treats the symptoms of gastroesophageal reflux disease (GERD)) HCL Oral Tablet 5mg, give 5mg by mouth four times a day for GERD.<BR/>Record review of Resident #79's consolidated physician order dated 06/12/23 indicated Venlafaxine (is used to treat depression) HCL Oral Tablet 75mg, give 75mg by mouth two times a day for depression.<BR/>Record review of Resident #79's consolidated physician order dated 08/15/23 indicated Lasix (is used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease) Oral tablet 20mg (Furosemide), give 1 tablet by mouth one time a day for edema. <BR/>Record review of Resident #79's Electronic MAR indicated Eliquis Oral Tablet 5mg scheduled for 8:00 a.m. and 7:00 p.m. indicated the following late administrations:<BR/>*08/15/23 at 9:43 a.m. by LVN D<BR/>*08/16/23 at 9:23 a.m. by LVN D<BR/>*08/17/23 at 10:33 a.m. by LVN C<BR/>*08/18/23 at 11:26 a.m. by LVN C<BR/>*08/19/23 at 3:45 p.m. by LVN D<BR/>*08/20/23 at 10:07 a.m. by LVN D<BR/>*08/21/23 at 10:13 a.m. by LVN D<BR/>*08/21/23 at 8:45 p.m. by LVN BB<BR/>*08/22/23 at 11:33 a.m. by LVN C<BR/>*08/23/23 at 12:25 p.m. by LVN C<BR/>*08/24/23 at 10:20 a.m. by LVN D<BR/>*08/25/23 at 10:08 a.m. by LVN D<BR/>*08/27/23 at 10:24 a.m. by LVN C<BR/>*08/28/23 at 10:27 a.m. by LVN C<BR/>*08/29/23 at 9:23 a.m. by LVN C<BR/>Record review of Resident #79's Electronic MAR indicated Hydrocodone-Acetaminophen Oral Tablet 10-325mg scheduled for 9:00 a.m., 5:00 p.m. and 1:00 a.m. indicated the following late administrations:<BR/>*08/16/23 at 3:51 a.m. by LVN BB<BR/>*08/17/23 at 10:33 a.m. by LVN C<BR/>*08/18/23 at 2:22 a.m. by ADON K<BR/>*08/18/23 at 11:26 a.m. by LVN C<BR/>*08/19/23 at 3:45 p.m. by LVN D<BR/>*08/20/23 at 6:38 p.m. by LVN D<BR/>*08/21/23 at 2:13 a.m. by LVN BB<BR/>*08/21/23 at 7:30 p.m. by LVN D<BR/>*08/22/23 at 3:33 a.m. by LVN BB<BR/>*08/22/23 at 11:34 a.m. by LVN C<BR/>*08/23/23 at 12:25 p.m. by LVN C<BR/>*08/24/23 at 10:21 a.m. by LVN D<BR/>*08/25/23 at 3:15 a.m. by LVN BB<BR/>*08/25/23 at 7:20 p.m. by LVN BB<BR/>*08/ 27/23 at 10:25 a.m. by LVN C<BR/>*08/28/23 at 10:27 a.m. by LVN C<BR/>*08/29/23 at 4:38 a.m. by ADON K<BR/>Record review of Resident #79's Electronic MAR indicated Lasix Oral tablet 20mg scheduled for 9:00 a.m. indicated the following late administrations:<BR/>*08/17/23 at 10:33 a.m. by LVN C<BR/>*08/18/23 at 11:26 a.m. by LVN C<BR/>*08/19/23 at 3:45 p.m. by LVN D<BR/>*08/21/23 at 10:13 a.m. by LVN D<BR/>*08/22/23 at 11:34 a.m. by LVN C<BR/>*08/23/23 at 12:25 p.m. by LVN C<BR/>*08/24/23 at 10:21 a.m. by LVN D<BR/>*08/27/23 at 10:25 a.m. by LVN C<BR/>*08/28/23 at 10:27 a.m. by LVN C<BR/>Record review of Resident #79's Electronic MAR indicated Metoclopramide HCL Oral Tablet 5mg scheduled for 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. indicated the following late administrations:<BR/>*08/15/23 at 9:43 a.m. by LVN D<BR/>*08/15/23 at 1:22 p.m. by LVN D<BR/>*08/16/23 at 9:23 a.m. by LVN D<BR/>*08/17/23 at 12:42 a.m. by LVN BB<BR/>*08/17/23 at 10:33 a.m. by LVN C<BR/>*08/18/23 at 11:26 a.m. by LVN C<BR/>*08/19/23 at 3:45 p.m. by LVN D (due at 8:00 a.m.)<BR/>*08/19/23 at 3;45 p.m. by LVN D (due at 12:00 p.m.)<BR/>*08/20/23 at 10:07 a.m. by LVN D<BR/>*08/20/23 at 3:24 p.m. by LVN D (due at 12:00 p.m.)<BR/>*08/21/23 at 10:13 a.m. by LVN D<BR/>*08/21/23 at 7:30 p.m. by LVN D (due at 12:00 p.m.)<BR/>*08/22/23 at 11:33 a.m. by LVN C (due at 8:00 a.m.)<BR/>*08/23/23 at 12:25 p.m. by LVN C (due at 8:00 a.m.)<BR/>*08/24/23 at 10:20 a.m. by LVN D (due at 8:00 a.m.)<BR/>*08/24/23 at 2:13 p.m. by LVN D<BR/>*08/25/23 at 10:08 a.m. by LVN D<BR/>*08/25/23 at 2:39 p.m. by LVN D<BR/>*08/25/23 at 7:20 p.m. by LVN BB (due at 4:00 p.m.)<BR/>Record review of Resident #79's Electronic MAR indicated Venlafaxine HCL Oral tablet 75mg scheduled for 8:00 a.m. and 5:00 p.m. indicated the following late administrations:<BR/>*08/15/23 at 9:43 a.m. by LVN D<BR/>*08/16/23 at 9:23 a.m. by LVN D<BR/>*08/17/23 at 10:33 a.m. by LVN C<BR/>*08/18/23 at 11:26 a.m. by LVN C<BR/>*08/19/23 at 3:45 p.m. by LVN D<BR/>*08/20/23 at 10:07 a.m. by LVN D<BR/>*08/20/23 at 6:38 p.m. by LVN D<BR/>*08/21/23 at 10:13 a.m. by LVN D<BR/>*08/21/23 at 7:30 p.m. by LVN D<BR/>*08/22/23 at 11:33 a.m. by LVN C<BR/>*08/23/23 at 12:25 p.m. by LVN C<BR/>*08/24/23 at 10:21 a.m. by LVN D<BR/>*08/24/23 at 6:54 p.m. by LVN D<BR/>*08/25/23 at 10:08 a.m. by LVN D<BR/>*08/25/23 at 7:20 p.m. by LVN BB<BR/>*08/27/23 at 10:24 a.m. by LVN C<BR/>*08/28/23 at 10:27 a.m. by LVN C<BR/>*08/29/23 at 9:23 a.m. by LVN C<BR/>During an interview on 08/28/23 at 12:27 p.m., Resident #79 said her medication were not given on time. She said she did not get her morning medication until around 9:30 a.m. or 10:00 a.m. and her evening medications were late also. <BR/>During an interview on 08/30/23 at 2:07 p.m., LVN D said she documented her medication administration as she was passing medications or in real time. She said timed medications were allowed to be given 1 hour before or 1 hour after scheduled time. LVN D said if a medication said daily or in the AM/PM then it could be given between 7am-10am or 7pm-10pm. LVN D said residents did complain about their medication being given late. She said medication should be given at the ordered time to follow the facility's policy and to ensure the next dosage could be given at the right time. LVN D said the managers and DON should oversee LVNs to ensure medications were given on schedule. <BR/>During an interview on 08/31/23 at 8:20 a.m., LVN C said she pulled her medications, compared label with order, verified correct resident then administrated and documented on the electronic MAR. She said scheduled medication should be given 1 hour before or 1 hour after to be considered on time. LVN C said she had given late medications because sometimes crisis happened. She said it depended on the medication if it was an issue given multiple doses to close together. LVN C said sometime medication had to be given early or late to get the medication back on schedule. She said it was important to give scheduled medication on time because the body was used to get it at a certain time, and it could be a specific reason why it was ordered at that time. She said the managers and DON should oversee LVNs to ensure medications were given on schedule.<BR/>During an interview on 08/31/23 at 9:45 a.m., the DON said nurses should document medication given immediately after administration. She said scheduled medication should be given 1 hour before or 1 hour after to be considered on time. The DON said LVNs were responsible for timely medication administration. She said managers should review records randomly and weekly to ensure LVNs were administrating medication on time. The DON said it was important to administrate medication timely to provide better care to the residents. <BR/>During an interview on 08/31/23 at 10:41 a.m., the Administrator said medications should be passed as indicated. He said LVNs were responsible for timely medication administration. The Administrator said late medication could result in adverse reaction and cause change in a resident condition. <BR/>Record review of a facility General Guidelines for Medication Administration revised date 08/20 indicated .a schedule of routine dose administration times is established by the facility and utilized on the administration record .medications are administered within 60 minutes of the scheduled administration time .<BR/>Record review of facility's policy Controlled Substances revised on 08/2020, indicated .Medications classified as controlled substances by the Drug Enforcement Administration (DEA) are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with state and federal laws and regulations . 5. Accurate inventory of all controlled medications is maintained at all times. When a controlled substance is administered, the licensed nursing personnel administering the medication immediately enters the following information on the accountability record and the Medication Administration Record (MAR): a. Date and time of administration (MAR and Accountability Record) b. Amount administered (Accountability Record) c. Remaining quantity (Accountability Record) d. Signature of the nursing personnel administering the dose (Accountability Record) e. Initials of the nurse administering the dose, completed after the medication has been administered (MAR). 6. When a dose of a controlled medication is removed from the container of administration but is refused by the resident or not given for any reason, the dose is not placed back in inventory. The dose must be destroyed according to facility policy and the disposal documented on the accountability record on the line representing that dose .<BR/>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 4 of 6 residents (Resident #s 9, 68, 23, 79) reviewed for pharmacy services.<BR/>ADON K failed to ensure she had a witness when wasting Resident #9's acetaminophen-codeine 300-60mg tablet (controlled medication used for pain). <BR/>The facility failed to ensure Resident #68's Lorazepam (controlled antianxiety medication) was accurately reconciled.<BR/>The facility failed to administer Resident #23 and Resident #79's scheduled medication per the facility's policy timeframe.<BR/>These failures could place the residents at risk of not having medications available for use, not receiving medications, and drug diversion. <BR/>Findings include:<BR/>1. Record review of Resident #9's face sheet dated 08/30/23, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of encephalopathy (brain disease that alters brain function or structure), dementia (memory loss), pain, and anxiety.<BR/>Record review of Resident #9's quarterly MDS assessment dated [DATE], indicated she rarely/never understood or understood others. The MDS indicated Resident #9's staff assessment for mental status indicated Resident #9 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #9 was totally dependent on staff for bed mobility, dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #9 did not receive any opioid medications within the last 7 days of the look back period.<BR/>Record review of Resident #9's order summary report dated 08/30/23, indicated the following orders:<BR/>*Acetaminophen-codeine 300-60mg: give 1 tablet via gastrostomy tube (tube inserted through the belly) four times a day for chronic pain with a start date of 12/23/21.<BR/>*Acetaminophen-codeine 300-60mg: give 1 tablet via gastrostomy tube every 4 hours as needed for pain with a start date of 12/23/21.<BR/>Record review of Resident #9's undated comprehensive care plan indicated she had a potential for pain related to diagnoses of diabetes (group of diseases that result in too much sugar in the blood), osteoporosis (condition in which bones become weak and brittle), and chest pain. The care plan also indicated Resident #9 received pain medications as needed. The care plan interventions indicated to administer analgesia (pain reliever) as per orders and to monitor/document for side effects of pain medications. <BR/>During an observation and interview at 08:59 AM, ADON K and LVN V were counting the narcotic medications for the medication cart for hall 300 rooms 316-331 as ADON K was ending her shift. During the count, Resident #9's controlled administration record for acetaminophen-codeine tablet indicated Resident #9 had 31 tablets left. The medication card for acetaminophen-codeine tablet indicated she had 30 tablets left. This indicated 1 tablet of acetaminophen-codeine was missing. ADON K said she told LVN AA she had dropped Resident #9's acetaminophen-codeine tablet last night and needed her to come and sign as a witness. ADON K said Resident #9's medication was given crushed, so she had to obtain another tablet because it had spilled on the floor. ADON K said she did not get LVN AA to sign the controlled medication records, as she had been busy all night and forgot when LVN AA arrived at the floor. <BR/>Record review of Resident #9's controlled administration record for acetaminophen-codeine 300-60mg tablet dated 08/15/23-08/29/23, indicated ADON K signed out one tablet at 0200 (2 AM) on 08/29/23 with 31 tablets remaining. The controlled administration record did not indicate any medication was wasted or witnessed. <BR/>During an interview on 08/29/23 at 11:03 AM, the DON said she would expect the nurses to notify her of any narcotic medication discrepancies immediately. The DON said ADON K was coming to talk to her about what had happened. The DON said ADON K should have had another nurse sign as a witness that the medication had been wasted at the time the incident occurred. The DON said ADON K was responsible for notifying her of the wasted medication.<BR/>During an interview on 08/29/23 at 6:10 PM, LVN AA said she was not called by ADON K last night to sign as a witness for a medication that had been wasted and did not witness a medication being wasted by ADON K. <BR/>During an interview on 08/29/23 at 6:21 PM, the DON said she was aware of LVN AA not witnessing ADON K wasting Resident # 9's acetaminophen-codeine tablet. The DON said she had started her investigation as per the facility's policy.<BR/>2. Record review of Resident #68's face sheet dated 08/30/23, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included seizures, anxiety, gastro-esophageal reflux disorder (digestive disease in which stomach acid or bile irritates the food pipe lining), and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). <BR/>Record review of Resident #68's comprehensive care plan revised on 01/09/23, indicated she required psychotropic medications for diagnoses of affective mood disorder, anxiety, and depression. The care plan interventions indicated to administer medications as ordered and to monitor side effects and effectiveness. <BR/>Record review of Resident #68's quarterly MDS assessment dated [DATE], indicated she usually made herself understood and understood others. The MDS indicated Resident #68 had a BIMS score of 13, indicating her cognition was intact. The MDS indicated #68 required supervision with all ADLs. The MDS indicated Resident #68 had received antianxiety medications 6 days of the 7 day look back period.<BR/>Record review of Resident #68's order summary report dated 08/30/23, indicated she had an order for lorazepam 1 mg give one tablet by mouth in the evening for anxiety disorder with a start date of 04/20/23.<BR/>During an observation and interview on 08/29/23 at 10:24AM, the middle hall short cart was reviewed for accuracy for reconciliation of narcotic medications and was noted Resident #68's Lorazepam 1mg medication card indicated she had 14 tablets left. The controlled drug administration record for Lorazepam 1mg indicated she had 13 tablets remaining. LVN R and LVN G corrected the count by making a line through the administration dated for 08/28/23 at 8:00 PM making the count correct. LVN R said it appeared Resident #68 did not receive her Lorazepam on 08/28/23 at 8:00 PM as Resident #68 had an extra tablet. LVN R said she counted the cart with the LVN U that morning and she did not know how that was missed. <BR/>Record review of Resident #68's controlled drug administration record for lorazepam 1 mg tablet dated 08/12/23-08/28/23, indicated LVN U signed out she administered one tablet on 08/28/23 at 8:00 PM with 13 tablets remaining.<BR/>Record review of Resident #68's MAR for August 2023, indicated Lorazepam 1mg was administered at 8:00 PM on 08/28/23 by LVN U.<BR/>During an interview on 08/29/23 at 11:03 AM, the DON said if there was an extra tablet in the packet then it was considered as the medication was not given. <BR/>During an interview on 08/30/23 at 1:40 PM, LVN U said she remembered popping the blister pack and said she must have popped the wrong hole. LVN U said she thought she had given Resident #68 her Lorazepam 1mg tablet. LVN U said since there was an extra tablet in the medication card she probably did not administer the Lorazepam to Resident #68 as she was the only one that gave her the Lorazepam. LVN U said was unsure who she counted the medication cart with, but remembers the count being correct when she left. <BR/>During an interview on 08/30/23 at 04:19 PM, ADON O said she expected the DON, medical director, and family to be notified as soon as a medication discrepancy was identified. ADON O said there should be a witness when a nurse wastes a narcotic medication. ADON O said she expected the nurse to find a witness as there was never just one nurse in the building. ADON O said the nurse was responsible for counting the narcotic medications prior to obtaining responsibility of that cart and ensuring the count was correct. <BR/>During an interview on 08/30/23 at 4:50 PM, the Administrator said with a narcotic medication discrepancy he expected the DON to be notified. The Administrator said he expected the nurse to have a witness when wasting a narcotic medication. The Administrator said failure to do so would cause the employee to be suspended pending investigation, notifying HHSC, notifying the medical director, and calling the local authorities. The Administrator said the charge nurse was responsible for counting the medication cart before and at end of shift with the oncoming nurse or the nurse that was leaving. The Administrator said if the narcotic count indicated there was an extra tablet, then the medication was considered as not administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 6 medication carts and 3 of 27 residents reviewed in sample (Resident #319, Resident #13 and Resident #81 ).<BR/>The facility failed to have Resident #319's Arthritis hot pain cream stored and locked in an area not accessible to other staff, residents, or visitors. <BR/>The facility failed to ensure Resident #13 did not have prescribed and OTC medications at bedside. <BR/>ADON K failed to ensure the medication cart for hall 300 rooms 316-331 was locked when it was left unattended while giving Resident #81's medication.<BR/>ADON K and LVN V failed to ensure the medication cart for hall 300 rooms 316-331 was locked when it was left unattended.<BR/>These failures could place residents at risk of injury.<BR/>Findings included:<BR/>1.Record review of Resident #319's face sheet dated 08/30/23 indicated she was a [AGE] year-old female that admitted to the facility on [DATE] with the diagnoses of diabetes, kidney disease, and chronic pain. <BR/>Record review of Resident #319's MDS assessment dated [DATE] indicated she had a BIMS score of 11 which means she had moderately impaired cognition. The MDS also indicated she required extensive assistance of 2 staff for bed mobility and extensive assistance of 1 staff for transfers, bathing, toileting, and dressing, and supervision for eating. <BR/>Record review of Resident #319's order summary report dated 08/30/23 indicated she did not have an order for arthritis hot pain cream. <BR/>During an observation and interview on 08/29/23 at 08:53 AM Resident #319 had a container of arthritis hot pain cream on dresser beside her bed. Resident said she used the cream on her hands and her knees when she needs to, and it really helped her. She said her family member brought it for her a couple days ago, but 08/29/23 was her first day to try it. <BR/>During an observation on 08/30/23 at 08:35 AM Resident #319 was sitting in her room in her wheelchair. The container of arthritis hot pain cream continues to lay on her dresser. She said she needed to use it because she had been having some issues with her knees and back, but her nurse had just given her medications to help.<BR/>During an observation and interview on 08/30/23 at 04:40 PM LVN N said no residents were allowed to have medications kept in their rooms. LVN N went to Resident #319's room and removed the arthritis hot pain cream and said she was going to contact the physician and obtain an order for the cream for the staffed nurses to give to Resident #319 as needed. LVN N said that she did not see the cream on Resident #319's dresser, but all staff were responsible for ensuring medications were not in resident's rooms. She said medications left in resident's rooms placed a risk for wandering residents to get the medication and overdose or possibly use in their eyes. <BR/>During an interview on 08/30/23 at 04:51 PM the ADON said medications were not supposed to be at any resident's bedside. She said nurses, as well as any staff who went into Resident #319's room was responsible for ensuring no medications were in the room. The ADON said with medications being left in Resident #319's room, it placed a risk for the medications to be used in the wrong way, overdosing, and allowing other residents to pick the medicine up and use.<BR/>During an interview on 08/30/23 at 05:09 PM the DON said no residents were to have medications at bedside. She said she expected residents and families to give any medications they get outside of the facility to the staffed nurse to handle properly. The DON said all staff were responsible for ensuring there are no medications in resident rooms and should have been more observant. The DON said with medications being left at Resident #319's bedside it placed a risk for anyone picking the medication up and ingesting, using the medication in an unproper way, or could have had an allergy to the medication. <BR/>During an interview on 08/31/23 at 09:49 AM the Administrator said all medications should be stored in nurse carts or medication room with lock and key. He said all staff are responsible for ensuring residents do not have medications at the bedside. The Administrator said having medications in resident rooms placed a risk for not having physician orders and not safely administering medications to residents. <BR/>2.Record review of Resident #13's face sheet dated 08/30/23, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dysphagia (difficulty swallowing), anxiety and depression (disorder characterized by persistently depressed mood or loss of interest in activities).<BR/>Record review of Resident #13's order summary report dated 08/30/23, indicated the following orders:<BR/>*Aspirin 81mg give one tablet by mouth one time a day for supplement with a start date of 01/03/21.<BR/>*B complex vitamin give one tablet by mouth one time a day for supplement with a start date of 01/03/21.<BR/>*Calcium 500+D3 tablet give one tablet by mouth one time a day for supplement with a start date of 09/17/20.<BR/>*Centrum Adults tablet give one tablet by mouth one time a day for supplement with a start date of 09/17/20.<BR/>*Coenzyme Q10 (acts as an antioxidant, which protects cells from damage and plays an important part in your metabolism) give one capsule by mouth in the morning for hyperlipidemia with a start date of 09/17/20.<BR/>*Coreg 25 mg give one tablet by mouth in the morning for essential hypertension (high blood pressure) with a start date of 08/25/22.<BR/>*Digoxin 125 mcg give one tablet by mouth one time day for atrial fibrillation (irregular heartbeat) with a start date of 04/12/23.<BR/>*Diltiazem 120 mg give one capsule by mouth in the morning for atrial fibrillation with a start date of 09/16/20.<BR/>*Furosemide 20 mg give three tablets by mouth in the morning for fluid retention with a start date of 09/17/20.<BR/>*Glimepiride 1 mg give one tablet by mouth one time a day for diabetes with a start date of 09/17/20<BR/>*Magnesium 400 mg give one tablet by mouth two times a day for supplement with a start date of 07/17/23.<BR/>*Oxybutynin 10 mg give one tablet by mouth one time a day for overactive bladder with a start date of 12/11/20.<BR/>*Pepcid 20 mg give one tablet by mouth two times a day for supplement with a start date of 01/03/21. <BR/>*Potassium 20 MEQ give one tablet by mouth one time a day for supplement with a start date of 12/10/20.<BR/>*Prilosec 20 mg give one tablet by mouth two times a day for GERD (digestive disease in which stomach acid or bile irritates the food pipe lining) with a start date of 12/14/20.<BR/>*Tramadol 50 mg give two tablets by mouth three times a day for chronic pain with a start date of 07/16/22.<BR/>*Venlafaxine 75 mg give one tablet by mouth two times a day for depression with a start date of 01/20/23.<BR/>*Vitamin C 1000 mg give one tablet by mouth two times a day for supplement with a start date of 01/03/21.<BR/>*Vitamin D3 125 mcg give two capsules by mouth one time a day for supplement with a start ate of 01/03/21.<BR/>*Zinc 50 mg give 2 tablets by mouth one time a day for supplement with a start date of 01/03/21. <BR/>Record review of Resident #13's quarterly MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS indicated Resident #13 had a BIMS score of 15, which indicated her cognition was intact. The MDS indicated Resident #13 required supervision with bed mobility, transfer, walking, locomotion, dressing, eating, toileting, and personal hygiene. <BR/>Record review of Resident #13's undated comprehensive care plan indicated she had diagnoses of overactive bladder, stroke, diabetes, hyperlipidemia, hypertension, fluid retention, anxiety, renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys caused by renal artery disease), depression and was at risk for pain. The care plan interventions indicated to administer medications as ordered. <BR/>During an observation and interview on 08/28/23 at 10:03 AM, Resident #13 was sitting up in her wheelchair in her room. A bottle of lubricating eye drops was on her bed. Resident #13 said she had the eye drops due to her dry eyes. Resident #13 also had a bottle of cranberry 500 mg tablets in a white basket that was on top of the seat of the recliner. Inside the white basket were also 2 medicine cups with pills. Resident #13 said the pills were her pills of the day that LVN CC had left for her to take as she knows she will take them. Resident #13 said the nurse comes back and checks to see if I took them. <BR/>During an observation and interview on 08/28/23 at 10:12 AM, LVN CC entered Resident #13's room and obtained the bottle of cranberry tablets, the lubricating eye drops and the 2 medicine cups with pills. LVN CC said she had given Resident #13 her medications to take that morning, turned her back, and then administered Resident #13's roommate her medications. LVN CC said she figured Resident #13 had taken the medications. LVN CC said the pills in the medication cups were Resident #13's morning medications. One medicine cup had 12 unidentified pills and the other had 6 unidentified pills which were left from her morning medications. LVN CC said Resident #13 liked her prescription medications in one cup and her OTC medications in another cup. LVN CC said the risk of Resident #13 having medications at bedside was someone could go in and take them or Resident #13 could take them whenever she wanted. LVN CC said she was responsible for ensuring Resident #13 took her medications. LVN CC said she was unaware Resident #13 had a bottle of cranberry tablets or the lubricating eye drops. LVN CC said the family tends to bring OTC medications and place them wherever they want. LVN CC said the risks of having OTC medications at bedside was someone could come in and take them. LVN CC said she was responsible for ensuring the residents did not have OTC medications at bedside. LVN CC said if medications were kept at beside there should be a physician's order indicating this and a self-administration assessment completed. LVN CC said she had not completed a self-administration assessment on Resident #13. <BR/>During an interview on 08/30/23 at 4:19 PM, ADON O said she expected the nurse to ensure medications were taken unless the resident had an order for self-administration. ADON O said by not ensuring medications were taken could cause a resident to miss a dose, resident could forget to take them, or other residents could take them. ADON O said the nurse who was administering the medications was responsible for ensuring medications were taken and not left at bedside. ADON O said OTC medications were not to be at bedside unless the resident had an order and an assessment that they could have at bedside. ADON O said by not knowing if a resident had OTC medications at bedside could cause medication to interfere with medications they were currently taking. ADON O said everyone was responsible for ensuring OTC medications were not at bedside.<BR/>During an interview on 08/30/23 at 4:50 PM, the Administrator said he expected the nurse to ensure medications were taken by the resident. The Administrator said OTC medications should be kept under lock and key to ensure proper administration. The Administrator said residents could have medications at bedside if they had a physician's order for self-administration. The Administrator said by having medications at bedside, anyone could go in the room and ingest them.<BR/>During an interview on 08/30/23 at 5:22 PM, the DON said she expected medications not to be left at bedside and expected the nurse to ensure the resident took them as it was their responsibility. The DON said she expected the family and resident to notify them if they bring or order OTC medications to the facility. The DON said having medications at bedside could cause an adverse event.<BR/>3. Record review of Resident #81's face sheet dated 08/30/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis that affects all four limbs, plus torso), diabetes mellitus (a group of diseases that result in too much sugar in the blood), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety. <BR/>Record review of Resident #81's order summary report dated 08/30/23, indicated he had the following orders:<BR/>*insulin glargine (long-acting type of insulin that works slowly) 100unit/ml inject 15 units subcutaneously (under the skin) in the morning for diabetes with a start date of 03/06/23.<BR/>*Novolog flex pen (fast-acting insulin) 100unit/ml inject per sliding scale subcutaneously before meals and at bedtime for diabetes with a start date of 02/24/23.<BR/>Record review of Resident #81's comprehensive care plan revised on 04/03/23, indicated he had a diagnoses of diabetes mellitus with interventions to administer diabetic medications as ordered. <BR/>Record review of Resident #81's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS indicated Resident #81 had a BIMS score of 15, indicating his cognition was intact. The MDS indicated he was totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated he received insulin injections 7 out of the 7 days of the look back period. <BR/>During an observation on 08/29/23 at 08:30 AM, ADON K entered Resident #81's room to obtain a blood sugar check. ADON K left the medication cart unlocked. A staff member came and stood next to the medication cart waiting on ADON K. Multiple staff members were observed passing down the hallway.<BR/>During an interview on 08/29/23 at 08:59 AM, ADON K said it was the nurse's responsibility to keep the cart locked when not present. ADON K said someone could have opened the cart and obtained medications.<BR/>4. During an observation and interview on 08/29/23 at 09:17 AM, the 316-331 medication cart was parked outside room [ROOM NUMBER], a supply room. The medication cart was noted to be unlocked. There was not a staff member present. LVN V came out of the supply room, and said she was the one responsible for leaving the cart unlocked. LVN V said she went to the supply room to obtain a syringe. LVN V said she was responsible for ensuring the medication cart was kept locked when left unattended. LVN V said by not locking the medication cart, someone could take the medications. <BR/>During an interview on 08/30/23 at 4:19 PM, ADON O said the medication carts should be kept locked when unattended for safety. ADON O said the nurse was responsible for ensuring the cart was kept locked.<BR/>During an interview on 08/30/23 at 4:50 PM, the Administrator said he expected the medication carts to be always locked when left unattended. The Administrator said leaving the cart unlocked could cause medications to be taken. The Administrator said the charge nurse was responsible for locking the cart. <BR/>During an interview on 08/30/23 at 5:22 PM, the DON said the nurses were responsible for locking their medication carts. The DON said not locking the medication carts someone could get into the medications inside the cart.<BR/>Record review of the facility's policy General Guidelines for Medication Administration revised on 08/2020, indicated .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer .15. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide .<BR/>Record review of the facility's policy Storage of Medications revised on 08/2020 indicated . Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .3. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 2 of 3 residents reviewed for personal food safety. (Resident #16 and Resident #34)<BR/>The facility did not implement the personal food policy related to personal refrigerators for Resident's #16 and Resident #34. <BR/>These failures could place the residents at risk for food borne illness.<BR/>The findings included:<BR/>1. Record review of Resident #16's face sheet dated 8/30/23 indicated she was a 100year old female who admitted to the facility on [DATE] with the diagnoses of high blood pressure, breast cancer, heart failure, and need for assistance with personal care. <BR/>Record review of Resident #16's MDS assessment dated [DATE] indicated that she had a BIMS score of 12 which meant she had moderately impaired cognition. The MDS also indicated that resident required extensive assistance of 2 staff for bed mobility, extensive assistance of 1 staff for transfers, toileting, dressing, and eating, and total assistance of 1 staff for bathing. <BR/>During an observation on 8/28/23 at 10:07 AM, Resident #16's refrigerator was in her room with temperature check sheet located on the outside of the refrigerator dated July 2023 with no temperatures on the sheet. There was no thermometer located in the refrigerator. <BR/>During an observation on 8/29/23 at 09:15 AM, Resident #16's refrigerator continued to have a July 2023 dated paper on the front of the refrigerator with no temperatures and no thermometer inside. <BR/>During an observation on 8/30/23 at 08:42 AM, Resident #16's refrigerator had a new undated temperature sheet on the outside of the refrigerator that was blank. There was no thermometer found inside. <BR/>During an observation on 8/30/23 at 04:36 PM, Resident #16's refrigerator had an undated sheet on the outside of the refrigerator with a date written in as 8/30/23 and a temperature of 40 degrees signed by Housekeeper L. <BR/>During an interview on 8/30/23 at 04:34 PM, CNA M said the housekeeping department was responsible for checking resident refrigerators. She said she had not noticed them being checked but she knew a housekeeper checked Resident #16's refrigerator on 8/30/23. <BR/>During an interview on 8/30/23 at 04:51 PM, ADON O said housekeeping was responsible for checking refrigerator temperatures daily. She said there should have been a thermometer in the refrigerator. ADON O said the failure could have caused Resident #16 to consume spoiled food. <BR/>During an interview on 8/30/23 at 05:09 PM, the DON said the temperature checks on Resident #16's refrigerator was assigned to the housekeepers. She said they should be checked daily. The DON said with the refrigerators not being checked, it could cause bacteria growth if temperatures are not within range and if resident consumes items in their refrigerator there could be adverse effects. <BR/>During an interview on 8/31/23 at 09:52 AM, the Administrator said he expected the resident refrigerators to be checked daily. He said the housekeepers and housekeeping supervisor were responsible for ensuring the refrigerator temperatures for all residents were completed daily. He said the risk for Resident #16 is that the refrigerator not cooling properly, and resident ingesting spoiled or expired food. <BR/>2. Record review of Resident #34's face sheet, dated 8/29/23, indicated Resident #34 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of heart failure, shortness of breath, high blood pressure, diabetes (high blood sugar), weakness, and abnormality of gait, and anxiety (nervousness).<BR/>Record review of Resident #34's quarterly MDS assessment, dated 7/07/23, indicated Resident #34 had clear speech and was understood by staff. The MDS indicated Resident #34 was able to understand others. The MDS indicated Resident #34 had a BIMS of 12, which indicated moderate cognitive function impairment. <BR/>During an observation and interview on 8/28/23 at 10:15 AM, Resident #34 had a temperature log on her personal refrigerator dated July at the top of log, but there were no temperatures recorded on the July temperature log and there was no log for August posted. Resident's refrigerator was packed full of food and unable to determine if there was a thermometer in it. Resident #34 said she did not know when the last time anyone had checked her refrigerator.<BR/>During an observation and interview on 8/29/23 at 9:35 AM, Resident #34's personal refrigerator July temperature log was removed, and an August temperature log was posted on the front of the refrigerator. There were no temperatures documented 8/01/23-8/29/23. There was a thermometer in the refrigerator door and surveyor observed the temperature to be 49 degrees and there was significantly less food in the refrigerator than observed on 8/28/23. Resident #34 said the staff had come in that morning and cleaned the refrigerator out and placed a new temperature log for August on the refrigerator.<BR/>During an interview on 8/30/23 at 8:36 AM, the ADON H said she had worked at the facility for three years and was responsible for ensuring everything was going smoothly on Hall 200 and ensuring everyone was doing what they were supposed to do. ADON H said the personal refrigerators should be checked by housekeeping when they cleaned the resident's room and document the temperature on the temperature log. ADON H said monitoring personal refrigerators was important to ensure food is stored at proper temperature to prevent food from spoiling and making residents sick.<BR/>During an interview on 8/30/23 at 2:37 PM, the Housekeeping Supervisor said she had worked at the facility since December 2022 in housekeeping, but she had been the Housekeeping Supervisor for about a month. The Housekeeping Supervisor said all of housekeeping was responsible for the personal refrigerators. The Housekeeping Supervisor said housekeeping should be checking the refrigerators weekly, along with cleaning it, removing expired food out of it, checking the temperature, and documenting it on the temperature log on the front of the refrigerator. The Housekeeping Supervisor said she was responsible for ensuring the personal refrigerators were being monitored and temperature logs were being completed. The Housekeeping Supervisor said it was important to ensure refrigerated items were checked and temperature logs were completed appropriately to ensure refrigerators were functioning properly to keep food from spoiling and removing expired food, so residents do not get sick. The Housekeeping Supervisor said there had been a high turnover of housekeeping staff and she may not have checked behind the staff to ensure the personal refrigerators were being monitored and temperatures checked and logged for Resident #34.<BR/>During an interview on 8/30/23 at 4:37 PM, the DON said she had worked at the facility for three years. The DON said it was the responsibility of housekeeping for monitoring the personal refrigerators for expired foods, checking, and documenting the temperatures of the personal refrigerators. The DON said it was important to monitor the refrigerators for expired foods and check the temperature of the refrigerator to ensure it was functioning properly, so food did not spoil and grow bacteria that could make residents sick.<BR/>During an interview on 8/30/23 at 5:34 PM, the Administrator said he would expect the personal refrigerators to be checked weekly and temperatures checked and documented on the temperature log, to ensure the food was kept at an appropriate temperature to prevent food spoiling and potentially causing the resident to get sick, and ensure the refrigerator was functioning properly. <BR/>Record review of the facility's policy, titled Refrigerator-Personal dated 5/2017, indicated . the resident's refrigerators would be checked weekly for cleanliness and remaining sanitary . Housekeeping Supervisor/designee would monitor resident's refrigerator weekly . clean and remove expired food as needed . keep thermometer in refrigerator and maintain at 41 degrees or below . log temperature weekly when checked .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 20 residents reviewed for incontinent care and catheter care infection control practices. (Resident #'s 35 and 76).<BR/>CNA E cleaned Resident #76's buttock using the same two wipes for multiple wiping motions.<BR/>CNA F used contaminated wipes for Resident #35's catheter care.<BR/>CNA F touched the package of wipes and the clean brief for Resident #35 without removing her gloves and sanitizing of her hands. <BR/>These failures could place residents with foley catheter care or incontinent care at risk for urinary tract infections.<BR/>Findings included: <BR/>1. Record review of a face sheet dated 7/13/2022 indicated Resident #76 was an [AGE] year-old-female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's dementia and difficulty swallowing.<BR/>Record review of the most recent Quarterly MDS dated [DATE] indicated Resident #76 sometimes understood and sometimes understood others. The MDS indicated Resident #76's brief interview memory score was a 2 indicating a severe cognitive deficit. The MDs indicated Resident #76 required total assistance of two staff with toileting . The MDS indicated Resident #76 was always incontinent of urine and bowel.<BR/>Record review of the comprehensive care plan dated 4/11/2019 indicated Resident #76 had a self-care deficit with a goal of her needs would be met daily. The care plan indicated Resident #76 required one staff for incontinent care. <BR/>During an observation on 7/12/2022 at 8:59 a.m. revealed CNA's E and F provided incontinent care to Resident #76. CNA F opened Resident #76's current brief and repositioned her in the bed. Resident #76's brief was visibly soiled with urine. Then CNA F touched the package of wipes and the clean brief without removing her gloves and sanitation of her hands. CNA E took 2 wipes from the wipe package and cleansed Resident #76's buttock making several wiping strokes, not turning the wipes nor obtaining new ones before discarding the wipes. CNA F removed the dirty brief and the draw sheet then touched the clean brief without changing her gloves . CAN F then touched the bed side table before removing her gloves and using hand sanitizer. <BR/>2.Record review of a face sheet dated 7/14/2022 indicated Resident #35 was a [AGE] year-old-male who admitted to the facility on [DATE] with the diagnoses of neuromuscular dysfunction (muscle weakness, muscle loss)of the bladder, morbid obesity, and low back pain. <BR/>Record review of the most recent Annual assessment dated [DATE] indicated Resident #35 understood others and was understood by others. Resident #35's brief interview for memory score was a 12 indicating moderate cognitive impairment. The MDS section H0100 Appliances indicated Resident #35 had an indwelling catheter and H0300 Urinary Continence indicated Resident #35 had a catheter. <BR/>Record review of the comprehensive care plan dated 10/18/2021 indicated Resident #35 had an indwelling catheter. The goal would be no signs or symptoms of a urinary infection. The care plan intervention was to change the catheter per orders, and catheter care with care daily and as needed.<BR/>Record review of consolidated physician's orders dated 7/14/2022 indicated Resident #35 had a Foley Catheter 16 french to bedside drainage bag for the diagnosis of dysfunction of the bladder.<BR/>Record review of consolidated physician's orders dated 07/14/2022 indicated Resident #35 had an order for Foley catheter care every shift and as needed.<BR/>During an observation and interview on 7/13/2022 at 11:59 a.m. revealed CNA's F and G provided catheter care for Resident #35. CNA F obtained a wipe from the bag of wipes lying at the foot of the bed. CNA F made one wipe down the inner thigh of Resident #35. CNA F then discarded the one wipe in the bag of clean wipes. CNA F continued to provide catheter care using the contaminated wipes. CNA F wiped the penis, scrotum and inner thighs using the contaminated wipes. During an interview with CNA's F and G, they indicated the incontinent care was appropriately done. CNA's F and G were asked about the discarding of the used wipe in with the clean wipes and they both indicated the discarding of the dirty wipe with the clean wipes and continuing to provide catheter care could place Resident #35 at risk for infection . The CNAs indicated they had been trained on catheter care. <BR/>During an interview on 7/14/2022 at 10:41 a.m., LVN D indicated she expected the CNA's to use a different wipe with each wiping motion. She indicated a resident was at risk for infection and skin issues when catheter care or incontinent care was not provided effectively. LVN D indicated the DON provided check offs for the CNAs to ensure effective catheter and incontinent care. <BR/>Record review of a CNA proficiency audit dated 7/7/2022 for CNAs E, F and G indicated they had been checked off as satisfactory in the performance of female perineal care and male foley catheter care.<BR/>During an interview on 7/14/2022 at 12:13 p.m., the DON indicated she expected incontinent care and catheter care to be provided according to the policy. The DON indicated failure to provide ineffective foley and catheter care was an opportunity for bacteria and illness. The DON said residents with catheters were at a greater risk of infection.<BR/>During an interview on 7/14/2022 at 1:05 p.m., the ADM indicated he expected incontinent care and catheter care to be provided as needed and indicated. The ADM indicated the nursing staff were responsible for ensuring the incontinent care and catheter care were provided accurately. The ADM indicated the provision of incorrect incontinent care and catheter care was an infection control issue.<BR/>Record review of an Infection Control-Prevention and Control Program dated May 2017 indicated the intent of this program was to assure that the home developed, implemented, and maintained an Infection Prevention and Control Program to prevent, recognize, the onset and spread of infection within the facility. The program will: 2. Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions. Procedure: 1. Policies, procedures, and practices which promote consistent adherence to evidence-based infection control practices; 5. Education, including training in infection prevention and control practices, to ensure compliance with facility requirements as well as State and Federal regulations.<BR/>According to the CDC Epidemiology and Prevention of UTI dated 7/2018 a component of prevention of a Urinary Tract Infection was to provide good perineal hygiene and UTIs are common and a significant cause of harm in long term care facilities. Accessed at Epidemiology and Prevention of UTI (cdc.gov) accessed on 7/18/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure all patient care equipment was in safe operating condition for 1 of 1 resident (Resident#14) reviewed safe, functional equipment. <BR/>The facility failed to ensure Resident #14 had an armrest cushion and secured side panel of her wheelchair.<BR/>This failure could place residents at risk for skin issues, discomfort, and falls.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 08/30/23 indicated Resident #14 was a [AGE] year-old female and admitted on [DATE] with diagnoses including repeated falls, age-related physical debility (weakness or feebleness), lack of coordination and unsteadiness on feet. <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #14 was understood and understood others. The MDS indicated Resident #14 had adequate hearing, clear speech, and impaired vision with corrective lenses. The MDS indicated Resident #14 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #14 required limited assistance for bed mobility, and total dependence for toilet use, personal hygiene, and bathing. The MDS indicated Resident #14 used a walker and wheelchair as a mobility device. <BR/>Record review of a care plan revised date 06/19/19 indicated Resident #14 had a self-care performance deficit related to weakness and debility. Interventions included mobility: Resident #14 used wheelchair for mobility and can self-propel short distances. <BR/>During an interview and observation on 08/28/23 at 11:25 a.m., Resident #14 was sitting in her recliner in the room. Resident #14 said her only complaint was her wheelchair arm was missing a cushion and loose. She said without the arm cushion, it was scratching her. Resident #14 said it had been broken for a while. She said staff knew about the arm cushion missing. Resident #14's wheelchair had no arm cushion on the right side and the side panel was loose. <BR/>During an interview on 08/30/23 at 9:03 a.m., CNA A said Resident #14 told her about the wheelchair being broken. She said Resident #14 mentioned telling her family about the issue. CNA A said she did notice this week when she gave Resident #14 a shower the wheelchair had some issues. She said Resident #14 was at risk for falls because she used the wheelchair for mobility. CNA A said she did not know who was responsible for the maintenance of resident's wheelchairs. <BR/>During an interview on 08/30/23 at 2:09 p.m., LVN D said Resident #14 used her walker more than her wheelchair for mobility. She said Resident #14 used the wheelchair for in the shower or when she went out on pass. LVN D said maintenance was responsible for resident's wheelchairs. She said Resident #14 having an unsafe wheelchair placed her at risk for injuries. <BR/>During an interview on 08/30/23 at 2:50 p.m., the Maintenance Director said he did not know about Resident #14 wheelchair issues. He said staff were supposed to place maintenance issue in the binder and he also like staff to verbally tell him<BR/>During an interview on 08/31/23 at 8:20 a.m., LVN C said she had not noticed Resident #14's wheelchair issues. She said maintenance was responsible for resident's wheelchairs. LVN C said Resident #14 was at risk for falls and skin breakdown due to her wheelchair arm not having a cushion and loose side. <BR/>During an interview on 08/31/23 at 9:45 a.m., the DON said who ever found the maintenance issue should place it in the requisition book. She said issues with wheelchairs should be reported to maintenance to see if it can be fixed but then reported to the DON and ADM. The DON said maintenance repair request should be placed in binder as soon as possible. She Resident #14 was at risk for adverse effects such as injuries due to her mobility device having issues. <BR/>During an interview on 08/31/23 at 10:41 a.m., the ADM said the maintenance director was responsible for the upkeep of resident assistive devices such as wheelchairs. He said staff should notify maintenance and place a work order in the maintenance book. The ADM said Resident #14 was at risk for skin breakdown and tears using a wheelchair with no arm cushion and loose side panel.<BR/>Record review of the 300-hall repair requisition book dated 05/23-08/23 did not reveal a work order for Resident #14's wheelchair. <BR/>Record review of a facility Resident Rights-Accommodation of Needs policy revised date 08/20 indicated .to ensure that the facility provides an .services that meet residents' individual needs .the facility's environment is designed to assist the resident in achieving independent functioning and maintaining the resident's dignity and well-being .providing access to assistive devices .<BR/>Record review of a facility Maintenance Services policy revised date 08/20 indicated .to protect the health and safety of residents .the maintenance department maintains all areas of the building, grounds, and equipment .the Maintenance department is responsible for .and equipment in a safe and operable manner at all times .maintaining all mechanical, electrical, and patient care equipment in safe operating conditions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 3 of 20 residents reviewed for ADLs. (Resident #'s 145, 76, and 145).<BR/>The facility failed to provide nail care for Resident #49.<BR/>The facility failed to provide facial hair grooming for Resident #76.<BR/>The facility failed to provide bathing for Resident #145.<BR/>These failures could place residents at risk for not receiving services/care and a decreased quality of life.<BR/>Findings included:<BR/>1.Record review of a face sheet dated 7/13/2022 indicated Resident #49 was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of Parkinson's disease, need for assistance with personal care and weakness.<BR/>The most recent Quarterly MDS dated [DATE] indicated Resident #49 understood others and was understood by others. Resident #49's brief interview memory score was a 2 indicating he had severe cognitive impairment. The MDS indicated Resident #49 required total assistance of one staff for personal hygiene.<BR/>Record review of a comprehensive care plan dated 6/2/2020 indicated Resident #49 had a self-care deficit with a goal of improvement with the intervention of bathing which included checking the nail length, trim and clean on bath days. <BR/>Record review of a 200 Hall shower schedule indicated Resident #49's bath days were Monday's, Wednesday's, and Friday's on the 6:00 a.m. to 6:00 p.m. shift.<BR/>During an observation on 7/11/2022 at 10:00 a.m. revealed Resident #49 was lying in his bed. His nails were long and with a brownish black material underneath the nails . Resident #49 said he would like have his nails cleaned and trimmed. <BR/>During an observation on 7/11/2022 at 12:55 p.m. revealed Resident #49's fingernails were approximately &frac12; inch long with a brownish black material underneath the fingernails.<BR/>During an observation on 7/11/2022 at 3:50 p.m. revealed Resident #49's fingernails continued to be long with brownish black material underneath the nails.<BR/>During an observation on 7/12/2022 at 2:00 p.m., Resident #49's nails continued to be long and with a brownish black material underneath the nails. <BR/>Record review of Resident #49's Shower Sheets indicated:<BR/>*7/1/2022 Resident #49's nails were cleaned with his bed bath.<BR/>*7/6/22022 Resident #49's nails were not cleaned with a refusal of a shower.<BR/>*7/08/2022 Resident #49's nails were not cleaned with his bed bath.<BR/>*7/11/2022 Resident #49's nails were cleaned with a bed bath.<BR/>*7/13/2022 Resident #49's nails were cleaned with a refusal of a shower.<BR/>2.Record review of a face sheet dated 7/13/2022 indicated Resident #145 was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of chronic respiratory failure, pneumonia, and seizures.<BR/>Record review of the most recent admission MDS dated [DATE] indicated Resident #145 understood others and was usually understood by others. The MDS indicated Resident #145's BIMS was a 10 indicating moderately impaired cognition. Under the section of Staff Assessment of Daily and Activity Preferences the MDS indicated Resident #145 preferred to have a bed bath. The MDS indicated Resident #145 was total assist of two staff for bed mobility, dressing, eating, personal hygiene and for bathing she required total assistance of one staff. <BR/>Record review of the comprehensive care plan dated 4/27/2022 and revised on 7/08/2022 indicated Resident #145 had an ADL self-care deficit related to myotonic muscular dystrophy (a multi-system disease affecting the skeletal muscles) . The care plan goal indicated Resident #145's needs would be met daily. The intervention was Resident #145 would have two staff to provide bathing.<BR/>Record review of an undated 200 Hall Shower Schedule indicated Resident #145 was to receive bathing on Tuesday's, Thursday's, and Saturday's on the 6:00 a.m. to 6:00 p.m. shift.<BR/>During an observation on 7/11/2022 at 9:40 a.m. revealed Resident #145's hair had a greasy appearance. Resident #145 was not interviewable due to her having the tracheostomy and unable to express self well concerning her bathing and hygiene. <BR/>Record review of the July 2022 point of care documentation from 7/01/2022 - 7/13/2022 indicated Resident #145 did not receive a bath on 7/02/2022 (Saturday) and on 7/07/2022 (Thursday). <BR/>Record review of the only shower sheet provided dated 7/05/2022 indicated Resident #145 received a shower, nails were cleaned, barrier cream applied, moisturizer applied, and her hair was not washed. <BR/>3. Record review of a face sheet dated 7/13/2022 indicated Resident #76 was an [AGE] year-old-female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's dementia and difficulty swallowing.<BR/>Record review of the most recent Quarterly MDS dated [DATE] indicated Resident #76 was sometimes understood by others and sometimes understands . The MDS indicated Resident #76's brief interview memory score was a 2 indicating a severe cognitive deficit. The MDS indicated Resident #76 required total assistance of one staff with personal hygiene including shaving.<BR/>Record review of the comprehensive care plan dated 4/11/2019 indicated Resident #76 had a self-care deficit with a goal of her needs would be met daily. The care plan indicated Resident #76 required one staff extensive assistance with personal hygiene.<BR/>During an observation on 7/11/2022 at 3:29 p.m. revealed Resident #76 had numerous gray colored facial hairs to her chin approximately 1 inch long . <BR/>During an observation on 7/12/2022 at 8:59 a.m. revealed Resident #76 continued to have long facial hairs to her chin. <BR/>During an observation on 7/12/2022 at 1:48 p.m. revealed Resident #76 continued to have long facial hairs to her chin. Resident #76 said she would like the hairs removed from her chin.<BR/>During an observation and interview on 7/14/2022 at 9:20 a.m. revealed Resident #76 continued to have long facial hairs to her chin. The DON indicated she would have the chin hairs taken care of today . <BR/>During an interview on 7/13/2022 at 9:50 a.m., CNA G indicated the CNAs were responsible for nail care, shaving and bathing on bath days and as needed. CNA G indicated the nurses would trim diabetic residents' nails, but the CNAs could clean anyone's fingernails. CNA G said residents could scratch themselves with long fingernails. CNA G said having dirty fingernails and eating was nasty. CNA G said if she did not get to a resident's bath on their scheduled day, she would get them the next day . CNA G indicated she was assigned to Resident's #76 and # 49.<BR/>During an interview on 7/13/2022 at 10:41 a.m., LVN D indicated the CNAs were responsible for bathing, shaving, and nail care. LVN D indicated nurses were responsible for ensuring the CNAs completed the ADLs. LVN D indicated monitoring of the ADLs occurred when the CNAs would turn in the shower sheets, she reviewed them and if there was a refusal she would try and encourage the resident to complete their ADLs. LVN D indicated she expected ADLs to be completed as scheduled and as needed.<BR/>During an interview on 7/13/2022 at 11:04 a.m., CNA E indicated she was responsible for ADLs. CNA E said she did not see the facial hair on Resident #76. CNA E indicated Resident #49's nails were now cleaned and trimmed. <BR/>During an interview on 7/14/2022 at 12:13 p.m., the DON indicated residents were encouraged to bathe/shower when they would refuse. The DON indicated if the resident prefers something different, she would be willing to implement the changes. The DON indicated she had done teaching with the staff to review their approach with the residents to ensure compliance with ADLs. The DON indicated the lack of ADLs could cause bacteria to form and illness to occur. The DON indicated the ADLs were monitored using the shower sheets, the computerized documentation, and with rounds. The DON expected the residents to receive their showers, nail care, and shaving on their scheduled days and as needed.<BR/>During an interview on 7/14/2022 at 1:05 p.m., the ADM indicated he expected the residents to receive their ADLs. The ADM indicated not receiving their ADLs could cause infection and affect the resident's dignity. He indicated the ADLs were monitored by nursing using the computerized documentation and with rounds.<BR/>During an interview on 7/14/2022 at 3:15 p.m., the DON indicated there were no policy and procedures for nailcare, shaving or bathing.<BR/>Record review of Care of Standards policy with a revised date of June 2020 indicated the purpose was to ensure all residents receive necessary care and services that were evidence-based and in accordance with accepted professional clinical standards of practice. Procedure l. The Director of Nursing Services (DON) ensured care and services were delivered according to accepted standards of clinical practice. Unless specifically addressed in an individual facility policy the Facility defers to the accepted national standards of clinical practice. ll.E. Skills and techniques for the New Nursing Assistant Textbook, 8th Edition ([NAME], [NAME]); F. Mosby's Textbook for Long-Term Care Nursing Assistants Sixth Edition ([NAME]) IV. The DON or designee evaluates staff competency in skills and techniques necessary to care for residents assessed needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision, for 2 of 2 smoking areas (West balcony, and East ground floor).<BR/> and eliminate accident and hazards for 3 of 19 residents (Residents #6, #62 and #39) reviewed for accidents and supervision. <BR/>1. The facility failed to provide supervision for Resident #6 and Resident #62 while smoking.<BR/>2. The facility failed to identify side rails and eliminate accident and hazards for Resident #39 's environment. <BR/>These failures could place residents at risk of injuries and burns.<BR/>Findings include:<BR/>1. Record review of Resident #6's face sheet, dated 07/14/22 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included encephalopathy (a disease that damages your brain), anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), HIV (human immunodeficiency virus) is a virus that attacks the body's immune system), cerebral edema (brain swelling). <BR/>Record review of Resident # 6's MDS, dated [DATE] indicated Resident # 6 made himself understood and understood others. Resident # 6 had a BIMS score of 15 which indicated he was cognitively intact. The MDS indicated Resident # 6 required supervision with bed mobility, dressing, toileting, personal hygiene, bathing and eating.<BR/>Record review of Resident #6 's care plan, dated 09/10/21, revealed Resident # 6 was a smoker. Interventions indicated: for smoking material to be maintained by staff and distributed during smoking times. Would smoke in designated smoking area and smoking breaks. <BR/>Record review of Resident #6's Smoking evaluation, dated 06/10/22, revealed Resident # 6 required direct supervision while smoking, all smoking material would be kept at the nurses' station and evaluation had been discussed with resident.<BR/>During an observation and interview on 07/14/22 at 9:30 a.m., ADON H and the surveyor saw Resident #6 with a cigarette and lighter in his hand while sitting on the balcony unattended by any staff member. ADON H talked with Resident #6 about the smoking policy and confiscated his paraphernalia. ADON H said it is hard to watch every resident because sometimes they go out on pass or have family and friends bring them cigarettes and staff were not aware. The ADON H said they have caught some residents with paraphernalia on them before and confiscated it. ADON H said the ADM talked to all residents that smoke this week about their cigarettes and the smoking policy. ADON H said all residents should follow the rules to keep it fair and to keep residents safe from burning themselves or starting a fire.<BR/>During an interview on 07/14/22 at 9:33 a.m., Resident #6 stated he was aware of the smoking policy but does not like it. Resident #6 said he feels he was safe and did not need anyone to watch him smoke. <BR/>2. Record review of Resident #62' s face sheet, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included dementia, tachycardia (a condition that makes your heartbeat more than 100 times per minute), atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), and hypertension (high blood pressure).<BR/>Record review of Resident #62's MDS, dated [DATE] indicated Resident #62 made himself understood and understood others. Resident #62 had a BIMS score of 15 which indicated he was cognitively intact. The MDS indicated Resident #62 required supervision with bed mobility, dressing, toileting, personal hygiene, and eating, independent in bathing.<BR/>Record review of Resident #62 's care plan, dated 01/06/22, revealed Resident #62 uses tobacco products: smoking, chewing or snuff. Interventions indicated: for smoking/tobacco supplies to be kept in the smoking supply box at the nurse's station. Will smoke only during the designated times determined by facility when supervision will be provided and will smoke in designated smoking area. <BR/>Record review of Resident # 62's Smoking evaluation, dated 05/18/22, revealed Resident #62 was a safe smoker with minimal supervision.<BR/>During an observation and interview on 07/11/22 at 3:48 p.m., revealed Resident #62 was outside on the smoking balcony with a lighter and smoking a cigarette. Resident #62 stated, he keeps his lighter, but that man referring to floor tech P lit my cigarette. I like to smoke on time, they set a time but never on time. Resident #62 walked away and would not answer any more questions.<BR/>During an interview on 07/11/22 at 3:50 p.m., CNA N looked out the door and verified that Resident #62 was indeed outside with a lighter and a lit cigarette. CNA N stated Resident #62 does what he wants to, he has 3 clocks set in his room and demands to smoke at smoke times. CNA N said residents are supposed to be supervised, to prevent them from burning themselves. <BR/>During an interview on 07/11/22 at 3:51 p.m., Floor tech P stated he lit Resident #62's cigarette and then left to go gather the other smokers. Floor tech P said the resident was very demanding when it came to smoke times and the DON and ADM was aware of his behavior. Floor tech P said he was not supposed to leave any resident unsupervised because they could burn themselves. <BR/>During an interview on 07/14/22 at 9:29 a.m., LVN L said to her knowledge all lighters and cigarettes are to be kept in a lock box that floor techs have for the safety of the residents.<BR/>During an interview on 07/13/22 at 3:30 p.m., Floor tech A said all residents who smoke are to keep their cigarettes and lighters in the lock box. He said they have about fifteen smokers. Floor Tech A said he supervises the residents who smoke for their safety.<BR/>During an interview on 07/14/22 at 1:29 p.m., the ADM said he talked with Resident # 6 with the Social Worker and gave him a final warning and Resident # 6 signed the notice. The ADM showed the signed form to the surveyor. The ADM said they have reviewed the policy with every resident who smokes starting on 7/11/22. The ADM said floor techs are the keepers of the lock box with cigarettes and lighters and he is supposed to follow up to make sure they are keeping the box locked and secure. The ADM said he instructed all staff if they see any resident with cigarettes or lighters to confiscate and report to him immediately. The ADM said the smoking policy states all cigarettes and lighters should be kept locked and his goals for the smoking residents are from them and their families to be compliant with the smoking policy so that they can be supervised and safe.<BR/>During an interview on 07/14/22 at 2:02 p.m., the DON said her expectation for smoking residents is to follow the policy and not try to sneak cigarettes and lighters. The DON said some residents have called their family to bring cigarettes, but they have directed staff if they see any paraphernalia to confiscate them. The ADM and Social Worker talked with residents and had them to sign an agreement this week and they need to abide by the agreement. The DON said she was told the ADM was also going to send a letter out to families about the smoking policy. The DON said ADM and Social Worker are the overseers of residents who smoke but failure to follow the policy could potentially cause injury to themselves such as burns.<BR/>Record review of policy Smoking by Residents dated March 2022, indicated, To respect the residents' choice and to maintain a safe healthy environment for both smokers and non-smokers. Smokers will be identified on admission and given a copy of smoking policy, IDT will create a care plan .Resident will be allowed to smoke in designated area only All smoking material will be stored in a secure area to ensure they are kept safe .All smoking sessions will be supervised by facility staff members.<BR/>Record review of smoking violation policy given by the DON on 07/13/22 indicated, Smoking by residents is only permitted in designated facility areas at designated times regulated by staff .It may be necessary to counsel patients or responsible parties who violate the smoking policy. Violation of this policy may compromise the safety of all residents and staff due to potential negative consequences that may occur.<BR/>3.Record review of Resident #39's face sheet dated 07/14/22 indicated Resident #39 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), dyspepsia (indigestion) and intellectual disabilities (a term used when there are limits to a person's ability to learn at an expected level and function in daily life). <BR/>Record review of Resident #39's most recent comprehensive MDS, dated [DATE], indicated Resident #39 rarely made herself understood and was rarely understood by others. Resident #39's brief interview for mental status score was not completed. The MDS indicated Resident #39 required total assist with bed mobility, dressing, eating, toileting, personal hygiene, and bathing. <BR/>Record review of the care plan dated 11/20/18 for Resident #39 indicated the resident was a risk for falls. Resident #39 was unaware of safety needs. Interventions indicated: anticipate and meet the resident's needs, bolster mattress to set safe bed boundaries, fall mat at bedside, low bed, keep in lowest position while in bed. <BR/>Record review of care plan dated 05/29/19 indicated Resident #39 has Cerebral Palsy, her muscles were spastic, and she was unable to control her body movements. Interventions indicated: required a low bed with a safety mat due to the possibility of falls from bed secondary to Cerebral Palsy with spastic movement.<BR/>During an observation on 07/11/22 at 3:47 p.m. revealed Resident #39 was in her bed with all 4 side rails up.<BR/>During an observation and interview on 07/12/22 at 3:10 p.m. revealed Resident #39 was in bed with all 4 side rails up. CNA G stated the resident's family member bought the current bed some months ago and they have been putting up all 4 side rails. CNA G said the DON and ADM were aware Resident #39 had the bed with side rails. CNA G said resident #39 has not had a fall and did not feel she was at risk for falling out of this bed.<BR/>During an observation on 07/13/22 at 9:27 a.m. revealed Resident #39 was in her bed with all 4 side rails up and fall mat on floor.<BR/>During an interview on 07/13/22 12:03 p.m., LVN L said she knew Resident # 39's bed had side rails but were not aware they were up. LVN L looked at the MAR to check the orders and said the orders indicated a low bed with a scoop mattress and a fall mat on the floor. LVN L said the bed was in the hallway for a while and when she came back to work from her off days the bed was in the room. LVN L said she thought the DON and ADM were aware of the bed, so she never questioned the bed. LVN L said they keep a close watch on Resident #39, but it could be a potential for her legs or head to be caught in between the rails but she never saw it and no staff ever reported it. LVN L stated Resident #39 mostly grinded her heels in bed, not thrashing. LVN L stated the only thing she did see was a potential to fall out of bed because it did not go down low to the ground. <BR/>During an interview on 07/14/22 at 9:30 a.m., ADON H said she knew Resident # 39 had the bed with rails, but her understanding was the ADM told maintenance to put the bed in Resident #39's room so she never questioned it. ADON H said she felt like the proper monitoring and tools were in place and Resident #39 was safe. ADON H said she could see the potential for Resident # 39 to bump her legs against side rails and cause bruises.<BR/>During an interview on 07/13/22 at 12:05 p.m., the ADM said from what he remember, the family was doing a Medicare spend down when they purchased the bed. The ADM said they placed a call to the family to let them know they were going to replace Residents # 39's bed with a low bed and a scoop mattress and were awaiting a return call. The ADM said he was not aware of siderails on the bed until today and he is getting the maintenance supervisor to place a zip tie on the side rails to prevent anyone from using them. In a subsequent interview at 12:20 p.m., the ADM said after looking at the bed for Resident #39, they are going to move the existing bed out and place a low bed with a scoop mattress in room. The ADM said he can see the risk of Resident #39 potentially getting caught in or in-between the rails and that could cause harm to any part of her body.<BR/>During an observation on 07/14/22 at 8:01 a.m., revealed Resident #39 was in a low bed with a scoop mattress and a fall mat. The bed with side rails had been removed from room.<BR/>During an interview on 07/14/22 at 8:06 a.m., CNA N said she thought Resident # 39's family member brought the bed and then someone put it in the room. CNA N said she liked the bed and did not believe Resident #39 was in any harm because she never saw her legs or head go through the rails.<BR/>During an interview on 07/14/22 at 8:09 a.m., CNA O said she never saw Resident # 39's legs or arms in between rails but it was a potential that it could.<BR/>During an interview on 07/14/22at 08:31 a.m., CNA G said resident # 39 could have fallen out of bed because it was not low enough, maybe get hurt or bruised related to side rails.<BR/>During an interview on 07/14/22 at 10:02 a.m., the Maintenance Supervisor said he was not aware of Resident # 39's bed until yesterday (07/13/2022), when he was instructed to move the bed out of room. The Maintenance Supervisor said he was not employed when that bed was placed in Resident # 39's room. The Maintenance Supervisor said after identifying the bed, he did believe it could have been a hazard if an emergency arose because the bed could not fit through the door. <BR/>During an interview on 07/14/22 at 2:02 p.m., the DON said she was told, the resident's family member had to do a spend down and bought the bed. The DON talked with Resident # 39's family member and he agreed to remove the bed, apply the low bed and scoop mattress. The DON said the bed was already in Resident # 39's room when she returned as DON. The DON said she had mention something to ADM while she was the MDS nurse about the bed but was informed by staff that the ADM instructed staff to put the bed in the room. The DON said they should use the least restrictive form of restraints. The DON said the low bed, fat mat and scoop mattress for Resident #39 was the least restrictive form of restraint. The DON said because of Resident #39's diagnosis of Cerebral Palsy with uncontrolled spasms she had the potential for body injury. <BR/>Record review of Restraints policy dated June 2020 indicated, Residents shall be provided an environment that is restraint free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measure shall be used. If facility is utilizing bed rail, the assessment bed rails entrapment risk assessment or other electronic documentation in PCC will be complete .prior to installation of bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 19 residents reviewed for respiratory care. (Resident #18, Resident #53).<BR/>The facility failed to properly store suction device (oral suctioning tool to clear the airway) and date tubing for Resident #18.<BR/>The facility failed to properly store a handheld nebulizer (HHN) and date tubing for Resident #53.<BR/>These failures could place residents who required respiratory care at risk for respiratory infections. <BR/>Findings included: <BR/>1. Record review Resident #18's face sheet dated 07/13/22 indicated Resident #18 was an [AGE] years old male, admitted to the facility with diagnoses of CVA (a stroke- is an interruption in the flow of blood to cells in the brain), Dysphagia (difficulty swallowing), Diabetes Mellitus (group of diseases that affect how your body uses blood sugar), Atrial Fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), and hypertension (high blood pressure).<BR/>Record review of Resident #18's most recent comprehensive MDS, dated [DATE], indicated Resident #18 rarely made himself understood and was rarely understood by others. Resident #18's brief interview for mental status score was not completed. The MDS indicated Resident #18 required extensive assist with bed mobility, dressing, eating, toileting, personal hygiene, and bathing. <BR/>Record review of the care plan dated 07/14/22 for Resident #18 indicated he required the use of a suction device for oral care, to remove secretion from his mouth due to cognitive impairment. The goal was to use suction machine with suction device to remove oral secretions.<BR/>Record review of physician's ordered dated 07/13/22 for Resident #18 indicated: May use suction device to suction secretions from cheeks while performing oral care and change suction device and tubing to suction machine Q week on Sunday and PRN.<BR/>During an observation on 07/12/22 at 8:34 a.m., revealed Resident #18's suction canister with about 500ml of blueish white liquid substance in color and the suction device tubing with no date and not bagged.<BR/>During an observation on 07/12/22 at 12:35 p.m., revealed Resident #18's suction canister with about 550 ml of blueish white liquid substance and the suction device tubing with no date and not in bag.<BR/>During an observation and interview on 07/13/22 at 9:55 a.m., revealed Resident #18's suction device tubing in a drawer without a cover and remained with no date. LVN K was in the room at this time and looked to verify the suction device tubing in the drawer with no date and not bagged. LVN K said the suction device tubing should be dated and, in a bag, when not in use and the suction canister and tubing should be changed on Saturday or Sunday nights. LVN K said having the suction device tubing in a bag would reduce the risk of getting a respiratory infection. <BR/>During an interview on 07/14/22 at 8:47 a.m., LVN M said she suctioned Resident #18 at least daily on her 7am-7pm shift. LVN M said she changes the set up on her first assigned day to work but it was ordered to be changed every Sunday night. LVN M said the suction device tubing should be kept in a bag to prevent respiratory infection.<BR/>2. Record review of the resident #53's face sheet dated 07/14/22 indicated Resident #53 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses of Schizophrenia (a serious mental disorder in which people interpret reality abnormally), COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing), Hypertension (high blood pressure), and Diabetes Mellitus. <BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #53 made herself understood and could understand others. Resident #53 had a BIMS score of 12 which indicated he was cognitively intact. The MDS indicated Resident #53 required total assist with bathing; extensive assist with bed mobility, dressing, toileting, personal hygiene; and set up for eating.<BR/>Record review of a Physician's order dated 07/14/22 indicated to give Ipratropium-Albuterol Solution 0.5-2.5mg/3ml vial, inhale orally every 6 hours for shortness of breath. Change nebulizer mask and tubing every Friday night.<BR/>Record review of care plan dated 02/04/22 indicated that Resident #53 had shortness of breath and diagnosis of COPD and asthma. Staff approach indicated: give aerosol or bronchodilators as ordered.<BR/>During an observation on 07/11/22 at 11:47 a.m., revealed Residents #53's HHN with no date on the tubing and was not bagged.<BR/>During an observation on 07/12/22 at 2:47 p.m., revealed Residents #53's HHN with no date on the tubing.<BR/>During an observation and interview on 07/13/22 at 10:06 a.m., revealed Residents #53's HHN nebulizer tubing was out of the bag with no date and the on bedside table. LVN K came to the room and verified the tubing was not dated and on the bedside table. LVN K said if tubing was not bagged it could cause a respiratory infection.<BR/>During an observation and interview on 07/14/22 at 8:47 a.m., LVN M went into Resident #53's room and verified that the HHN nebulizer tubing was not dated. LVN M said they would date the tubing and place back in bag when they finished to prevent infection. <BR/>During an interview on 07/14/22 at 9:30 a.m., the ADON H said tubing should be changed weekly some are on Friday's and some are Sundays; they should have an order for which date to change them. Vents are different. The ADON H said nurses are supposed to date and placed in a bag to prevent bacteria and germs. <BR/>During an interview on 07/14/22 at 9:55 a.m., LVN L said tubing should be changed every Sunday night. LVN L said nurses should put the date on them and place in a bag to keep away germs.<BR/>During an interview on 07/14/22 at 2:02 p.m., the DON said all tubing are scheduled to be changed on the MAR for Sunday nights. The DON said they do not have a policy on suction device or HHN tubing, but she expects tubing to be dated and properly stored. The DON said they have department heads who do ambassador rounds daily and nurse managers are to follow up to make sure they are dated and properly stored. The DON said failure to keep the tubing in bags could lead to illness related to bacteria.<BR/>During an interview on 07/14/22 at 1:29 p.m., the ADM said all tubing should be in a bag and dated. The ADM said he expected the ADON and DON to follow the protocol and failure to follow could lead to infection control issues. <BR/>Record review of the suctioning policy dated May 2017 indicated, It is the policy of this home that oral suctioning of a resident's mouth, pharynx and nasopharynx will be provided to remove mucus, drainage or salvia away from the resident's airway.<BR/>Record review of the aerosol therapy (hand0held Nebulizer) policy dated 04/18/16 indicated, the respiratory therapist or licensed nurse will provide .hand-held nebulizer therapy as ordered by physician The order should include medication, dose and frequency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.<BR/>The facility did not ensure beverages were stored in a lunch box/cooler were free from a white and yellow colored material resembling mold or were discarded as needed. These beverages were in the facility's dishware.<BR/>This failure could place the residents at risk for an unsafe environment. <BR/>Findings included:<BR/>Record review of a face sheet dated 7/13/2022 indicated Resident #76 was an [AGE] year-old-female who admitted on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's dementia and difficulty swallowing. The face sheet indicated Resident #76 resided in room [ROOM NUMBER].<BR/>Record review of the most recent Quarterly MDS dated [DATE] indicated Resident #76 sometimes understood and sometimes understands. The MDS indicated Resident #76's brief interview memory score was a 2 indicating a severe cognitive deficit. The MDS indicated Resident #76 required total assistance of one staff for meals. Section K of the MDS indicated Resident #76 had a mechanically altered diet.<BR/>Record review of a comprehensive care plan dated 12/23/2019 indicated Resident #76 required a pureed diet with honey liquids due to a swallowing problem. The intervention was to serve diet as ordered.<BR/>During an observation on 7/11/2022 at 9:36 a.m., Resident room [ROOM NUMBER] had a small lunch/box cooler sitting on a dresser underneath the television. The lunch box/cooler had 4 covered plastic glasses with beverages inside. The inside of the covered glasses and floating in the beverages was a whitish yellow colored material resembling mold.<BR/>During an observation on 7/11/2022 at 3:29 p.m., the lunch cooler remained on the dresser with the same 4 beverages. The beverages continued to have a whitish yellow colored material floating in the beverage.<BR/>During an observation on 7/12/2022 at 8:59 a.m., the lunch cooler remained on the dresser with the 4 beverages with the whitish yellow colored material floating in the beverage.<BR/>During an interview on 7/12/2022 at 1:54 p.m., CNA F indicated any thickened beverages would come from the dietary department on the meal trays and on the snack cart. She was unaware of where the cooler came from.<BR/>During an interview on 7/12/2022 at 1:55 p.m., CNA E indicated residents who receive thickened beverages would receive the thickened beverage from the snack cart or the dietary department.<BR/>During an interview on 7/12/2022 at 3:30 p.m., the DON said there was not a thickened beverage program where beverages would be stored in a lunch cooler in the resident's room. The DON indicated Resident #76 was on thickened beverages. The DON indicated she was unsure how or where the lunch chest came from. The DON indicated the drinks could make someone sick. <BR/>During an interview on 7/14/2022 at 1:05 p.m., the ADM indicated he expected all staff to discard drinks before becoming not consumable. The ADM said all staff were responsible to ensure compliance. The ADM said the ambassador program was an audit program. The ambassador program included rounds to ensure rooms were clean and neat.<BR/>An Environment policy was request on 7/14/2022 at 10:00 a.m. but was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 20 residents reviewed for incontinent care and catheter care infection control practices. (Resident #'s 35 and 76).<BR/>CNA E cleaned Resident #76's buttock using the same two wipes for multiple wiping motions.<BR/>CNA F used contaminated wipes for Resident #35's catheter care.<BR/>CNA F touched the package of wipes and the clean brief for Resident #35 without removing her gloves and sanitizing of her hands. <BR/>These failures could place residents with foley catheter care or incontinent care at risk for urinary tract infections.<BR/>Findings included: <BR/>1. Record review of a face sheet dated 7/13/2022 indicated Resident #76 was an [AGE] year-old-female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's dementia and difficulty swallowing.<BR/>Record review of the most recent Quarterly MDS dated [DATE] indicated Resident #76 sometimes understood and sometimes understood others. The MDS indicated Resident #76's brief interview memory score was a 2 indicating a severe cognitive deficit. The MDs indicated Resident #76 required total assistance of two staff with toileting . The MDS indicated Resident #76 was always incontinent of urine and bowel.<BR/>Record review of the comprehensive care plan dated 4/11/2019 indicated Resident #76 had a self-care deficit with a goal of her needs would be met daily. The care plan indicated Resident #76 required one staff for incontinent care. <BR/>During an observation on 7/12/2022 at 8:59 a.m. revealed CNA's E and F provided incontinent care to Resident #76. CNA F opened Resident #76's current brief and repositioned her in the bed. Resident #76's brief was visibly soiled with urine. Then CNA F touched the package of wipes and the clean brief without removing her gloves and sanitation of her hands. CNA E took 2 wipes from the wipe package and cleansed Resident #76's buttock making several wiping strokes, not turning the wipes nor obtaining new ones before discarding the wipes. CNA F removed the dirty brief and the draw sheet then touched the clean brief without changing her gloves . CAN F then touched the bed side table before removing her gloves and using hand sanitizer. <BR/>2.Record review of a face sheet dated 7/14/2022 indicated Resident #35 was a [AGE] year-old-male who admitted to the facility on [DATE] with the diagnoses of neuromuscular dysfunction (muscle weakness, muscle loss)of the bladder, morbid obesity, and low back pain. <BR/>Record review of the most recent Annual assessment dated [DATE] indicated Resident #35 understood others and was understood by others. Resident #35's brief interview for memory score was a 12 indicating moderate cognitive impairment. The MDS section H0100 Appliances indicated Resident #35 had an indwelling catheter and H0300 Urinary Continence indicated Resident #35 had a catheter. <BR/>Record review of the comprehensive care plan dated 10/18/2021 indicated Resident #35 had an indwelling catheter. The goal would be no signs or symptoms of a urinary infection. The care plan intervention was to change the catheter per orders, and catheter care with care daily and as needed.<BR/>Record review of consolidated physician's orders dated 7/14/2022 indicated Resident #35 had a Foley Catheter 16 french to bedside drainage bag for the diagnosis of dysfunction of the bladder.<BR/>Record review of consolidated physician's orders dated 07/14/2022 indicated Resident #35 had an order for Foley catheter care every shift and as needed.<BR/>During an observation and interview on 7/13/2022 at 11:59 a.m. revealed CNA's F and G provided catheter care for Resident #35. CNA F obtained a wipe from the bag of wipes lying at the foot of the bed. CNA F made one wipe down the inner thigh of Resident #35. CNA F then discarded the one wipe in the bag of clean wipes. CNA F continued to provide catheter care using the contaminated wipes. CNA F wiped the penis, scrotum and inner thighs using the contaminated wipes. During an interview with CNA's F and G, they indicated the incontinent care was appropriately done. CNA's F and G were asked about the discarding of the used wipe in with the clean wipes and they both indicated the discarding of the dirty wipe with the clean wipes and continuing to provide catheter care could place Resident #35 at risk for infection . The CNAs indicated they had been trained on catheter care. <BR/>During an interview on 7/14/2022 at 10:41 a.m., LVN D indicated she expected the CNA's to use a different wipe with each wiping motion. She indicated a resident was at risk for infection and skin issues when catheter care or incontinent care was not provided effectively. LVN D indicated the DON provided check offs for the CNAs to ensure effective catheter and incontinent care. <BR/>Record review of a CNA proficiency audit dated 7/7/2022 for CNAs E, F and G indicated they had been checked off as satisfactory in the performance of female perineal care and male foley catheter care.<BR/>During an interview on 7/14/2022 at 12:13 p.m., the DON indicated she expected incontinent care and catheter care to be provided according to the policy. The DON indicated failure to provide ineffective foley and catheter care was an opportunity for bacteria and illness. The DON said residents with catheters were at a greater risk of infection.<BR/>During an interview on 7/14/2022 at 1:05 p.m., the ADM indicated he expected incontinent care and catheter care to be provided as needed and indicated. The ADM indicated the nursing staff were responsible for ensuring the incontinent care and catheter care were provided accurately. The ADM indicated the provision of incorrect incontinent care and catheter care was an infection control issue.<BR/>Record review of an Infection Control-Prevention and Control Program dated May 2017 indicated the intent of this program was to assure that the home developed, implemented, and maintained an Infection Prevention and Control Program to prevent, recognize, the onset and spread of infection within the facility. The program will: 2. Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions. Procedure: 1. Policies, procedures, and practices which promote consistent adherence to evidence-based infection control practices; 5. Education, including training in infection prevention and control practices, to ensure compliance with facility requirements as well as State and Federal regulations.<BR/>According to the CDC Epidemiology and Prevention of UTI dated 7/2018 a component of prevention of a Urinary Tract Infection was to provide good perineal hygiene and UTIs are common and a significant cause of harm in long term care facilities. Accessed at Epidemiology and Prevention of UTI (cdc.gov) accessed on 7/18/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's PRN orders for psychotropic drugs were limited to fourteen (14) days for 1 of 24 residents selected for unnecessary medications review. (Resident #59). <BR/>Resident #59 had a PRN order for Lorazepam, a psychotropic medication, for more than fourteen days without physician documentation re-evaluating the medication to continue it PRN or to become a scheduled medication. <BR/>This failure could place residents who receive PRN psychotropic medications at risk of receiving unnecessary medications. <BR/>Findings included: <BR/>Record review of the undated face sheet indicated Resident #59 was an [AGE] year-old male that admitted on [DATE] and readmitted on [DATE].<BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #59 had clear speech, was understood by others, and understood others. He had a BIMS score of 9 indicating moderate cognitive impairment. <BR/>Record review of the care plan dated 8/29/24 indicated Resident #59 required psychotropic medications for a diagnosis of anxiety. The care plan indicated he was on hospice care and had impaired cognitive function related to dementia.<BR/>Record review of the physician's orders dated 10/15/24 indicated Resident #59 had diagnoses that included: Acute and chronic respiratory failure (inadequate gas exchange in the respiratory system that cannot be kept at normal levels), dementia (thinking and social symptoms that interfere with daily functioning), psychotic disturbance (a severe mental disorder that causes a person to lose touch with reality and have abnormal perceptions and thoughts), and mood disturbance (change in a person's mental state that can involve feelings of distress, sadness or anxiety). <BR/>The physician's orders for Resident #59 indicated: <BR/>-8/29/24 Lorazepam oral tablet 1 mg, give one tablet by mouth every 4 hours as needed for anxiety/restlessness. No end date was noted for the order.<BR/>Record review of the MAR for August 2024 indicated Resident #59 had not received Lorazepam. <BR/>Record review of the MAR for September 2024 indicated Resident #59 received Lorazepam oral tablet, 1 mg once on 9/5/24 and on once on 9/25/24. <BR/>Record review of the MAR for October 2024 indicated Resident #59 had not received Lorazepam. <BR/>Record review of the pharmacy book for September of 2024 indicated: Resident #59, Lorazepam 1 mg every 4 hours for anxiety/restlessness ordered 8/29/24. There were no recommendations. <BR/>During an interview on 0/16/24 at 1:29 PM, ADON A per the CMS regulations, residents could not have a PRN order for antianxiety medication longer than 2 weeks. <BR/>During an interview on 10/16/24 at 2:07 PM, the DON said no resident should have a PRN order for Lorazepam or any psychotropic drug for more than 14 days. She said if the order was more than 14 days the MD had to give some sort of rational as to why the medication was needed more than 14 days. The DON said the risk of psychotropics was oversedation and there was a greater risk of the medication not working properly if used for a longer period of time. She said she did not realize Resident #59 had a PRN order for Lorazepam. <BR/>During an interview on 10/16/24 at 2:23 PM, the ADM said she was not aware if any resident should have an order for antianxiety or psychotropics for longer than 2 weeks. <BR/>Record review of a Psychotherapeutic Drug Management Policy provided by the Regional RN indicated: <BR/>Purpose<BR/>1.To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the r resident, and/or are decreasing or negatively impacting the residents' quality of life.<BR/>2.To help promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, promote resident safety and security, and to enhance the resident's ability to interact positively with his/her environment .<BR/>Policy<BR/> .2.The Facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits.<BR/>Procedure <BR/>I. Residents should not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. <BR/>1.PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rational in the r resident's medical record and indicate the duration for the PRN order .<BR/>3.PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident in person, for the appropriateness of that medication .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete an accurate assessment to reflect the status for 1 of 20 residents reviewed for assessments. (Resident #66)<BR/>The facility did not ensure Resident #66's MDS assessment accurately reflected his non-hospice status. <BR/>This failure could place residents at risk for decreased quality of care due to inaccuracy of assessments.<BR/>Findings included: <BR/>A record review of the consolidated physician's orders dated July 2022 indicated Resident #66 admitted to the facility on [DATE]. He was [AGE] years old, with diagnoses that included: acute respiratory distress syndrome (fluid collects in the air sacs of the lungs causing shortness of breath), hypertension (blood against the artery walls is too high), reduced mobility (limited mobility due to age or disease), and depression (conditions causing lowering of a person's mood.) The physician's orders did not indicate Resident #66 was on hospice care. <BR/>A record review of the MDS assessment dated [DATE] indicated Resident #66 was cognitively intact. The MDS indicated he required the supervision of 2 staff for bed mobility and the extensive assistance of two or more staff for transfer. Section O of the MDS indicated he was on hospice care while a resident in the facility. <BR/>A record review of the care plan dated 6/7/22 indicated Resident #66 required oxygen for acute respiratory failure and required antidepressant medication for depression. The care plan indicated Resident #66 required 2 staff to turn and reposition in bed and 2 staff to assist with transfer. The care plan did not address hospice. <BR/>During an interview on 7/13/22 at 8:02 AM, RN C said she did the skilled MDS's. She said she had marked Resident #66 for hospice by mistake on the MDS dated [DATE]. She said he had never been on hospice and was not currently on hospice. She said she already submitted a correction. <BR/>During an interview on 7/13/22 at 2:43 PM, the Regional MDS nurse said they did not have a policy for MDS accuracy. She said they used the RAI manual.<BR/>During an interview on 7/13/22 at 2:48 PM, the DON said she expected the MDS to accurately reflect the resident's status. She said the risk of the MDS being inaccurate could be the care plan could also be inaccurate. <BR/>During an interview on 7/14/22 at 9:02 AM, ADON B said she expected MDS's to accurately reflect a resident's status. She said if a resident was marked inaccurately on the MDS it could affect their plan of care, possibly in a negative way. <BR/>During an interview on 7/14/22 at 9:04 AM, the ADM said he expected the MDS to accurately reflect the resident's status. He said he could see a risk to care if the care plan was also inaccurate. <BR/>During an interview on 7/14/22 at 9:40 AM, the ADM said he checked Resident #66's plan of care and physician's orders. He said the MDS was marked in error, so it did not affect Resident #66''s plan of care or his physician's orders. He said there was not a risk to Resident #66 because he continued in therapy and all physician's orders were followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 3 of 20 residents reviewed for ADLs. (Resident #'s 145, 76, and 145).<BR/>The facility failed to provide nail care for Resident #49.<BR/>The facility failed to provide facial hair grooming for Resident #76.<BR/>The facility failed to provide bathing for Resident #145.<BR/>These failures could place residents at risk for not receiving services/care and a decreased quality of life.<BR/>Findings included:<BR/>1.Record review of a face sheet dated 7/13/2022 indicated Resident #49 was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of Parkinson's disease, need for assistance with personal care and weakness.<BR/>The most recent Quarterly MDS dated [DATE] indicated Resident #49 understood others and was understood by others. Resident #49's brief interview memory score was a 2 indicating he had severe cognitive impairment. The MDS indicated Resident #49 required total assistance of one staff for personal hygiene.<BR/>Record review of a comprehensive care plan dated 6/2/2020 indicated Resident #49 had a self-care deficit with a goal of improvement with the intervention of bathing which included checking the nail length, trim and clean on bath days. <BR/>Record review of a 200 Hall shower schedule indicated Resident #49's bath days were Monday's, Wednesday's, and Friday's on the 6:00 a.m. to 6:00 p.m. shift.<BR/>During an observation on 7/11/2022 at 10:00 a.m. revealed Resident #49 was lying in his bed. His nails were long and with a brownish black material underneath the nails . Resident #49 said he would like have his nails cleaned and trimmed. <BR/>During an observation on 7/11/2022 at 12:55 p.m. revealed Resident #49's fingernails were approximately &frac12; inch long with a brownish black material underneath the fingernails.<BR/>During an observation on 7/11/2022 at 3:50 p.m. revealed Resident #49's fingernails continued to be long with brownish black material underneath the nails.<BR/>During an observation on 7/12/2022 at 2:00 p.m., Resident #49's nails continued to be long and with a brownish black material underneath the nails. <BR/>Record review of Resident #49's Shower Sheets indicated:<BR/>*7/1/2022 Resident #49's nails were cleaned with his bed bath.<BR/>*7/6/22022 Resident #49's nails were not cleaned with a refusal of a shower.<BR/>*7/08/2022 Resident #49's nails were not cleaned with his bed bath.<BR/>*7/11/2022 Resident #49's nails were cleaned with a bed bath.<BR/>*7/13/2022 Resident #49's nails were cleaned with a refusal of a shower.<BR/>2.Record review of a face sheet dated 7/13/2022 indicated Resident #145 was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of chronic respiratory failure, pneumonia, and seizures.<BR/>Record review of the most recent admission MDS dated [DATE] indicated Resident #145 understood others and was usually understood by others. The MDS indicated Resident #145's BIMS was a 10 indicating moderately impaired cognition. Under the section of Staff Assessment of Daily and Activity Preferences the MDS indicated Resident #145 preferred to have a bed bath. The MDS indicated Resident #145 was total assist of two staff for bed mobility, dressing, eating, personal hygiene and for bathing she required total assistance of one staff. <BR/>Record review of the comprehensive care plan dated 4/27/2022 and revised on 7/08/2022 indicated Resident #145 had an ADL self-care deficit related to myotonic muscular dystrophy (a multi-system disease affecting the skeletal muscles) . The care plan goal indicated Resident #145's needs would be met daily. The intervention was Resident #145 would have two staff to provide bathing.<BR/>Record review of an undated 200 Hall Shower Schedule indicated Resident #145 was to receive bathing on Tuesday's, Thursday's, and Saturday's on the 6:00 a.m. to 6:00 p.m. shift.<BR/>During an observation on 7/11/2022 at 9:40 a.m. revealed Resident #145's hair had a greasy appearance. Resident #145 was not interviewable due to her having the tracheostomy and unable to express self well concerning her bathing and hygiene. <BR/>Record review of the July 2022 point of care documentation from 7/01/2022 - 7/13/2022 indicated Resident #145 did not receive a bath on 7/02/2022 (Saturday) and on 7/07/2022 (Thursday). <BR/>Record review of the only shower sheet provided dated 7/05/2022 indicated Resident #145 received a shower, nails were cleaned, barrier cream applied, moisturizer applied, and her hair was not washed. <BR/>3. Record review of a face sheet dated 7/13/2022 indicated Resident #76 was an [AGE] year-old-female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's dementia and difficulty swallowing.<BR/>Record review of the most recent Quarterly MDS dated [DATE] indicated Resident #76 was sometimes understood by others and sometimes understands . The MDS indicated Resident #76's brief interview memory score was a 2 indicating a severe cognitive deficit. The MDS indicated Resident #76 required total assistance of one staff with personal hygiene including shaving.<BR/>Record review of the comprehensive care plan dated 4/11/2019 indicated Resident #76 had a self-care deficit with a goal of her needs would be met daily. The care plan indicated Resident #76 required one staff extensive assistance with personal hygiene.<BR/>During an observation on 7/11/2022 at 3:29 p.m. revealed Resident #76 had numerous gray colored facial hairs to her chin approximately 1 inch long . <BR/>During an observation on 7/12/2022 at 8:59 a.m. revealed Resident #76 continued to have long facial hairs to her chin. <BR/>During an observation on 7/12/2022 at 1:48 p.m. revealed Resident #76 continued to have long facial hairs to her chin. Resident #76 said she would like the hairs removed from her chin.<BR/>During an observation and interview on 7/14/2022 at 9:20 a.m. revealed Resident #76 continued to have long facial hairs to her chin. The DON indicated she would have the chin hairs taken care of today . <BR/>During an interview on 7/13/2022 at 9:50 a.m., CNA G indicated the CNAs were responsible for nail care, shaving and bathing on bath days and as needed. CNA G indicated the nurses would trim diabetic residents' nails, but the CNAs could clean anyone's fingernails. CNA G said residents could scratch themselves with long fingernails. CNA G said having dirty fingernails and eating was nasty. CNA G said if she did not get to a resident's bath on their scheduled day, she would get them the next day . CNA G indicated she was assigned to Resident's #76 and # 49.<BR/>During an interview on 7/13/2022 at 10:41 a.m., LVN D indicated the CNAs were responsible for bathing, shaving, and nail care. LVN D indicated nurses were responsible for ensuring the CNAs completed the ADLs. LVN D indicated monitoring of the ADLs occurred when the CNAs would turn in the shower sheets, she reviewed them and if there was a refusal she would try and encourage the resident to complete their ADLs. LVN D indicated she expected ADLs to be completed as scheduled and as needed.<BR/>During an interview on 7/13/2022 at 11:04 a.m., CNA E indicated she was responsible for ADLs. CNA E said she did not see the facial hair on Resident #76. CNA E indicated Resident #49's nails were now cleaned and trimmed. <BR/>During an interview on 7/14/2022 at 12:13 p.m., the DON indicated residents were encouraged to bathe/shower when they would refuse. The DON indicated if the resident prefers something different, she would be willing to implement the changes. The DON indicated she had done teaching with the staff to review their approach with the residents to ensure compliance with ADLs. The DON indicated the lack of ADLs could cause bacteria to form and illness to occur. The DON indicated the ADLs were monitored using the shower sheets, the computerized documentation, and with rounds. The DON expected the residents to receive their showers, nail care, and shaving on their scheduled days and as needed.<BR/>During an interview on 7/14/2022 at 1:05 p.m., the ADM indicated he expected the residents to receive their ADLs. The ADM indicated not receiving their ADLs could cause infection and affect the resident's dignity. He indicated the ADLs were monitored by nursing using the computerized documentation and with rounds.<BR/>During an interview on 7/14/2022 at 3:15 p.m., the DON indicated there were no policy and procedures for nailcare, shaving or bathing.<BR/>Record review of Care of Standards policy with a revised date of June 2020 indicated the purpose was to ensure all residents receive necessary care and services that were evidence-based and in accordance with accepted professional clinical standards of practice. Procedure l. The Director of Nursing Services (DON) ensured care and services were delivered according to accepted standards of clinical practice. Unless specifically addressed in an individual facility policy the Facility defers to the accepted national standards of clinical practice. ll.E. Skills and techniques for the New Nursing Assistant Textbook, 8th Edition ([NAME], [NAME]); F. Mosby's Textbook for Long-Term Care Nursing Assistants Sixth Edition ([NAME]) IV. The DON or designee evaluates staff competency in skills and techniques necessary to care for residents assessed needs.

Based on observation, interview and record review, the facility failed to follow their own established smoking policy for 2 of 2 smoking areas (West balcony and East ground floor).<BR/>The facility failed to provide fire retardant ashtrays.<BR/>This failure could place residents at risk for injury, burns and an unsafe smoking environment.<BR/>Findings included: <BR/>During an observation on 7/13/22 at 9:26 AM, the balcony smoking area of the 2nd floor had 1 regular trash can (the type for paper trash, not cigarette items) and 1 tree chimney type ashtray. The [NAME] side 2nd floor smoking area had 2 tree-type ashtrays and 1 regular trash can. The [NAME] side ground floor smoking area had 1 tree-type ashtray and 1 regular trash can. <BR/>During an observation and interview on 7/13/22 at 9:29 AM Floor Tech A was supervising 4 residents smoking on the ground floor outdoor smoking area. He said they had used the tree ashtrays now for 5-6 months. He said he did not know why they used them. He said they used to have ashtrays, but he did not remember when that was. He said sometimes the tree ashtrays smoked and usually smoked because a resident had put paper or plastic in them, or a resident did not put their cigarette out before putting it in the tree slot. He said when that happened, he would open the tree ashtray and the put the fire out. <BR/>During an interview on 7/13/22 at 9:42 AM, the DON came out to the smoking area while the residents were smoking. She said they had used the tree type ashtrays for a long time, but she could not remember how long. She said she did not know why they used them exactly but probably because they were safe. She said the ashtrays did smoke sometimes and when they did, she would put water in them to make them stop smoking. <BR/>During an interview on 7/13/22 at 3:03 PM, the DON said the facility ashtray policy indicated they could not use plastic ashtrays. She said they had ordered metal ashtrays. The ashtrays they were metal but were tree chimney type ashtrays. <BR/>During an interview and record review on 7/13/22 at 3:08 PM, the DON provided a confirmation of an order for 6 tough guy metal ashtrays and 2 oily waste cans for a total of $1,739.66. <BR/>During an observation and interview on 7/14/22 at 8:43 AM, the ADM showed 3 surveyors that the tree ashtrays (with the plastic on the top) had metal in the bottom. He also showed the surveyors another type of tree ashtray he had that was completely metal, and he said he had several in the building. He said he would put all the metal ones out and replace the tree ashtrays (with the plastic on the top). He said their policy indicated they had to be metal. He said per the policy they could not have plastic on the ashtrays. <BR/>A record review of the undated Ashtray policy provided by the ADM indicated: <BR/>Purpose.<BR/>To protect the health and safety of resident, facility staff and the public.<BR/>Policy<BR/>For safety reasons, only metal ashtrays are permitted in areas where smoking is permitted .<BR/>Procedure. <BR/>1. In areas where smoking is permitted, only metal ashtrays that have holders located inside the perimeter of the tray may be used .<BR/>IV. Plastic ashtrays may not be used in any area of the facility <BR/>A record review of the Smoking Violation Policy indicated: <BR/> .3. Ashtrays made of non-combustible materials and safe design, and metal containers with self-closing covers into which ashtrays can be emptied, shall be provided in all designated smoking areas as well as at all entrances

Based on observation, interview and record review, the facility failed to follow their own established smoking policy for 2 of 2 smoking areas (West balcony and East ground floor).<BR/>The facility failed to provide fire retardant ashtrays.<BR/>This failure could place residents at risk for injury, burns and an unsafe smoking environment.<BR/>Findings included: <BR/>During an observation on 7/13/22 at 9:26 AM, the balcony smoking area of the 2nd floor had 1 regular trash can (the type for paper trash, not cigarette items) and 1 tree chimney type ashtray. The [NAME] side 2nd floor smoking area had 2 tree-type ashtrays and 1 regular trash can. The [NAME] side ground floor smoking area had 1 tree-type ashtray and 1 regular trash can. <BR/>During an observation and interview on 7/13/22 at 9:29 AM Floor Tech A was supervising 4 residents smoking on the ground floor outdoor smoking area. He said they had used the tree ashtrays now for 5-6 months. He said he did not know why they used them. He said they used to have ashtrays, but he did not remember when that was. He said sometimes the tree ashtrays smoked and usually smoked because a resident had put paper or plastic in them, or a resident did not put their cigarette out before putting it in the tree slot. He said when that happened, he would open the tree ashtray and the put the fire out. <BR/>During an interview on 7/13/22 at 9:42 AM, the DON came out to the smoking area while the residents were smoking. She said they had used the tree type ashtrays for a long time, but she could not remember how long. She said she did not know why they used them exactly but probably because they were safe. She said the ashtrays did smoke sometimes and when they did, she would put water in them to make them stop smoking. <BR/>During an interview on 7/13/22 at 3:03 PM, the DON said the facility ashtray policy indicated they could not use plastic ashtrays. She said they had ordered metal ashtrays. The ashtrays they were metal but were tree chimney type ashtrays. <BR/>During an interview and record review on 7/13/22 at 3:08 PM, the DON provided a confirmation of an order for 6 tough guy metal ashtrays and 2 oily waste cans for a total of $1,739.66. <BR/>During an observation and interview on 7/14/22 at 8:43 AM, the ADM showed 3 surveyors that the tree ashtrays (with the plastic on the top) had metal in the bottom. He also showed the surveyors another type of tree ashtray he had that was completely metal, and he said he had several in the building. He said he would put all the metal ones out and replace the tree ashtrays (with the plastic on the top). He said their policy indicated they had to be metal. He said per the policy they could not have plastic on the ashtrays. <BR/>A record review of the undated Ashtray policy provided by the ADM indicated: <BR/>Purpose.<BR/>To protect the health and safety of resident, facility staff and the public.<BR/>Policy<BR/>For safety reasons, only metal ashtrays are permitted in areas where smoking is permitted .<BR/>Procedure. <BR/>1. In areas where smoking is permitted, only metal ashtrays that have holders located inside the perimeter of the tray may be used .<BR/>IV. Plastic ashtrays may not be used in any area of the facility <BR/>A record review of the Smoking Violation Policy indicated: <BR/> .3. Ashtrays made of non-combustible materials and safe design, and metal containers with self-closing covers into which ashtrays can be emptied, shall be provided in all designated smoking areas as well as at all entrances

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete an accurate assessment to reflect the status for 1 of 20 residents reviewed for assessments. (Resident #66)<BR/>The facility did not ensure Resident #66's MDS assessment accurately reflected his non-hospice status. <BR/>This failure could place residents at risk for decreased quality of care due to inaccuracy of assessments.<BR/>Findings included: <BR/>A record review of the consolidated physician's orders dated July 2022 indicated Resident #66 admitted to the facility on [DATE]. He was [AGE] years old, with diagnoses that included: acute respiratory distress syndrome (fluid collects in the air sacs of the lungs causing shortness of breath), hypertension (blood against the artery walls is too high), reduced mobility (limited mobility due to age or disease), and depression (conditions causing lowering of a person's mood.) The physician's orders did not indicate Resident #66 was on hospice care. <BR/>A record review of the MDS assessment dated [DATE] indicated Resident #66 was cognitively intact. The MDS indicated he required the supervision of 2 staff for bed mobility and the extensive assistance of two or more staff for transfer. Section O of the MDS indicated he was on hospice care while a resident in the facility. <BR/>A record review of the care plan dated 6/7/22 indicated Resident #66 required oxygen for acute respiratory failure and required antidepressant medication for depression. The care plan indicated Resident #66 required 2 staff to turn and reposition in bed and 2 staff to assist with transfer. The care plan did not address hospice. <BR/>During an interview on 7/13/22 at 8:02 AM, RN C said she did the skilled MDS's. She said she had marked Resident #66 for hospice by mistake on the MDS dated [DATE]. She said he had never been on hospice and was not currently on hospice. She said she already submitted a correction. <BR/>During an interview on 7/13/22 at 2:43 PM, the Regional MDS nurse said they did not have a policy for MDS accuracy. She said they used the RAI manual.<BR/>During an interview on 7/13/22 at 2:48 PM, the DON said she expected the MDS to accurately reflect the resident's status. She said the risk of the MDS being inaccurate could be the care plan could also be inaccurate. <BR/>During an interview on 7/14/22 at 9:02 AM, ADON B said she expected MDS's to accurately reflect a resident's status. She said if a resident was marked inaccurately on the MDS it could affect their plan of care, possibly in a negative way. <BR/>During an interview on 7/14/22 at 9:04 AM, the ADM said he expected the MDS to accurately reflect the resident's status. He said he could see a risk to care if the care plan was also inaccurate. <BR/>During an interview on 7/14/22 at 9:40 AM, the ADM said he checked Resident #66's plan of care and physician's orders. He said the MDS was marked in error, so it did not affect Resident #66''s plan of care or his physician's orders. He said there was not a risk to Resident #66 because he continued in therapy and all physician's orders were followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed assess for risk of entrapment from bed rails, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for 1 of 19 residents (Residents #39) reviewed for bedrails. <BR/>The facility did not assess or get consent for Residents #39 for the use of bedrails. <BR/>These failures could put the residents at risk for potential injuries. <BR/>The findings were:<BR/>Record review of Resident #39's face sheet dated 07/14/22 indicated Resident #39 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), dyspepsia (indigestion) and intellectual disabilities (a term used when there are limits to a person's ability to learn at an expected level and function in daily life). <BR/>Record review of Resident #39's most recent comprehensive MDS, dated [DATE], indicated Resident #39 rarely made herself understood and was rarely understood by others. Resident #39's brief interview for mental status score was not completed. The MDS indicated Resident #39 required total assist with bed mobility, dressing, eating, toileting, personal hygiene, and bathing. <BR/>Record review of the care plan dated 11/20/18 for Resident #39 indicated the resident was a risk for falls. Resident #39 was unaware of safety needs. Interventions indicated: anticipate and meet the resident's needs, bolster mattress to set safe bed boundaries, fall mat at bedside, low bed, keep in lowest position while in bed. <BR/>Record review of care plan dated 05/29/19 indicated Resident #39 has Cerebral Palsy, her muscles were spastic, and she was unable to control her body movements. Interventions indicated: required a low bed with a safety mat due to the possibility of falls from bed secondary to Cerebral Palsy with spastic movement.<BR/>During an observation on 07/11/22 at 3:47 p.m. revealed Resident #39 was in her bed with all 4 side rails up.<BR/>During an observation and interview on 07/12/22 at 3:10 p.m. revealed Resident #39 was in bed with all 4 side rails up. CNA G stated the resident's family member bought the current bed some months ago and they have been putting up all 4 side rails. CNA G said the DON and ADM were aware Resident #39 had the bed with side rails. CNA G said resident #39 has not had a fall and did not feel she was at risk for falling out of this bed.<BR/>During an observation on 07/13/22 at 9:27 a.m. revealed Resident #39 was in her bed with all 4 side rails up and fall mat on floor.<BR/>During an interview on 07/13/22 12:03 p.m., LVN L said she knew Resident #39's bed had side rails but were not aware they were up. LVN L looked at the MAR to check the orders and said the orders indicated a low bed with a scoop mattress and a fall mat on the floor. LVN L said the bed was in the hallway for a while and when she came back to work from her off days the bed was in the room. LVN L said she thought the DON and ADM were aware of the bed, so she never questioned the bed. LVN L said they keep a close watch on Resident #39, but it could be a potential for her legs or head to be caught in between the rails but she never saw it and no staff ever reported it. LVN L stated Resident #39 mostly grinded her heels in bed, not thrashing. LVN L stated the only thing she did see was a potential to fall out of bed because it did not go down low to the ground. <BR/>During an interview on 07/14/22 at 9:30 a.m., ADON H said she knew Resident #39 had the bed with rails, but her understanding was the ADM told maintenance to put the bed in Resident #39's room so she never questioned it. ADON H said she felt like the proper monitoring and tools were in place and Resident #39 was safe. ADON H said she could see the potential for Resident #39 to bump her legs against side rails and cause bruises.<BR/>During an interview on 07/13/22 at 12:05 p.m., the ADM said from what he remember, the family was doing a Medicare spend down when they purchased the bed. The ADM said they placed a call to the family to let them know they were going to replace Residents # 39's bed with a low bed and a scoop mattress and were awaiting a return call. The ADM said he was not aware of siderails on the bed until today and he is getting the maintenance supervisor to place a zip tie on the side rails to prevent anyone from using them. In a subsequent interview at 12:20 p.m., the ADM said after looking at the bed for Resident #39, they are going to move the existing bed out and place a low bed with a scoop mattress in room. The ADM said the policy is not to have side rails but for therapeutic, so Resident #39 should not have had side rails. The ADM said he expected staff to communicate any concerns over anything or if they see any bed rails up. The ADM said he expected ADON/DON to follow up with walking rounds and express any concerns. The ADM said he can see the risk of any residents getting caught in the space between the rail and could potentially cause loss of circulation, bruising or fractures. The ADM said he could see the risk of Resident #39 potentially getting caught in or in-between the rails and that could cause harm to any part of her body. <BR/>During an observation on 07/14/22 at 8:01 a.m., revealed Resident #39 was in a low bed with a scoop mattress and a fall mat. The bed with side rails had been removed from room.<BR/>During an interview on 07/14/22 at 8:06 a.m., CNA N said she thought Resident #39's family member brought the bed and then someone put it in the room. CNA N said she liked the bed and did not believe Resident #39 was in any harm because she never saw her legs or head go through the rails.<BR/>During an interview on 07/14/22 at 8:09 a.m., CNA O said she never saw Resident #39's legs or arms in between rails but it was a potential that it could.<BR/>During an interview on 07/14/22at 08:31 a.m., CNA G said resident #39 could have fallen out of bed because it was not low enough, maybe get hurt or bruised related to side rails.<BR/>During an interview on 07/14/22 at 10:02 a.m., the Maintenance Supervisor said he was not aware of Resident # 39's bed until yesterday (07/13/2022), when he was instructed to move the bed out of room. The Maintenance Supervisor said he was not employed when that bed was placed in Resident #39's room. The Maintenance Supervisor said after identifying the bed, he did believe it could have been a hazard if an emergency arose because the bed could not fit through the door. <BR/>During an interview on 07/14/22 at 2:02 p.m., the DON said she was told, the resident's family member had to do a spend down and bought the bed. The DON talked with Resident #39's family member and he agreed to remove the bed, apply the low bed and scoop mattress. The DON said the bed was already in Resident #39's room when she returned as DON. The DON said she had mention something to ADM while she was the MDS nurse about the bed but was informed by staff that the ADM instructed staff to put the bed in the room. The DON said they should use the least restrictive form of restraints. The DON said she looked in computer and did not see any assessments or consents related to side rails. The DON said the low bed, fat mat and scoop mattress for Resident #39 was the least restrictive form of restraint. The DON said because of Resident #39's diagnosis of Cerebral Palsy with uncontrolled spasms she had the potential for body injury. <BR/>Record review of Restraints policy dated June 2020 indicated, Residents shall be provided an environment that is restraint free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measure shall be used. If facility is utilizing bed rail, the assessment bed rails entrapment risk assessment or other electronic documentation in PCC will be complete .prior to installation of bed rails.