Twin Pines Nursing and Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident was treated with respect, dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 3 residents (Resident #5) reviewed for dignity, in that:<BR/>The facility failed to ensure Resident #5 was not left exposed during wound care on 4/24/24.<BR/>This failure could place residents at risk of poor self-esteem and decreased self-worth and quality of life. <BR/>Findings include:<BR/>Record review of Resident #5's admission Record, dated 4/20/24, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, and Depression. <BR/>Record review of Resident #5's quarterly MDS assessment, dated 2/26/24, revealed the resident had a BIMS score of 00, which indicated severe cognitive impairment.<BR/>Record review of Resident #5's Care Plan, revised 4/20/24, revealed: The resident has a pressure ulcer or potential for pressure ulcer development . Administer wound care as ordered .<BR/>Record review of Resident #5's Order Summary Report, dated 4/26/24, revealed an order for wound care as follows: Cleanse stage IV sacral wound with vashe (Wound Cleanser). Apply collagen and calcium alginate with silver to wound bed. Paint peri-wound with skin prep. Secure with silicone dressing QD and PRN every day shift for wound care.<BR/>Observation of wound care to the sacrum for Resident #5 on 4/24/24 at 7:12 AM revealed LVN C approached Resident #5 and explained the procedure. Further observation revealed after removing the resident's dressing, LVN C walked away from Resident #15, leaving the resident's buttocks and sacral wound exposed, to retrieve the trash can. LVN C returned with the trash can and continued with the treatment.<BR/>During an attempted interview on 4/27/24 at 12:53 PM, Resident #5 did not respond to investigator's questions. <BR/>During an interview on 4/27/24 at 1:45 PM, LVN D stated Resident #5 was not supposed to be left exposed during wound care. LVN D further stated the resident should have been covered and given privacy during care. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated she expected nurses to provide privacy during wound care to preserve the resident's privacy and dignity. <BR/>Record review of the facility's policy, titled, Resident Rights, revised 11/28/16, reflected: The resident has a right to a dignified existence . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life . The facility must protect and promote the rights of the resident . Respect and dignity -The resident has a right to be treated with respect and dignity .Privacy and confidentiality -The resident has a right to personal privacy .1. Personal privacy includes accommodations, medical treatment . personal care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 2 of 14 residents (Resident #2 and Resident #3) reviewed for resident call system . The facility failed to provide a working communication system that was easily at reach, which would allow Resident #2 and Resident #3 the ability to safely call staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. Findings include:Resident #2 Record review of Resident #2's face sheet, dated 11/26/2025, revealed s an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included dementia (memory, thinking, difficulty), chronic obstructive pulmonary disease (chronic progressive lung disease), heart failure (hypertension (high blood pressure), malaise (feeling of general discomfort), muscle wasting, muscle weakness, history of falling and lack of coordination. Record review of Resident #2's quarterly MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 09 indicating moderate impairment. The MDS also revealed Resident #2 was partial to moderate assistance with transfers for toileting and shower transfers. Resident #2 was supervision or touching assistance with bed transfers. Record review of Resident #2's care plan dated 11/11/2025 revealed Potential for falls due to reported history of frequent falls while at home. Osteoporosis (disease that weakens the bones and make them more likely to break), impaired cognitive functioning and safety awareness with dementia, incontinence with some control present, Arthritis and arthritic joint pain, neuropathy, decline in functional independence, weakness, impaired balance, unsteady gait, and cardiovascular and psychotropic medication administration. Interventions were Call light in easy reach. Remind resident to call for staff assistance when needed and answer call promptly. Check on the resident at routine intervals to assess needs, monitor safety issues and offer assist as needed. Resident has experienced a decline in functional independence for mobility with increased weakness and reduced endurance. Potential for improved function and return to prior levels of independence with skilled PT interventions. Interventions were Call light in easy reach. Encourage/remind resident to call for staff assist as needed. Check on her at routine intervals to assess needs, monitor safety issues and offer assistance as needed. Resident #3 Record review of Resident #3's face sheet, dated 11/26/2025, revealed s a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included heart failure, dementia (memory, thinking, difficulty), protein-calorie malnutrition (inadequate intake of both protein and calories), atrial fibrillation (abnormal heart rhythm), skin cancer, anxiety (feeling of uneasiness or worry), constipation and major depressive disorder (mental health disorder characterized by persistent depressed mood). Record review of Resident #3's admission MDS assessment dated [DATE], revealed Resident #3 had a BIMS score of 00 indicating severe cognitive impairment. The MDS also revealed Resident #3 was partial/moderate assistance with all transfers. Record review of Resident #3's care plan dated 11/08/2025 revealed The resident has Oxygen Therapy intervention was Provide reassurance and allay anxiety (to calm or relieve feeling of worry and nervousness): Have an agreed-on method for the resident to call for assistance (call light,). Stay with the resident during episodes of respiratory distress. The resident has a communication problem related to Neurological symptoms. Interventions were Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, avoid isolation. Resident is at risk of falls related to actual fall on 11/19/2025. Interventions were Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an observation of Resident #2 on 11/26/2025 at 8:07a.m., revealed her call light was on the floor under the top of her bed. Resident #2 was lying in her bed. During an observation of Resident #3 on 11/26/2025 at 8:15a.m., revealed was on his bedside table out of Resident #3's reach. Resident #3 was laying in his bed. An interview was attempted with Resident #3 on 11/26/2025 at 8:16a.m., revealed Resident #3 was nonverbal. During an interview with Resident #3's private sitter on 11/26/2025 at 10:57a.m., revealed that she had worked for Resident #3's family for two weeks. She said Resident #3's call light has always been on his bedside table and not in his reach ever since she started working with him. She said that she felt like Resident #3 could use the call light if needed something. During an interview with the ADM on 11/26/2025 at 2:47p.m., revealed the facility did not have policy for call light placement. During an interview with CNA A on 11/26/2025 at 2:54p.m., revealed the policy for call light placement was the call light must be within the reach of the resident. She said all staff were responsible for making sure the call light was in the resident's reach. She said the call light should be within reach of the resident any time the resident was in the room. She said if the call light was not in the reach of the resident the resident could get hurt or really need assistance. She said the DON and ADM monitored to ensure residents call lights were within their reach. She said it was monitored through observation. During an interview with LVN B on 11/26/2025 at 3:05p.m., revealed the call lights need to be within the residents reach. She also said the person who was in the resident's room last was to make sure the call light was within the reach of the resident. She said the call light should always be within the resident's reach. She said if the call light was not within the reach of the resident could fall because the resident tried to do something by their self. She said the nurses monitored to ensure the call lights were within reach of the resident. She said the nurses monitored by observation. She said some of the resident's would throw the call lights onto the floor and staff should be rounding on those residents more frequently. She said she was not sure why Resident #2 and Resident #3's call lights were not within their reach. During an interview with the DON on 11/26/2025 at 3:34p.m., revealed she was not sure if there was a policy for call light placement. However, she did say the expectation was the call light to always be in reach of the resident. She said anyone who went into the resident's room was responsible for making sure the call light was within reach of the resident. She said the call light should be within the resident's reach every time they are in there room. She said if the call light was not placed in reach of the resident could cause the resident to be in distress and upset the resident. She said the staff on the hall were to monitor to ensure the call light was within reach. She also said anytime a staff went into the room and the call light was not within the resident's reach the staff should put it within the resident's reach immediately. She said management were to do rounds every morning and ask the residents if they were having any issues or concerns. She said she did not know why call lights were not within reach of Resident #2 or Resident #3. During an interview with the ADM on 11/26/2025 at 4:02p.m., She said she expected the call light to be in reach of the resident. She said that the last person in the resident's room was responsible for ensuring the call light was within reach of the resident. She said that managers did champion rounds and that call light placement was one of the things the managers check. She said the call light should be in the reach of the resident any time the resident was in their room. She said if the call light was not in the resident reach the resident could have skin breakdown, be on the floor or needs help getting off the toilet. She said department managers monitored to ensure that residents call lights were within their reach. She said the department managers monitored through doing rounds. She said she did not know why Resident #2 and Resident #3's call lights were not within their reach. Record review of Resident Rights dated 03/09/2025 revealed The facility must provide equal access to quality care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the a comprehensive care plan was developed within seven days of the comprehensive assessment and review and revise the care plan after each assessment for 1 of 12 residents (Resident #15) reviewed for care plans. <BR/>The facility failed to ensure Resident #15's care plan was revised to reflect edema to left hand with elevation. <BR/>These failures could place residents at risk of current needs not being met. <BR/>Findings included:<BR/>Record review of Resident #15's admission Record, dated 4/23/24, reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), COPD (lung diseases that block airflow and make it difficult to breathe) , Cognitive Communication Deficit, Dysphagia (difficulty swallowing) , Functional Quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition ) , Pressure ulcer of sacral region Stage 4, Depression and Anxiety. <BR/>Record review of Resident #15's quarterly MDS assessment, dated 3/15/24, reflected a BIMS score of 5, which indicated severe cognitive impairment. Resident #15's functional limitation in range of motion to bilateral upper and lower extremities; was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) for all self-care and Dependent for mobility.<BR/>Record review of Resident #15's Progress Notes reflected:<BR/>Effective Date: 03/11/2024 20:08 [8:08 pm] .Note Text: resident has 3+ edema to left arm no warmth or redness noted VS within normal limits informed NP .orders to elevate arm .Author: [LVN H]<BR/>Effective Date: 03/13/2024 16:03 [4:03 pm] .Note Text: New order per [NP] Xray to left hand .due to swelling .Author: [ADON A]<BR/>Effective Date: 03/14/2024 12:52 [12:52 pm] .Note Text .New orders received to start keflex 500 mg po bid x 10 days for cellulitis, keep left hand elevated on pillows .Author: [LVN C]<BR/>Effective Date: 04/09/2024 09:20 [9:20 am] .Note Text: Left hand swollen .Author: [LVN E]<BR/>Record review of Resident #15's Care Plan last reviewed 3/29/24, did not address edema and elevation of left arm. <BR/>Record review of Resident #15's Order Summary Report, dated 4/26/24, reflected: elevate left arm, dated 3/11/24. <BR/>During an interview on 4/27/24 at 12:47 PM, LVN A stated care plans were completed and updated by herself and RN A (MDS Coordinators). LVN A further stated care plans were completed quarterly when the MDS assessment was completed and PRN if there were changes in condition, services and/or needs. LVN A stated care plans were updated as soon as possible. LVN A further stated the facility had morning meetings and if changes were reported, she tried to update the appropriate care plans during the meeting. LVN A stated the facility also had daily nursing meetings with the DON, ADONs, Administrator and an the MDS nurse and standard of care meetings. LVN A stated she knew Resident #15's hand was swollen and when she saw it top of her stomach, she assumed it was elevated. LVN A further stated she was not aware Resident #15 had an order for her left arm to be elevated. LVN A stated she was not going to say whether or not Resident #15's left arm edema should have been care planned because the facility's care plans were liberalized/generalized. LVN A further stated yes, it should have been care planned. LVN A stated the left arm edema and elevation for Resident #15 was not care planned, she further stated she did not know why it had not been care planned. <BR/>During interview on 4/27/24 at 2:17 PM, RN A stated the nurses on working on the floor were responsible for updating care plans with acute changes to the resident's conditions. RN A further stated the facility had a morning meeting every day and changes to the resident condition/orders were shared at this meeting. RN A stated she and LVN A were mainly responsible for admissions assessments, quarterly assessments and care plans. RN A further stated the MDS Coordinators (LVN A and RN A) updated care plans, but care plans were updated for acute changes in condition by the floor nurses. RN A stated updates were done when changes happened, and added there was not a timeframe, but the goal was to update the care plans immediately. RN A further stated she was not aware Resident #15's edema to left arm and that her care plan had not been updated to reflect the edema and elevation to her left arm, stating the floor nurse should have updated Resident #15's care plan. RN A stated this change should have been shared in the morning meeting, and she did not remember the edema/elevation to Resident #15's left arm being discussed in the morning meetings. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated she expected care plans to be updated the day the change occurred. The DON stated the MDS, and charge nurses were responsible for updating care plans quarterly and when there were changes to orders. <BR/>Record review of the facility's, undated, policy, titled Comprehensive Care Planning, read: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life .The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented .revised based on changing goals, preferences and needs of the resident and in response to current interventions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 2 residents (Residents #1 and #2) reviewed for accidents. 1. The facility failed to identify and address hazards and risk in Resident #1's environment when staff failed to ensure they addressed Resident #1's behavior of unbuckling the seatbelt during transport in the facility van. On 06/13/2025, Resident #1 sustained a fall during van transport, with the seat belt noted to be on the wheelchair but the fastener unlatched, resulting in a laceration to her forehead. 2. The facility failed to identify and address hazards and risk in Resident #2's environment when staff failed to ensure they addressed Resident #2's fall on 06/18/2025. An Immediate Jeopardy (IJ) was identified on 07/11/2025. The IJ template was provided to the facility on [DATE] at 10:39 p.m. While the IJ was removed on 07/13/2025 at 4:20 p.m., the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal. This failure could place residents at risk for accidents injuries, hospitalization and death related to unsafe vehicle transport. The findings included: 1.Record review of Resident #1&rsquo;s admission record dated 07/08/2025 revealed she was a [AGE] year-old woman admitted on [DATE] with re-admission on [DATE], and with diagnoses which included: End-Stage Renal disease (condition where kidneys lose the ability to remove waste and balance fluids in balance requiring dialysis); Syncope (fainting or temporary loss of consciousness) and collapse; Vascular Dementia (impaired cognitive thinking due to constricted blood flow) and Bradycardia (slow heart beat).<BR/>Record review of Resident #1&rsquo;s Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 5, indicating severe cognitive impairment, and was assessed as being dependent for transfers, and had no behavioral symptoms.<BR/>Record review of Resident #1&rsquo;s Care Plan initiated 07/03/2022 revealed a focus area for &ldquo;The resident is risk for falls due to dx [diagnosis] of syncope,&rdquo; and included &ldquo;Resident had action [sic] fall in facility van causing laceration to forehead&rdquo; initiated 07/03/2022 and revised 06/14/2025. There were no interventions listed which addressed the resident&rsquo;s behavior of unbuckling the seat belt and no new interventions for this fall were listed.<BR/>Record review of Resident #1&rsquo;s other focus areas in her Care Plan initiated 07/03/2022, revealed there was no other focus areas for her behavior of trying to stand up during transport or for trying to unbuckle her seatbelt in the facility van during transport.<BR/>Record review of Resident #1&rsquo;s Physician Order Summary Report, dated 07/12/2025, revealed an order initiated on 01/17/2025 for dialysis at 12:05 PM on Monday, Wednesday, and Friday at a local dialysis center.<BR/>Record review of Resident #1&rsquo;s Nurses Notes from 03/11/2025 to 06/12/2025 revealed there was no notation of Resident #1 trying to stand up during transport or for trying to unbuckle her seatbelt in the facility van during transport.<BR/>Record review of Resident #1&rsquo;s Progress Note dated 6/13/2025 at 11:22 a.m. by the DON revealed &ldquo;Resident had a fall. Location: in facility van during transport to dialysis. Cognition/Behavior at Time of Event: Cognitive Impairment. The fall caused a skin tear to above left eyebrow. new/bleeding&hellip;.Administrator received call from Van Driver of resident fall in van. Upon arrival to scene, noted resident on floor of van face down with head partially under 2nd row of seats. Blood noted on floor and on resident&rsquo;s hair. Cream colored emesis (vomit) noted on wc [wheelchair] and unable to check vs [vital signs]. Respirations slow and irregular. 911 called per van driver. Ems arrived and transported to ER&hellip;&rdquo; The MD was notified on 06/13/2025 at 12:02 PM. Resident #1&rsquo;s Responsible Party was notified on 06/13/2025 at 11:52 AM. &ldquo;Interventions in place prior to fall: None, Interventions initiated in response to fall: none.&rdquo;<BR/>Record review of Resident #1&rsquo;s Nurse&rsquo;s Notes dated 06/13/2025 by LVN-H revealed the nurse received a call from the hospital emergency room regarding Resident #1&rsquo;s medication list which was faxed to the hospital and the nurse was informed the resident had another episode of vomiting at the hospital and was intubated (a tube inserted into the mouth and throat to hold open the airway so air can be pushed in and out of the lungs via machine) at that time.<BR/>Record review of Resident #1&rsquo;s Event Nurses&rsquo; Note-Fall, dated 06/13/2025, revealed the resident had an unwitnessed fall in the facility van during transport to dialysis sustaining a skin tear above her left eyebrow. Resident #1&rsquo;s responsible party was notified on 06/13/2025 at 11:52 AM and her physician was notified on 06/13/2025 at 12:02 PM. Under &ldquo;Interventions in place prior to this fall&rdquo; had &ldquo;None of the above&rdquo; was checked. Under &ldquo;Interventions initiated in response to this fall&rdquo; had &ldquo;None of the above&rdquo; checked and no interventions were listed.<BR/>Record review of hospital records dated 6/20/2025 revealed Resident #1 had a CT (Computed tomography &ndash; type of imaging using x-ray techniques to obtain detailed images) of head was completed 06/19/2025 and showed &ldquo;no acute intracranial finding&rdquo;. Further review revealed Resident #1 was treated for and placed on seizure precautions and treated also for sepsis-resolved (condition where the body&rsquo;s responses to infection causes injury to its own tissues and organs), likely secondary to aspiration pneumonia (lung infections caused by inhaling something other than air into your lungs, such as food or vomit), and Paroxysmal Atrial Fibrillation (noted she converted to normal sinus rhythm on 6/16/2025).<BR/>Telephone interview with Family Member #1 on 07/11/2025 at 12:08 p.m. revealed Resident #1 was no longer in hospital and had been moved to a different nursing facility, but was still fighting an infection and very weak. He stated Resident #1 had a history of falls, but expected the facility to know this and take appropriate precautions. He stated he felt the facility should have sent extra staff instead of just the driver to help take care of vulnerable residents.<BR/>During an interview on 07/09/2025 at 3:57 p.m., the Van Driver stated that she loaded Resident #1 in the van on 06/13/2025, leaving facility at 11:16 a.m. and after pulling out onto the road, she heard Resident #1 make a loud noise, and saw in the rear-view mirror that Resident #1 had vomit coming from her mouth. She stated that as she attempted to turn to pull off to the side of road, she saw Resident #1 stiffen up and fall forward out of the wheelchair and land face down on the floor of the van. The Van Driver stated she called the Administrator who told her to call 911. The Van Driver further stated that she had secured Resident #1 securely in her wheelchair into the van with 4 straps that were attached to the L-bar of Resident #1&rsquo;s wheelchair frame, but stated she believed Resident #1 had unbuckled her seatbelt, because she had unbuckled her seatbelt during transport in the past.<BR/>Further interview with the Van Driver on 07/10/2025 at 4:15 p.m. revealed that she stated there were two other prior incidents of Resident #1 removing her seatbelt and trying to stand up in the van. She stated the first incident happened about 2 months prior to the June 13th incident, where Resident #1 took her seatbelt off and she told Resident #1 to keep her seatbelt fastened because she could fall. She stated the second incident happened about 2 weeks prior to the June 13th incident, where Resident #1 attempted to pull herself up to standing by pulling on the seat in front of her during transport. The Van Driver stated she reported one of the incidents to LVN -A, and one incident to the Administrator, who told her to contact therapy to ask what could be done, and therapy told her they could tilt her wheelchair backwards so she couldn&rsquo;t grab things.<BR/>During an interview with LVN-A on 07/10/2025 at 11:44 a.m., she stated that sometime during that first week of June 2025, the Van Driver came to the Nurse&rsquo;s station after returning Resident #1 back to facility from dialysis, and told her, the DON and former ADON, who were all standing at the nurse&rsquo;s station, that Resident #1 had tried to stand up in the van during transport. LVN-A stated she educated Resident #1 about not standing up in the van, that it was dangerous, and she stated Resident #1 denied that she had done that. LVN-A further stated that she did not report the incident to anyone because the DON was standing at the Nurse&rsquo;s station with her when the Van Driver reported the incident and had instructed her to educate Resident #1 on not unbuckling her seatbelt.<BR/>During an interview with the DON on 07/10/2025 at 4:54 p.m., the DON stated she was never made aware of any prior incidents of Resident #1 taking off her seatbelt or trying to stand up out of her wheelchair during van transport. <BR/>Interview on 07/10/2025 at 4:30 p.m. with the Administrator revealed she had inspected the van after the incident and observed vomit on the chest strap when she pulled it out from the retracting device, indicating the chest strap had been in place across Resident #1&rsquo;s chest when she first started to vomit and believed Resident #1 may have pressed down on her abdomen with her hand when she vomited, accidentally pushing on the release button of the seatbelt. When asked about any prior incidents, the Administrator stated that the Van Driver had informed her of an incident where Resident #1 had attempted to slide down out of her wheelchair, could not remember the exact date, but thought it might have been a couple of months prior to the current incident, and that was when she suggested the Van Driver check with therapy to see if wheelchair could be modified. She stated the Van Driver never told her Resident #1 had unbuckled her seatbelt or tried to stand up in van. She stated the Van Driver came back and told her therapy stated the wheelchair could be tilted back slightly, and they agreed that was what they were going to try to do to address the problem. The Administrator further stated that if Resident #1 had intentionally tried to undo her seatbelt or stand up in the van during transport she would expect that to be reported to her, but no one ever had. She stated the team never met to discuss the incident reported to her of Resident #1 trying to slide out of the wheelchair and the intervention they discussed about the therapy assessment of the wheelchair was never care planned but should have been.<BR/>Interview with PT - B on 07/11/2025 at 11:46 a.m. revealed she confirmed a CNA had come down to ask about what could be done about Resident #1 leaning forward in wheelchair and PT-B instructed CNA and Resident #1&rsquo;s family member how to recline the wheelchair. No documentation available as Resident #1 was not on services at this time.<BR/>Interview with the Activity Director on 7/11/2025 at 9:41 a.m. revealed that he also transports residents in the van to recreational activities, but will also transport residents at times to their medical appointments when the primary Van Driver is out sick. He stated the primary Van Driver and he are the only staff who transported residents at the facility. The Activity Director stated he had transported Resident #1 in the van many times and had observed her undo her seatbelt or try to stand up in van during transport several times. The Activity Director further stated he educated Resident #1 not to unbuckle her seat belt, but stated she would get anxious at times and forget. The Activity Director stated he reported this behavior of unbuckling her seatbelt during transport to the primary Van Driver so she could be aware and monitor but did not report the incidents to anyone else.<BR/>During a telephone interview with the Van Driver on 07/11/2025 at 11:54 a.m., she stated that she did not recall the Activity Director ever informing her or warning her about Resident #1&rsquo;s behavior of unbuckling her seatbelt during transport.<BR/>During an interview with the Administrator on 07/11/2025 at 11:46 a.m., the Administrator stated that had she known Resident #1 had incidents of unbuckling her seatbelt in van during transport, she would have assigned an escort to go along with her during transport or contracted with local company for ambulance transportation services for Resident #1.<BR/>2. Record review of Resident #2&rsquo;s admission record dated 07/08/2025 revealed she was an [AGE] year-old woman admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: Vascular Dementia-Severe (impaired cognitive thinking due to constricted blood flow), Schizoaffective Disorder (a mental health condition that includes both symptoms of schizophrenia, such as hallucinations and delusion and mood disorders), and Poly- osteoarthritis (condition where cartilage in multiple joints wears down causing bones to rub against each other leading to pain and stiffness).<BR/>Record review of Resident #2&rsquo;s Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment and she was assessed as needing substantial/maximal assistance for transfers.<BR/>Record review of Resident #2&rsquo;s Nurses Notes dated 06/18/2025 at 6:06 p.m. by LVN-I, revealed the resident had an unwitnessed fall from the low bed in her room onto the floor next to the bed sustaining a skin tear that was 2cm. to her right hand, and complaining of head, neck, right arm and right leg pain. Under &ldquo;Interventions in place prior to this fall&rdquo; had &ldquo;Floor mat, Low bed.&rdquo; Under &ldquo;Interventions initiated in response to this fall&rdquo; had &ldquo;Floor mat, Low bed, neuro-checks.&rdquo;<BR/>Record review of Resident #2&rsquo;s Nurses Notes dated 06/18/2025 at 10:55 p.m. by LVN-I revealed resident had returned from the ER with a diagnosis of right knee patella (kneecap) fracture, with knee immobilizer in place.<BR/>Record review of Resident #2&rsquo;s Care Plan initiated 07/03/2022 for &ldquo;The resident is risk for falls r/t Poor communication/comprehension&hellip;.Resident H/O fall out of bed due to self positions to the point of being on the edge&rdquo; initiated 07/03/2022 and last revised 07/07/2023, revealed it was not revised to address the resident&rsquo;s actual fall on 06/18/2025 and no new interventions were listed.<BR/>Record review of Resident #2&rsquo;s other focus areas of Care Plan initiated 07/03/2022 revealed there was no care plan or new interventions which addressed her fall on 06/18/2025.<BR/>Interview with CNA-K on 07/09/2025 at 1:52 p.m. revealed she stated she had completed check and change with Resident #2 about an hour before her fall and stated she put the bed in the lowest position, and the head of bed was just slightly elevated. Then as she was walking down hall with LVN-H to leave at end of her shift, she heard Resident #2 mumbling, looked in her room and saw her on the floor, face down. She stated she also observed the bed was not in the lowest position, and the head of the bed was straight up at 90-degree angle. The fall mat was in place by her bed.<BR/>Interview with LVN-H on 07/10/2025 at 10:40 a.m. revealed she works day shift and was getting ready to leave for the day when she heard Resident #2 talking from her room, and when she went to check on her, found Resident #2 lying on the mat on the floor next to her bed. LVN-H stated she observed that Resident #2&rsquo;s head of bed was up to the full 90 degrees, and the bed was not in lowest position, and stated that Resident #2 had been observed to work the bed controller in the past. LVN H stated she believed Resident #2 had accidentally changed position of bed as she manipulated the bed controller. She stated they always make sure her call light was within reach but does not believe she understands its purpose as Resident #2 will push the button on the call light, but when they answer, she cannot say what she needed or why she activated the light.<BR/>Interview on 07/10/2025 at 5:59 p.m. with LVN-I revealed she works night shift and had just come on duty on 6/18/2025 when she was called into Resident #2&rsquo;s room after she had been found on the floor. She stated Resident #2 was lying on the mat on the floor next to her bed, and that the mat had been in place. However, she noted the bed was not in its lowest position and the head of the bed was in an upright position and stated Resident #2 will take the bed controller and randomly press buttons on it, which can move her bed out of the lowest position. LVN-I stated they have done interventions to keep her from falling again, such as moving the bed controller to the end of the bed to keep her from moving the bed up higher and moving things away from her bed that she can grab, like the drawers out of her dresser.<BR/>Interview with the DON on 07/11/2025 at 8:28 a.m. revealed all acute incidents such as falls are discussed in the morning team meetings and the team discusses actions/interventions needed. She did not remember specifically what was discussed regarding Resident #2&rsquo;s fall on 6/18/2025. The DON stated that the MDS Nurse is responsible for revising the care plan per the quarterly and annual MDS assessments, and the DON and ADONs are responsible for updating care plans for acute changes. The DON did not know why there was no care plan revision done following Resident #2&rsquo;s fall on 06/18/2025 and -stated that could result in staff not being aware of the care needs of the residents, and could result in acute events such as falls happening again.<BR/>During an interview with the Administrator on 07/11/2025 at 10:16 a.m., the Administrator stated that Resident #2&rsquo;s fall on 06/18/2025 was addressed by the team in the morning clinical meeting to review causes of the fall and devise new interventions to prevent other falls in future. The Administrator stated that interventions were put into place, including moving furniture to create a safe space, and moving the bed controller away from Resident #2&rsquo;s reach, so that she could not move the bed out of the recommended low bed position. The Administrator further stated however, that Resident #2&rsquo;s care plan was not revised to include these new interventions to prevent further falls but should have been. She stated that either the MDS Nurse or DON can update the care plan to include new focus areas and interventions after discussion in the morning clinical meeting and did not know why Resident #2&rsquo;s care plan was not revised. The Administrator stated not updating the care plan to include all relevant new information such as interventions put in place to prevent falls, could result in staff not having the needed information to care for the Resident properly.<BR/>Record review of facility policy titled &ldquo;Fall Policy&rdquo;, undated revealed &ldquo;The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as requires&rdquo; and &ldquo;Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall.&rdquo;<BR/>This was determined to be an Immediate Jeopardy (IJ) on 07/11/2025. The Administrator was provided with the IJ template on 07/11/2025 at 10:39 PM. <BR/>On 07/12/2025 the facility provided a plan of removal. The Plan of removal was accepted on 07/12/2025 at 11:33 AM. It is documented as follows:<BR/>The following in-services were initiated by the Regional Compliance nurse and DON on 7/11/25. Any staff member not present or in-serviced on 7/11/25 will not be allowed to assume their duties until in-serviced. <BR/>Direct Staff to include therapy staff.<BR/>1. Implementing interventions to minimize the risk of falls. <BR/>2. Fall Prevention Policy <BR/>3. Reporting all incidents and accidents to the administrator immediately.<BR/>Facility transportation staff was removed from transport duties and counseled by Administrator on 07/11/2025 on Van Driving policy.<BR/>All transportation staff retrained on Incident Reporting Policy to Administrator on 7/11/25 by administrator.<BR/>The medical director was notified of the immediate jeopardy situation on 7/11/25 at 10:30 pm by administrator. <BR/>Ad Hoc QAPI meeting will be held on 7/11/25 to discuss the IJ and review plan of removal. <BR/>Any falls/incidents that occur over the weekend will be reported to the facility administrator and/or DON.<BR/>Monitoring: <BR/>DON and Administrator will review all falls during the morning meeting to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. <BR/>DON and Administrator will review all falls during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. <BR/>Above will be reviewed during the facility monthly QA meeting for no less than 60 days, or until the Administrator determines substantial compliance has been achieved and maintained.<BR/>Incidents involving van transport will be reviewed 5x weekly in morning meeting to determine if there were any incidents. This will be continued for a period of 6 weeks and PRN thereafter as determined by the QAPI committee.<BR/>Verification of the facility&rsquo;s POR for F689 was as follows:<BR/>Record review of an AD Hoc QAPI Contributors signature page dated 07/11/2025 revealed a meeting was held with the Administrator, DON, Medical Director, Social Services, Activity Director and three other employees.<BR/>Record review of an undated, untitled sheet revealed the Medical Director was notified on 07/11/2025 at 11:04 AM of the IJ situation by the Administrator. <BR/>Record review of an Incident/Fall Review Monitoring Tool revealed all falls would be reviewed 5 days per week for 6 weeks.<BR/>Record review of a Falls Review Monitoring Tool revealed the Administrator and the DON would discuss falls and interventions implemented weekly at a SOC (Standard of Care) meeting that was held with the Administrator, DON, and other Interdisciplinary Team members.<BR/>Record review of the QA Monitoring Tool revealed falls and incidents and if interventions were implemented would be reviewed monthly at the QAPI Meetings that will be held on 07/15/2025 and 08/19/2025. <BR/>Record review of the Van Incident Monitoring Tool revealed all incidents involving van transport were reviewed five times a week for 6 weeks by the DON and Administrator. <BR/>Record review of an undated employee list revealed the facility had 89 full time employees and 32 part-time/prn employees for a total of 121 employees.<BR/>Record review of an In-service record log, dated 07/12/2025 revealed all 121 employees had been in-serviced by phone or in person on reporting allegations of abuse/neglect immediately to the administrator; any unsafe conditions must be reported to the administrator immediately; all falls and/or other accidents or unusual occurrences would be reported to the administrator; any unsafe behaviors or incidents that occur on the fan during transport needs to be reported to the administrator and DON immediately; all unsafe behaviors that could lead to a fall must be reported immediately to the administrator; and on the Fall Policy. <BR/>In an interview on 07/12/2025 at 4:23 PM, the Administrator stated the &ldquo;SOC&rdquo; was Standard of Care which was a weekly meeting that was held to discuss resident care.<BR/>Interviews on 07/12/2025 from 4:40 PM to 7:00 PM and 07/13/2025 from 8:30 AM to 4:00 PM with 29 employees out of 121 employees (25 full time employees, 4 prn/part time employees) which consisted of 1 RA (RA W), 2 MA (MA T, MA U), 2 Housekeepers (Housekeeper Q, Housekeeper R), 10 CNAs (CNA L, CNA M, CNA N, CNA O, CNA X, CNA Y, CNA K, CNA BB, CNA AA, CNA Z) 3 of them worked 6 PM to 6 AM shift, 4 LVNs (LVN I, LVN H, LVN J, LVN P) 2 of them worked 6 PM to 6 AM shift), 3 dietary employees (Dietary Aide T, Dietary Supervisor E, and [NAME] S), 1 Activity Director, 1 Van Driver, 2 PTA (PTA EE, PTA CC), 1 OTA (OTA DD) revealed the had received the in-service training as indicated in the POR for F689. All the employees stated they would report any signs of abuse to the Abuse Coordinator who was the Administrator, they had her phone number to contact her. They also stated they would report immediately to the abuse coordinator any falls or unsafe behaviors to the administrator which included any unsafe behaviors when residents were transported in the van. The employees stated they had been in-serviced on the facility&rsquo;s Fall Prevention policy and interventions to minimize falls and provided examples of how that could be done. <BR/>In an interview on 07/13/2025 at 10:41 AM the Van Driver stated she works full time as the van driver; and received training on reporting incidents, on when to pull the van over, on when to report anything to the administrator about unusual behaviors that occurred when a resident was transported, reporting unusual behaviors from residents. Van Driver D said she was also trained to report any falls a resident had to the administrator, the DON and nurse. The Van Driver stated she was also trained to report any signs of abuse or neglect to the administrator immediately. The Van Driver said she received one-on-one training about the fall with Resident #1, was retrained by administrator on transporting residents, and the Administrator rode with her for a whole week in June 2025. Then the administrator rode with her twice a week for four weeks, then the administrator would randomly ride with her. The Van Driver stated she the Administrator was riding with her twice a week for two more weeks. The Van Driver said she would print out daily the calendar of the residents who would be transported; record on the calendar any behaviors from the resident when they were transported and provided the calendar to the administrator at the end of the day. The Van Driver stated she was also in-serviced recently on abuse and neglect; and would report it immediately to the administrator. <BR/>In an interview on 07/13/2025 at 2:03 PM, DON stated they would review in the morning meeting which resident would need an escort when transported to their scheduled appointment. The DON said residents who had falls were reviewed daily in the morning meeting. The DON stated she and the Administrator had in-serviced the employees on Abuse and Neglect, on Falls, who to report to, what to report for abuse or neglect, and fall prevention. The DON stated staff were to report to her or the Administrator if they had witnessed any unsafe behaviors from a resident or when the resident was transported. The DON stated if a resident had a fall, the charge nurse would notify her of the fall. The DON said they would review the falls throughout the day to see how they could be prevented. The DON stated the monitoring would be done with the monitoring tools that were developed and reviewed in the daily morning meeting, the weekly SOC meeting and QAPI meetings. The DON stated they would review which residents need to have an escort or need to have a contracted transport company take a resident to dialysis if needed. The DON said they had an Ad Hoc QAPI meeting on 7/11/2025 with the department heads, the Administrator, the Area Director of Operations; and the Medical Director was informed by the Administrator. The DON said she and the ADON would review the 24-hour summary to see if there were any changes that happened such as falls or behaviors and to see if they were reviewed. The DON stated the resident&rsquo;s dashboard would be reviewed throughout the day for any falls or behaviors that would need to be addressed. The DON said she and the Administrator were reviewing residents who were going to be transported, and it was discussed if the resident needed to have an escort. The DON stated the SOC meeting was held weekly on Fridays, and they would review residents who had a fall or accident to see if any interventions were needed.<BR/>In an interview on 07/13/2025 at 2:23 PM, the Administrator stated the interventions implemented included re-educating all staff on reporting unusual occurrences, and an employee could not return to work unless they received the training. The Administrator said all staff were provided her phone number to contact her to report any abuse or unsafe behaviors. The Administrator stated a monitoring tool was implemented to review all falls in the morning meeting to ensure interventions were implemented and was care planned. The Administrator said the SOC tool would be used weekly to verify the interventions were listed, if the staff knew about the interventions, and would be reviewed at the next QAPI meeting. The Administrator stated a van monitoring tool was implemented to ensure if anything happened during transport was recorded. The Administrator said the monitoring sheet was reviewed daily to determine if a resident needed an escort or need an ambulance to transport them. The Administrator stated the van drivers would turn in the van monitoring tool at the end of the day with notes about if a resident tried to stand up, any issues with their chair, or if they looked weak. The Administrator said the Van Driver was retrained on transporting residents in the van. The Administrator stated after the incident with Resident #1 she rode in the van daily for the first week, then the second week she rode in the van a twice a week. The Administrator stated an Ad Hoc QAPI meeting was held on 07/11/2025 with the department heads and Area Director of Operations. The Administrator said staff were retained about un-safe behaviors to be reported immediately to her or the DON. The Administrator stated when employees see a resident exhibiting behaviors, they were to stay with the resident to make sure they are safe, call for help, then report it to the administrator. The Administrator said they have a clinical care meeting and will follow-up on the entries on the resident&rsquo;s clinical record dashboard for behaviors with instructions for that resident, and the interventions were added to the resident&rsquo;s care plan. The Administrator stated if something happened on the weekend, staff would contact the Administrator. The Administrator said the Van Driver and Activity Director were in-serviced to pull over when a resident did something unsafe in the van and then call her. The Administrator said she a calendar was used with residents who have appointments to determine if a resident needed to have an escort to their appointment. The Administrator stated she and the DON would review all falls to make sure the i

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. <BR/>The facility failed to transport Resident #1 to a scheduled appointment with an oncologist, MD F as ordered on 02/10/2025. <BR/>This failure could place residents at risk for not receiving appropriate care and treatment and or a decline in their health. <BR/>Findings included: <BR/>Record review of Resident #1's admission Record, dated 02/13/2025, reflected Resident #1 was a [AGE] year-old male. He was admitted on [DATE]. MD G was noted as Resident #1's attending physician.<BR/>Record review of Resident #1 Diagnosis Report, dated 02/13/2025, reflected Resident #1 was noted to have diagnoses including secondary malignant neoplasm (a cancerous tumor either caused by a prior cancer treatment or a tumor unrelated and in a new location from a prior cancer) of unspecified site, squamous cell carcinoma (a type of skin cancer) of skin of scalp and neck, unilateral paralysis of vocal cords (a condition in which one vocal cord cannot move or has limited movement) and larynx (voice box), and localized enlarged lymph nodes (swollen clusters of immune system cells). <BR/>Record review of Resident #1's admission MDS, signed as completed on 11/17/2024, reflected Resident #1 had a BIMS score of 13, indicating he was cognitively intact. He was documented as requiring substantial/maximal assistance with sit to stand, chair/bed-to-chair transfers, and car transfers. He used a wheelchair and required supervision or touching assistance when wheeling 50 feet with two turns and 150 feet. His active diagnoses included cancer. <BR/>Record review of Resident #1's Care Plan, dated as last review completed 01/24/2025, reflected Resident #1 had a communication problem r/t paralysis of left side vocal cords due to localized enlarged lymph nodes resulting in squamous cell carcinoma of left side of neck. Resident also with mets [Metastasis; a process by which cancer cells spread to other parts of the body] to chest. Interventions included: Anticipate and meet needs., initiated 11/09/2024.<BR/>Record review of Resident #1's Progress Notes reflected: <BR/>- A Nursing Progress Note, effective date 02/04/2025 at 03:05 p.m. by LPN C, [Oncologist Office Manager] with [MD F] called at this time and appt for this resident was made for Monday 2/10/25 @ 2:00PM[sic]. <BR/>- A Nursing Progress Note, effective date 02/10/2025 at 03:48 p.m. by ADON A, CONTACTED [MD F] REGARDING SCHEDULING RESIDENT APPOINMENT [sic] NO ANSWER VM WAS LEFT WITH CONTACT INFO. <BR/>Record review of Resident #1's Order Recap Report, dated 02/13/2024 with order dates 11/08/2024 - 02/28/2025, reflected an order, order dated 02/04/2025 with start date 02/10/2025 and end date 02/11/2025, ordered by MD G, [MD F] called at this time and appt for this resident was made for Monday 2/10/25 @ 2:00PM one time only for 1 Day. Order status was noted to be documented as Completed. <BR/>Record review of Resident #1's 2/1/2025 - 2/28/2025 Treatment Administration Record, dated as printed on 02/13/2025, reflected the order [MD F] called at this time and appt for this resident was made for Monday 2/10/25 @ 2:00PM one time only for 1 Day. The order was documented as Administered by LPN E on 02/10/2025 at 10:32 a.m.<BR/>During an interview on 02/13/2025 at 10:21 p.m., Resident #1's RP stated Resident #1 had missed an oncology appointment due to the transportation not having been scheduled. Resident #1's RP stated Resident #1 had cancer that had not progressed far but was virulent (rapidly harmful), which indicated Resident #1 could not miss any of his cancer treatment appointments. <BR/>During an interview on 02/13/2025 at 12:04 p.m., Resident #1 reported the facility had canceled prior appointments he was scheduled due to lack of transportation. Resident #1 stated he believed he missed two appointments but was not sure. Resident #1 stated the facility was aware he missed his appointments and felt that the facility was not good about taking him to his appointments. <BR/>During an interview on 02/13/2025 at 02:00 p.m., the Transportation Nurse stated the facility procedure for scheduling resident appointments was for the nurses on Resident #1's side of the facility to first put in the order for the appointment and then they would also put in the appointment on the appointments calendar. The Transportation Nurse stated she was made aware of upcoming appointments by reviewing the appointment calendar and she would also be knowledgeable of scheduled appointments she had scheduled herself. She stated she was unaware of Resident #1 having had missed any appointments scheduled in January or February (of 2025). <BR/>During an interview on 02/13/2025 at 02:15 p.m., LPN E stated the facility procedure for scheduling resident appointments was for the nurse who received the appointment to put in the appointment order once scheduled and then to put the appointment on the appointment calendar. LPN E stated it was the responsibility of the nursing staff to correctly schedule appointments and that the appointment calendar was specifically for transportation scheduling. LPN E stated she was Resident #1's nurse on the day he had a scheduled radiation appointment, 02/10/2025. She stated she notified her nursing aides and reminded Resident #1 of his appointment that morning so he would be ready for transportation at 01:00 p.m. She stated he was ready, dressed, and with his paperwork for the appointment prepared prior to her leaving for a lunch break. She said that when she returned from her lunch break, she was asked by ADON A why Resident #1 missed his appointment. She stated at that time she verified that the resident's appointment was ordered, which she had already marked as completed prior to her break. She stated she also checked the appointment calendar and found that his appointment on the calendar was no longer present. She stated she remembered his appointment having been on the calendar earlier that morning but that she had been previously observed that appointments could be deleted or disappear. She did not state that she had reported her observations of appointments having been deleted. She stated she did not know for certain how Resident #1's appointment did not show on the appointment calendar once reviewed following his missed 02/10/2025 appointment. <BR/>During an interview on 02/13/2025 at 02:29 p.m., ADON B stated she was aware Resident #1 missed his radiology appointment. She stated a radiology appointment was pretty important for the Resident's care and that a resident should not miss any appointments unless there was an outlying reason. <BR/>During an interview on 02/13/2025 at 02:41 p.m., the Oncologist Office Manager for MD F confirmed Resident #1 missed his scheduled 02/10/2025 appointment. She stated MD F was unavailable for interview; however, she stated that the 02/10/2025 appointment was Resident #1's first appointment with MD F which meant the doctor would not be able to estimate the impact on Resident #1's health for having a 8-day delay in appointment visits. <BR/>Attempted interview on 02/13/2025 at 03:20 p.m. with MD G, Resident #1's primary physician. MD G's office staff member reported he was unavailable for interview.<BR/>During an interview on 02/13/2025 at 03:33 p.m., ADON A stated she was aware Resident #1 recently missed an appointment. ADON A stated she was not sure of what caused the missed appointment. ADON A stated her understanding was that the appointment was not on the appointment calendar and the van driver would have then not been aware of the appointment. She stated Resident #1 was ready to go to his appointment but between 01:30 p.m. and 02:00 p.m., he did not get picked up by transportation. She stated she believed LPN E was on break during that time. ADON A stated that appointments were communicated to nursing staff through the 24-hour report, the Medication Administration Report which shows the appointment order, and on the transportation calendar. ADON A stated she was unsure if the transportation nurse had access to the 24-hour report but did have access to the transportation calendar. ADON A stated following Resident #1's missed appointment, she spoke with LPN E and re-educated LPN E on her responsibility to ensure the residents leave for their scheduled appointments. <BR/>During an interview on 02/13/2025 at 04:38 p.m., the ADMIN stated she and the ADONs review the transportation calendar each morning during their morning meeting. The ADMIN revealed she believed access to the transportation calendar was restricted to only the nursing staff and department managers. She stated appointments could be rescheduled and or deleted but was unsure how to view a report to show that information. She stated nursing staff would typically make appointments and they were to then put the appointment in the transportation calendar, which would communicate the scheduled appointment with the transportation nurse. The ADMIN stated the facility did not have a formal procedure or monitoring report to ensure that scheduled appointments were put both into the resident's orders and onto the transportation calendar. The ADMIN stated that the facility's biggest confusion was that scheduled appointments needed to be in both places and if an appointment was not on the transportation calendar, there would be a miscommunication. The ADMIN stated every appointment was important and Resident #1's condition could worsen if he was not making his appointments. <BR/>Record review of facility policy Appointments, labeled as part of Nursing Policy & Procedure Manual 2003, reflected The facility will assist with outside facility resident appointments to ensure the resident attends any scheduled appointment., and under procedure, 2. If facility transportation is to be used, the staff member responsible for transportation will be notified to schedule the appointment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodations of residents needs for 2 of 2 residents (Resident #5 and Resident #15) reviewed for accommodations of needs, in that.<BR/>The facility failed to ensure Resident #5, and Resident #15 were able to press the call light when assistance was needed.<BR/>This deficient practice could place residents at risk of not receiving care or attention when needed.<BR/>Findings included:<BR/>Record review of Resident #5's admission Record, dated 4/20/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, Muscle Weakness, Abnormal Posture, Muscle Wasting and Atrophy (decrease in size or wasting away of a body part or tissue), Pain, and Depression. <BR/>Record review of Resident #5's MDS assessment, dated 2/26/24, revealed the resident had a BIMS score of 00, suggesting severe cognitive impairment. Further review of this assessment revealed Resident #15 functional limitation in range of motion to bilateral upper and lower extremities, was dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for all self-care and dependent for mobility.<BR/>Record review of Resident #5's Care Plan, dated 1/24/23, revealed the following focus area last revised on 6/21/23: The resident is at risk for falls .Interventions .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed .The resident needs a safe environment with .a working and reachable call light . Further review of this document revealed the following focus area last revised on 11/4/23: Resident has a communication problem r/t to cog/comm deficit, such as expressing words, emotions, spontaneous speech and needs time to communicate basic needs .Goal: Resident will be able to make basic needs known by allowing time for her to express herself and emotions on a daily basis .Interventions .Ensure/provide a safe environment: Call light in reach .Monitor effectiveness of communication strategies and assistive devices .<BR/>During observation and interview on 4/20/24 at 6:23 pm, Resident #5 was seen lying in bed with family at bedside. Resident #5 was awake, alert, and her upper limbs were contracted across her chest. Interview with resident was attempted but answers were unintelligible. Resident #5 slightly moved left hand but was unable to press call light when asked by the investigator to press the button. Resident #5's family member said she was unable to press the call light herself and believed the facility staff were aware of this. <BR/>During an interview on 4/22/24 at 11:28 am, LVN D said Resident #5 was not able to press the call light. <BR/>During an interview on 4/22/24 at 12:10 pm, CNA D said Resident #5 was not able to press the call light button. CNA D further stated that Resident #5 was checked on and repositioned every two hours.<BR/>During an interview on 4/27/24 at 12:47 pm, LVN A said she did not believe Resident #5, cognitively and physically, was able to press the call light. <BR/>Record review of Resident #15's admission Record dated 4/23/24 revealed the resident was re-admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), COPD (lung diseases that block airflow and make it difficult to breathe) , Cognitive Communication Deficit, Dysphagia (difficulty swallowing) , Functional Quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition ) , Pressure ulcer of sacral region Stage 4, Depression and Anxiety. <BR/>Record review of Resident #15's MDS assessment dated [DATE] revealed a BIMS score of 5, suggesting severe cognitive impairment. Further review of this assessment revealed Resident #15 functional limitation in range of motion to bilateral upper and lower extremities; was dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for all self-care and Dependent for mobility.<BR/>Record review of Resident #15's Care Plan, dated 3/8/23, revealed the following focus area last revised on 9/27/23: The resident is at risk for falls r/t recent admit to hospital and now with increased weakness and decreased mobility skills .Interventions .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Further review of this document revealed the following focus area last revised on 4/11/23: The resident has a communication problem r/t she is hared [sic] of hearing and speaker must adjust tone to be heard .Goal: The resident will be able to make basic needs known by on a daily basis .Interventions .Ensure/provide a safe environment: Call light in reach .Monitor effectiveness of communication strategies and assistive devices .<BR/>Observation and atteBased 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 residents needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 11 residents (Resident #5 and Resident #15) reviewed for accommodations of needs.<BR/>The facility failed to ensure Resident #5 and Resident #15 were able to press the call light when assistance was needed.<BR/>This deficient practice could place residents at risk of not receiving care or attention when needed.<BR/>Findings include:<BR/>1. Record review of Resident #5's admission Record, dated 4/20/24, reflected the resident was admitted to the facility on [DATE]. Resident #5 had diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, Muscle Weakness, Abnormal Posture, Muscle Wasting and Atrophy (decrease in size or wasting away of a body part or tissue), Pain, and Depression. <BR/>Record review of Resident #5's quarterly MDS assessment, dated 2/26/24, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Resident #5 functional limitation in range of motion to bilateral upper and lower extremities, was dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for all self-care and dependent for mobility.<BR/>Record review of Resident #5's Care Plan, dated 1/24/23, reflected the following focus area last revised on 6/21/23: The resident is at risk for falls .Interventions .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed .The resident needs a safe environment with .a working and reachable call light . Further review of this document revealed the following focus area last revised on 11/4/23: Resident has a communication problem r/t to cog/comm deficit, such as expressing words, emotions, spontaneous speech and needs time to communicate basic needs .Goal: Resident will be able to make basic needs known by allowing time for her to express herself and emotions on a daily basis .Interventions .Ensure/provide a safe environment: Call light in reach .Monitor effectiveness of communication strategies and assistive devices <BR/>During observation and interview on 4/20/24 at 6:23 PM, Resident #5 was seen lying in bed with family at the bedside. Resident #5 was awake, alert and her upper limbs were contracted across her chest. Interview with the resident was attempted but answers were unintelligible. Resident #5 slightly moved their left hand but was unable to press the call light when asked by the State Surveyor to press the button. Resident #5's family member said she was unable to press the push button call light herself and believed the facility staff were aware of this. Resident #5's family member further stated it would have been better for the resident to have a flat call light. <BR/>During an interview on 4/22/24 at 11:28 AM, LVN D said Resident #5 was not able to press the push button call light. LVN D further stated a soft call light would have been better for Resident #5 was but did the facility did not have any. <BR/>During an interview on 4/22/24 at 12:10 PM, CNA D said Resident #5 was not able to press the call light button. CNA D further stated Resident #5 was checked on and repositioned every two hours.<BR/>During an interview on 4/27/24 at 12:47 PM, LVN A said she did not believe Resident #5, cognitively and physically, was able to press the call light. <BR/>2. Record review of Resident #15's admission Record, dated 4/23/24, reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), COPD (lung diseases that block airflow and make it difficult to breathe) , Cognitive Communication Deficit, Dysphagia (difficulty swallowing) , Functional Quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition ) , Pressure ulcer of sacral region Stage 4, Depression and Anxiety. <BR/>Record review of Resident #15's quarterly MDS assessment, dated 3/15/24, reflected a BIMS score of 5, which indicated severe cognitive impairment. Resident #15's functional limitation in range of motion to bilateral upper and lower extremities; was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers was required for the resident to complete the activity) for all self-care and dependent for mobility.<BR/>Record review of Resident #15's Care Plan, dated 3/8/23, reflected the following focus area last revised on 9/27/23, reflected: The resident is at risk for falls r/t recent admit to hospital and now with increased weakness and decreased mobility skills .Interventions .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Further review of this document revealed the following focus area last revised on 4/11/23: The resident has a communication problem r/t she is hared [sic] of hearing and speaker must adjust tone to be heard .Goal: The resident will be able to make basic needs known by on a daily basis .Interventions .Ensure/provide a safe environment: Call light in reach .Monitor effectiveness of communication strategies and assistive devices <BR/>Observation and attempted interview on 4/25/24 at 5:24 PM revealed Resident #15 was seen lying in bed. She was awake, alert, and her arms were crossed across her chest, right arm appeared contracted across her chest and left hand was observed with severe edema (swelling) and appeared to have limited range of motion. Interview with the resident was attempted but Resident #15 did not respond to questions. Resident #15 was unable to press the call light when asked. <BR/>During an interview on 4/27/24 at 12:47 PM, LVN A said all staff should have been checking for residents' ability to press the call light button. LVN A further stated if a resident was unable to press the push button call light button, they were given a soft call light (a special device used for residents with limited ROM) they could press when assistance was needed. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON said interventions for Resident #5 and Resident #15 included: rounding every 2 hours, turning every 2 hours and CNAs were sent to check on the residents more often because they had a higher acuity and needed more assistance than others. The DON said Resident #5 and Resident #15 were able to press the call light button but refused to do so. <BR/>Record review of the facility's policy, titled Resident Rights, revised 11/28/16, reflected: . Respect and dignity - 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs .mpted interview on 4/25/24 at 5:24 pm revealed Resident #15 was seen lying in bed. She was awake, alert, and her arms were crossed across her chest, right arm appeared contracted across her chest and left hand was observed with severe edema and appeared to have limited range of motion. Interview with resident was attempted but Resident #15 did not respond to questions. Resident #15 was unable to press the call light when asked. <BR/>During an interview on 4/27/24 at 12:47 pm, LVN A said all staff should have been checking for residents' ability to press the call light button. LVN A further stated that if a resident was unable to press the call light button, they were given a soft call light (a special device used for residents with limited ROM). <BR/>During an interview on 4/27/24 at 6:32 pm, the DON said she had not evaluated Resident #5's and Resident #15's ability to press the call light button. She added that interventions for Resident #5 and Resident #15 included: rounding every 2 hours, turning every 2 hours and CNAs were sent to check on the residents more often because they have a higher acuity and need more assistance than others. <BR/>Record review of the facility's policy, titled, Resident Rights, revised 11/28/16, revealed: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality . The facility must provide equal access to quality care regardless of diagnosis, severity of condition . Planning and implementing care - d. The right to receive the services and/or items included in the plan of care .3. The planning process must-- b. Include an assessment of the resident's strengths and needs . Respect and dignity - 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents have a right to personal privacy for 2 of 2 residents (Residents #70 and #78) reviewed for privacy, in that:<BR/>1. MA M did not close the computer screen exposing Resident #70's personal medical information.<BR/>2. LVN K and LVN L did not completely close Resident #78's privacy curtain while providing wound care.<BR/>This failure could place residents at-risk of loss of dignity due to lack of privacy.<BR/>The findings included:<BR/>1. Record review of Resident #70's face sheet dated, 12/4/24, revealed a [AGE] year old female with an admission date of 2/27/23, with diagnoses that included: Dementia (is the loss of cognitive functioning thinking, remembering, and reasoning), Bipolar disorder (mental health conditions characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function), and Major Depression Disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest).<BR/>Record review of Resident #70's quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated an intact cognition. <BR/>Observation and Interview on 12/4/24 at 12:15 PM revealed MA M administering medications to Resident #70 in the dining room and stepping away from the computer without locking the screen. MA A stated she was near the computer, and she did not need to lock the screen. She stated by stepping away from the computer and not locking the screen, Resident #70's information may have been exposed. <BR/>In an Interview with the RCN on 12/4/24 at 2:12 PM she stated MA M should have closed the screen when she stepped away from computer, which risked Resident's #70's medical information being exposed. She stated it was her expectation that all nursing staff closed the screen when away from the computer, she added the DON would be responsible for over seeing this and the ADON would be monitoring this at random to ensure compliance. <BR/>2. Record review of Resident #78's face sheet, dated 12/04/2024, reflected an [AGE] year old female with an initial admission date of 01/13/2023 and re-admission on [DATE], with diagnoses which included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions); Type 2 Diabetes Mellitus (chronic condition resulting in persistently high blood sugar levels) and pressure ulcer of sacral region stage 4 (full thickness tissue loss with exposed bone, or muscle located near tailbone).<BR/>Record review of Resident #78's Quarterly MDS assessment, dated 11/05/2024, revealed a BIMS score of 3, indicating severe cognitive impairment and required partial/moderate assistance, in toileting hygiene.<BR/>Record review of Resident #78's Care Plan initiated 3/8/2023 revealed a focus area for Stage 4 left gluteal pressure wound revised on 11/27/2024, with interventions that included: Cleanse with NS [normal saline], Pat dry with 4x4 gauze. Apply Isosorb [medicated gel to treat wounds] and Collagen [helps with skin regeneration] to wound bed. Cover with silicone dressing. Daily.<BR/>Observation on 12/04/2024 at 11:55 a.m., reflected LVN K and LVN L attempted, but were not able to completely close the privacy curtains around Resident #78's bed, as the privacy curtain jammed and would not completely extend the distance needed to block visual view completely around the bed. This left a 2- foot opening between the curtains near the foot of the bed while they provided wound care for Resident #78, during which the resident's buttocks were exposed and could be seen by anyone entering the room. <BR/>During an interview with LVN K and LVN L on 12/04/2024 at 12:33 p.m. they verbally confirmed the privacy curtains were not completely closed while they provided wound care for Resident #78, because they could not physically close the curtain. They also stated they knew it was important to close the curtains all the way to provide privacy to the resident. They stated it was housekeeping's responsibility to maintain the privacy curtains in the resident's rooms. <BR/>During an interview with the RCN on 12/04//2024 at 1:55 pm, the RCN stated privacy must be provided with closed privacy curtains for any patient care activity including wound care and peri-care to protect their dignity, and that she would make sure the privacy curtains in resident rooms were fixed so that they closed completely. <BR/>During an interview with the Housekeeping Supervisor on 12/06/2026 at 12:33 p.m., the Housekeeping Supervisor stated that housekeeping was responsible for cleaning and maintaining the privacy curtains in resident's rooms and that they have had problems with missing hooks, or worn-out wheel bearings, resulting in jams preventing the privacy curtains from closing all the way. She stated she has in-serviced the housekeeping staff to test the curtains after hanging them up to ensure they close completely to provide 100% privacy to the residents. She stated the housekeepers should make a request to the maintenance department when curtains jam and don't close properly with a copy to her so she could follow up on the work. However, after a brief search of her email, the Housekeeping Supervisor was unable to provide any copies of requests to maintenance to fix the broken privacy curtains, which may have resulted in privacy curtains not being fixed when broken.<BR/>Review of the facility's policy titled Resident Rights Policy, undated, reflected, The resident has a right to personal privacy and confidentiality of his or her personal and medical records and 1. Personal privacy includes accommodations, medical treatment, written and telephone communication, personal care, visits and meetings of family and resident groups

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 (Resident #84) of 21 residents and 2 of 8 resident halls (Halls A and 300) reviewed for maintaining a safe, clean, comfortable, and homelike environment, in that: <BR/>1. Resident #84's wheelchair was visibly soiled with substances that appeared to be crumbs, dust, and residue of dried liquids. <BR/>2. A storage closet on the 300 Hall was unlocked and contained hazardous materials. <BR/>3. A shower room on Hall A was soiled with a smear of odorous brown substance on the wall. <BR/>These failures could place residents at risk of living in an unsanitary and uncomfortable environment and diminished quality of life. <BR/>The findings were: <BR/>1. Record review of Resident #84's face sheet, dated 08/26/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses including Other Seizures, Cerebral Infarction due to Unspecified Occlusion or Stenosis of Unspecified Cerebral Artery, and Personal History of Traumatic Brain Injury. <BR/>Record review of Resident #84's Quarterly MDS, dated [DATE], revealed a BIMS score of 12 which indicated the resident had moderate cognitive impairment. Further review revealed Resident #84 required extensive assistance from facility staff to perform activities of daily living. <BR/>Record review of Resident #84's care plan, revised 11/13/2018, revealed a focus, Resident [#84] has a physical mobility deficit [related to] recent admit to hospital and now with increased weakness and decreased mobility skills, and interventions, Appropriate assistive device to be used for mobility and locomotion. Resident requires [wheelchair]. He requires supervision assist X 1 staff at times . Resident is mobile using [wheelchair]. He requires supervision assist X 1 staff (at times) on and off unit. <BR/>Observation on 08/24/2022 at 5:52 p.m. revealed Resident #84's wheelchair was visibly soiled with substances that appeared to be crumbs, dust, and residue of dried liquids. <BR/>During an interview with Resident #84, at the same time as the observation, Resident #84 indicated he was aware his wheelchair was soiled and disliked that it was soiled. <BR/>During an interview with LVN G on 08/24/2022 at 5:55 p.m., LVN G confirmed that Resident #84's wheelchair was soiled and stated it would be cleaned. <BR/>During an interview with the Administrator on 08/25/2022 at 5:30 p.m., the Administrator confirmed resident wheelchairs should be maintained for cleanliness. <BR/>2. Observation on 08/23/2022 at 12:12 p.m. revealed an unlocked storage closet on Hall 300 which contained three unsecured spray bottles with liquid. Bottle #1 was labeled odor counteractant with warnings do not drink and may cause eye irritation. Bottle #2 was labeled multi-surface cleaner with warnings danger and keep out of reach of children. Bottle #3 was labeled disinfecting heavy-duty acid bathroom cleaner with warnings keep out of reach of children and hazard to humans and domestic animals. Two empty spray bottles with similar warning on the labels were observed with the three bottles containing liquid. <BR/>During an interview with Housekeeper D on 08/23/2022 at 12:18 p.m., Housekeeper D confirmed the storage closet on Hall 300 was unlocked and contained three unsecured bottles with liquid and warnings on their labels. Housekeeper D stated that the closet was always unlocked and that she stored and retrieved her housekeeping cart in the closet at each of her shifts. <BR/>3. Observation on 08/23/2022 at 12:32 p.m. of the shower room on Hall A revealed the wall was soiled with a smear of odorous brown substance. <BR/>During an interview with CNA E on 08/23/2022 at 12:35 p.m., CNA E confirmed the wall of the shower room on Hall A was soiled with a smear of odorous brown substance. <BR/>During an interview with the Administrator on 08/25/2022 at 5:30 p.m., the Administrator confirmed hazardous substances should be secured and resident shower rooms should not be soiled. <BR/>Record review of the facility's policy titled, Sanitation Assurance Program - Overview, dated 2021, revealed, 2. Daily Cleaning/Disinfecting Process d. Shower Rooms.<BR/>Record review of the facility's policy titled, Social Services Manual 2003, revised 11/28/2016, revealed, Safe Environment - The resident has a right to a safe, clean, comfortable and homelike environment .<BR/>Record review of the facility's policy titled, Resident Rights, revised 11/28/2016, revealed, Safe Environment - The resident has a right to a safe, clean, comfortable and homelike environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan including the minimum healthcare information necessary to properly care for the resident within 48 hours of the resident's admission, for 1 (Resident #259) of 28 residents reviewed, in that: <BR/>Resident #259's baseline care plan did not include his allergies or his physician-prescribed diet. <BR/>This failure could result in improper care. <BR/>The findings were: <BR/>Record review of Resident #259's face sheet, dated 12/05/2024, revealed he was admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease, Hyperlipidemia, and Chronic Kidney Disease. <BR/>Record review of Resident #259's clinical record as of 12/05/2024, revealed the resident was allergic to the medications Atorvastatin, Flomax, and Tramadol. Further review revealed the resident's physician ordered a regular diet with regular texture and regular consistency on 11/26/2024. <BR/>Record review of Resident #259's baseline care plan, dated 11/26/2024, revealed the document included neither his allergies to medications nor his physician-prescribed diet. <BR/>During an interview with RN/MDS B on 12/06/2024 at 10:32 a.m., RN/MDS B confirmed that Resident #259's baseline care plan did not include his allergies or his physician-prescribed diet and should have included both items. RN/MDS B further stated that the development of baseline care plans was the responsibility of the DON who had recently resigned and that the oversight should have been noted by the admitting nurse or one of the facility ADONs. <BR/>Record review of the facility policy, Baseline Care Plans, undated, revealed, Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events .The baseline care plan will be developed within 48 hours of a resident's admission, include the minimum healthcare information necessary to properly care for a resident including, but not limited to - physician orders, dietary orders .interim approaches for meeting a resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 12 residents (Resident #12) reviewed for care plans. <BR/>The facility failed to ensure Resident #12's care plan was revised to reflect prescribed diet and weight loss. <BR/>These failures could place residents at risk of current needs not being met. <BR/>Findings included:<BR/>Record review of Resident #12's admission Record, dated 4/22/24, reflected the resident was admitted to the facility on [DATE]. Resident #12 had diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning) , Malnutrition, Dysphagia (difficulty swallowing) , Cognitive Communication Deficit, Depression and GERD (digestive disease in which stomach acid or bile irritates the food pipe lining) . <BR/>Record review of Resident #12's quarterly MDS assessment, dated 1/3/24, reflected the resident had a BIMS score of 99, which indicated the resident was unable to complete the interview. Resident #12 weighed 147 pounds, a weight loss of 5% or more, was not on physician-prescribed weight-loss regimen and was on a mechanically altered and therapeutic diet. <BR/>Record review of Resident #12's Care Plan, dated 12/20/17, reflected the following focus area last revised on 6/3/23: Potential for weight loss due to impaired cognition with Dementia, Depression, edentulous status without the use of his dentures currently. DX: GERD and Malnutrition .Goal: Resident will maintain stable weight and adequate nutrition by consuming 75-100% of meals X 3 per day with diet and liquids at most lenient texture and with compliance to diet as ordered x90 days .Target date:4/9/24 <BR/>Record review of Resident #12's Order Summary, dated 4/20/24, reflected: Regular diet Mechanical Soft texture, Nectar consistency, Red Glass Program, Pur&eacute;ed meats with gravy, no straw. Magic cup with lunch for Per MBS study 2/13/23 related to Unspecified Protein-Calorie Malnutrition, start date 7/6/23; Readycare 2.0 four times a day for Weight Loss give 90CC, start date 2/27/24; Super Cereal in the morning for with breakfast, start date 10/25/23. <BR/>Record review of the facility's Weight and Vitals Summary, dated, 4/20/24, reflected Resident #12 weighed 145.6 lbs on 1/5/24 a 14.8% weight loss compared to 7/10/23 (170.8 lbs), 148.4 lbs on 1/12/24 a 13.1% weight loss compared to 7/10/23 (170.8 lbs), 143.4 lbs on 1/19/24 a 11.8% weight loss compared to 8/1/23 (162.2 lbs), 144.4 lbs on 2/2/24 a 10.3% weight loss compared to 8/11/23 (161 lbs), 144.4 lbs on 2/6/24 a 10.3% weight loss compared to 8/11/23 (161 lbs), and 144.4 lbs on 2/9/24 a 10.3% weight loss compared to 8/11/23 (161 lbs).<BR/>Record review of Resident #12's Progress Notes reflected:<BR/>Effective Date: 01/10/2024 09:31 [9:31 am] Type: Dietary Note .Note Text: Wt's 147.2 lbs, 145.6 lbs - loss of 11.6 lbs/90 days (7.38%), 25.2 lbs/180 days (14.75%). On a Mech Soft Diet, Nectar Thick Liquids, Pureed Meats with gravy, no straw, Super Cereal in a.m. with breakfast, Magic Cup with lunch . Red Glass Program. Provided a House Shake after meals and at bedtime d/t weight loss .Current diet, nutritional supplements and p. o. intake areadequate [sic] as evidenced by fairly stable weekly weights past 4 weeks. Recommend continuing with same plan of care - goal is no significant weight changes next 30 days. Author .Dietitian<BR/>Effective Date: 01/22/2024 18:28 [6:28 pm] Type: Nursing . Note Text: Contacted [NP] due to resident [sic] 5LBS wight [sic] loss in a week, did inform weight loss may have been due to resdient [sic] having a resp infection, will continue to monitor and weigh resdient [sic] weekly Author: [ADON A] Assistant Director of Nursing<BR/>Effective Date: 02/26/2024 10:16 [10:16 am] Type: Dietary Note .Note Text: Wt's 145.6 lbs, 144.4 lbs - loss of 17.8 lbs/180 days (10.97%). On a Mech Soft Diet, Nectar Thick Liquids, Super Cereal in a.m., pureed meats with gravy, no straw . Magic Cup with lunch. Red glass Program. Provided a House Shake after meals and at bedtime .Review of chart indicates p. o. intake is good for most meals, however, continued weight loss trend noted. Recommend the following: .House Shake after meals and at bedtime. Provide 90ml ReadyCare 2.0 or Med Pass 2.0 QID with med pass. Goal is no further weight loss. Author .Dietitian<BR/>Effective Date: 03/30/2024 07:18 [7:18 am] Type: Dietary Note . Note Text: Wt's 144.4 lbs, 142 lbs - loss of 17.4 lbs/180 days (10.92%). On a Mech Soft Diet, Nectar Thick Liquids, Pureed Meats with gravy, no straw, Magic Cup with lunch .Red Glass Program. Provided 90ml ReadyCare 2.0 QID . Review of chart indicates 2.24 RD recommendations are in place and weight has stabilized as evidenced by most recent weekly weight of 142 lbs. Recommend continuing with same plan of care . Author .Dietitian <BR/>Effective Date: 04/18/2024 11 :08 [11:08 am] Type: Dietary Note . Note Text: Wt's 142 lbs, 141 lbs - loss of 16.2 lbs/180 days (10.31 %). On a Mech Soft Diet, Nectar Thick Liquids, Super Cereal with breakfast, Pureed Meats with gravy, no straw, Magic Cup with lunch . Red Glass Program. Provided 90ml ReadyCare 2.0 QID .Current diet, nutritional supplements and p. o. intake are adequate as evidenced by fairly stable weight past 90 days. Recommend continuing with same plan of care . Author .Dietitian <BR/>During an interview on 4/27/24 at 12:47 PM, LVN A stated care plans were completed and updated by herself and RN A (MDS Coordinators). LVN A further stated care plans were completed quarterly when the MDS assessment was completed and PRN if there were changes in condition, services and/or needs. LVN A stated care plans were updated as soon as possible. LVN A further stated the facility had morning meetings and if changes were reported, she tried to update the appropriate care plans during the meeting. LVN A stated the facility also had daily nursing meetings with the DON, ADONs, Administrator and an the MDS nurse and standard of care meetings. LVN A stated care plans were supposed to reflect diet as ordered and stated Resident #12's diet was not included in the resident's care plan. <BR/>During interview on 4/27/24 at 2:17 PM, RN A stated the nurses on working on the floor were responsible for updating care plans with acute changes to the resident's conditions. RN A further stated the facility had a morning meeting every day and changes to the resident condition/orders were shared at this meeting. RN A stated she and LVN A were mainly responsible for admissions assessments, quarterly assessments and care plans. RN A further stated the MDS Coordinators (LVN A and RN A) updated care plans, but care plans were updated for acute changes in condition by the floor nurses. RN A stated updates were done when changes happened, and added there was not a timeframe, but the goal was to update the care plans immediately. RN A stated she not aware Resident #12's care plan had not been updated to reflect his weight loss and diet orders. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated diet orders were to be care planned. The DON further stated she expected care plans to be updated the day the change occurred. The DON stated the MDS, and charge nurses were responsible for updating care plans quarterly and when there were changes to orders. <BR/>Record review of the facility's, undated, policy, titled Comprehensive Care Planning, read: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life .The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented .revised based on changing goals, preferences and needs of the resident and in response to current interventions <BR/>Record review of the facility's policy, titled Red Glass and Fortified Food Program, dated 2012, revealed: .The red glass program uses the presence of a red glass on the resident's meal tray to alert facility staff to which residents may have had a weight loss and/or need additional monitoring and encouragement to complete meals and fluids. Dietary will provide the red glass .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 2 residents (Residents #1 and #2) reviewed for accidents. 1. The facility failed to identify and address hazards and risk in Resident #1's environment when staff failed to ensure they addressed Resident #1's behavior of unbuckling the seatbelt during transport in the facility van. On 06/13/2025, Resident #1 sustained a fall during van transport, with the seat belt noted to be on the wheelchair but the fastener unlatched, resulting in a laceration to her forehead. 2. The facility failed to identify and address hazards and risk in Resident #2's environment when staff failed to ensure they addressed Resident #2's fall on 06/18/2025. An Immediate Jeopardy (IJ) was identified on 07/11/2025. The IJ template was provided to the facility on [DATE] at 10:39 p.m. While the IJ was removed on 07/13/2025 at 4:20 p.m., the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal. This failure could place residents at risk for accidents injuries, hospitalization and death related to unsafe vehicle transport. The findings included: 1.Record review of Resident #1&rsquo;s admission record dated 07/08/2025 revealed she was a [AGE] year-old woman admitted on [DATE] with re-admission on [DATE], and with diagnoses which included: End-Stage Renal disease (condition where kidneys lose the ability to remove waste and balance fluids in balance requiring dialysis); Syncope (fainting or temporary loss of consciousness) and collapse; Vascular Dementia (impaired cognitive thinking due to constricted blood flow) and Bradycardia (slow heart beat).<BR/>Record review of Resident #1&rsquo;s Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 5, indicating severe cognitive impairment, and was assessed as being dependent for transfers, and had no behavioral symptoms.<BR/>Record review of Resident #1&rsquo;s Care Plan initiated 07/03/2022 revealed a focus area for &ldquo;The resident is risk for falls due to dx [diagnosis] of syncope,&rdquo; and included &ldquo;Resident had action [sic] fall in facility van causing laceration to forehead&rdquo; initiated 07/03/2022 and revised 06/14/2025. There were no interventions listed which addressed the resident&rsquo;s behavior of unbuckling the seat belt and no new interventions for this fall were listed.<BR/>Record review of Resident #1&rsquo;s other focus areas in her Care Plan initiated 07/03/2022, revealed there was no other focus areas for her behavior of trying to stand up during transport or for trying to unbuckle her seatbelt in the facility van during transport.<BR/>Record review of Resident #1&rsquo;s Physician Order Summary Report, dated 07/12/2025, revealed an order initiated on 01/17/2025 for dialysis at 12:05 PM on Monday, Wednesday, and Friday at a local dialysis center.<BR/>Record review of Resident #1&rsquo;s Nurses Notes from 03/11/2025 to 06/12/2025 revealed there was no notation of Resident #1 trying to stand up during transport or for trying to unbuckle her seatbelt in the facility van during transport.<BR/>Record review of Resident #1&rsquo;s Progress Note dated 6/13/2025 at 11:22 a.m. by the DON revealed &ldquo;Resident had a fall. Location: in facility van during transport to dialysis. Cognition/Behavior at Time of Event: Cognitive Impairment. The fall caused a skin tear to above left eyebrow. new/bleeding&hellip;.Administrator received call from Van Driver of resident fall in van. Upon arrival to scene, noted resident on floor of van face down with head partially under 2nd row of seats. Blood noted on floor and on resident&rsquo;s hair. Cream colored emesis (vomit) noted on wc [wheelchair] and unable to check vs [vital signs]. Respirations slow and irregular. 911 called per van driver. Ems arrived and transported to ER&hellip;&rdquo; The MD was notified on 06/13/2025 at 12:02 PM. Resident #1&rsquo;s Responsible Party was notified on 06/13/2025 at 11:52 AM. &ldquo;Interventions in place prior to fall: None, Interventions initiated in response to fall: none.&rdquo;<BR/>Record review of Resident #1&rsquo;s Nurse&rsquo;s Notes dated 06/13/2025 by LVN-H revealed the nurse received a call from the hospital emergency room regarding Resident #1&rsquo;s medication list which was faxed to the hospital and the nurse was informed the resident had another episode of vomiting at the hospital and was intubated (a tube inserted into the mouth and throat to hold open the airway so air can be pushed in and out of the lungs via machine) at that time.<BR/>Record review of Resident #1&rsquo;s Event Nurses&rsquo; Note-Fall, dated 06/13/2025, revealed the resident had an unwitnessed fall in the facility van during transport to dialysis sustaining a skin tear above her left eyebrow. Resident #1&rsquo;s responsible party was notified on 06/13/2025 at 11:52 AM and her physician was notified on 06/13/2025 at 12:02 PM. Under &ldquo;Interventions in place prior to this fall&rdquo; had &ldquo;None of the above&rdquo; was checked. Under &ldquo;Interventions initiated in response to this fall&rdquo; had &ldquo;None of the above&rdquo; checked and no interventions were listed.<BR/>Record review of hospital records dated 6/20/2025 revealed Resident #1 had a CT (Computed tomography &ndash; type of imaging using x-ray techniques to obtain detailed images) of head was completed 06/19/2025 and showed &ldquo;no acute intracranial finding&rdquo;. Further review revealed Resident #1 was treated for and placed on seizure precautions and treated also for sepsis-resolved (condition where the body&rsquo;s responses to infection causes injury to its own tissues and organs), likely secondary to aspiration pneumonia (lung infections caused by inhaling something other than air into your lungs, such as food or vomit), and Paroxysmal Atrial Fibrillation (noted she converted to normal sinus rhythm on 6/16/2025).<BR/>Telephone interview with Family Member #1 on 07/11/2025 at 12:08 p.m. revealed Resident #1 was no longer in hospital and had been moved to a different nursing facility, but was still fighting an infection and very weak. He stated Resident #1 had a history of falls, but expected the facility to know this and take appropriate precautions. He stated he felt the facility should have sent extra staff instead of just the driver to help take care of vulnerable residents.<BR/>During an interview on 07/09/2025 at 3:57 p.m., the Van Driver stated that she loaded Resident #1 in the van on 06/13/2025, leaving facility at 11:16 a.m. and after pulling out onto the road, she heard Resident #1 make a loud noise, and saw in the rear-view mirror that Resident #1 had vomit coming from her mouth. She stated that as she attempted to turn to pull off to the side of road, she saw Resident #1 stiffen up and fall forward out of the wheelchair and land face down on the floor of the van. The Van Driver stated she called the Administrator who told her to call 911. The Van Driver further stated that she had secured Resident #1 securely in her wheelchair into the van with 4 straps that were attached to the L-bar of Resident #1&rsquo;s wheelchair frame, but stated she believed Resident #1 had unbuckled her seatbelt, because she had unbuckled her seatbelt during transport in the past.<BR/>Further interview with the Van Driver on 07/10/2025 at 4:15 p.m. revealed that she stated there were two other prior incidents of Resident #1 removing her seatbelt and trying to stand up in the van. She stated the first incident happened about 2 months prior to the June 13th incident, where Resident #1 took her seatbelt off and she told Resident #1 to keep her seatbelt fastened because she could fall. She stated the second incident happened about 2 weeks prior to the June 13th incident, where Resident #1 attempted to pull herself up to standing by pulling on the seat in front of her during transport. The Van Driver stated she reported one of the incidents to LVN -A, and one incident to the Administrator, who told her to contact therapy to ask what could be done, and therapy told her they could tilt her wheelchair backwards so she couldn&rsquo;t grab things.<BR/>During an interview with LVN-A on 07/10/2025 at 11:44 a.m., she stated that sometime during that first week of June 2025, the Van Driver came to the Nurse&rsquo;s station after returning Resident #1 back to facility from dialysis, and told her, the DON and former ADON, who were all standing at the nurse&rsquo;s station, that Resident #1 had tried to stand up in the van during transport. LVN-A stated she educated Resident #1 about not standing up in the van, that it was dangerous, and she stated Resident #1 denied that she had done that. LVN-A further stated that she did not report the incident to anyone because the DON was standing at the Nurse&rsquo;s station with her when the Van Driver reported the incident and had instructed her to educate Resident #1 on not unbuckling her seatbelt.<BR/>During an interview with the DON on 07/10/2025 at 4:54 p.m., the DON stated she was never made aware of any prior incidents of Resident #1 taking off her seatbelt or trying to stand up out of her wheelchair during van transport. <BR/>Interview on 07/10/2025 at 4:30 p.m. with the Administrator revealed she had inspected the van after the incident and observed vomit on the chest strap when she pulled it out from the retracting device, indicating the chest strap had been in place across Resident #1&rsquo;s chest when she first started to vomit and believed Resident #1 may have pressed down on her abdomen with her hand when she vomited, accidentally pushing on the release button of the seatbelt. When asked about any prior incidents, the Administrator stated that the Van Driver had informed her of an incident where Resident #1 had attempted to slide down out of her wheelchair, could not remember the exact date, but thought it might have been a couple of months prior to the current incident, and that was when she suggested the Van Driver check with therapy to see if wheelchair could be modified. She stated the Van Driver never told her Resident #1 had unbuckled her seatbelt or tried to stand up in van. She stated the Van Driver came back and told her therapy stated the wheelchair could be tilted back slightly, and they agreed that was what they were going to try to do to address the problem. The Administrator further stated that if Resident #1 had intentionally tried to undo her seatbelt or stand up in the van during transport she would expect that to be reported to her, but no one ever had. She stated the team never met to discuss the incident reported to her of Resident #1 trying to slide out of the wheelchair and the intervention they discussed about the therapy assessment of the wheelchair was never care planned but should have been.<BR/>Interview with PT - B on 07/11/2025 at 11:46 a.m. revealed she confirmed a CNA had come down to ask about what could be done about Resident #1 leaning forward in wheelchair and PT-B instructed CNA and Resident #1&rsquo;s family member how to recline the wheelchair. No documentation available as Resident #1 was not on services at this time.<BR/>Interview with the Activity Director on 7/11/2025 at 9:41 a.m. revealed that he also transports residents in the van to recreational activities, but will also transport residents at times to their medical appointments when the primary Van Driver is out sick. He stated the primary Van Driver and he are the only staff who transported residents at the facility. The Activity Director stated he had transported Resident #1 in the van many times and had observed her undo her seatbelt or try to stand up in van during transport several times. The Activity Director further stated he educated Resident #1 not to unbuckle her seat belt, but stated she would get anxious at times and forget. The Activity Director stated he reported this behavior of unbuckling her seatbelt during transport to the primary Van Driver so she could be aware and monitor but did not report the incidents to anyone else.<BR/>During a telephone interview with the Van Driver on 07/11/2025 at 11:54 a.m., she stated that she did not recall the Activity Director ever informing her or warning her about Resident #1&rsquo;s behavior of unbuckling her seatbelt during transport.<BR/>During an interview with the Administrator on 07/11/2025 at 11:46 a.m., the Administrator stated that had she known Resident #1 had incidents of unbuckling her seatbelt in van during transport, she would have assigned an escort to go along with her during transport or contracted with local company for ambulance transportation services for Resident #1.<BR/>2. Record review of Resident #2&rsquo;s admission record dated 07/08/2025 revealed she was an [AGE] year-old woman admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: Vascular Dementia-Severe (impaired cognitive thinking due to constricted blood flow), Schizoaffective Disorder (a mental health condition that includes both symptoms of schizophrenia, such as hallucinations and delusion and mood disorders), and Poly- osteoarthritis (condition where cartilage in multiple joints wears down causing bones to rub against each other leading to pain and stiffness).<BR/>Record review of Resident #2&rsquo;s Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment and she was assessed as needing substantial/maximal assistance for transfers.<BR/>Record review of Resident #2&rsquo;s Nurses Notes dated 06/18/2025 at 6:06 p.m. by LVN-I, revealed the resident had an unwitnessed fall from the low bed in her room onto the floor next to the bed sustaining a skin tear that was 2cm. to her right hand, and complaining of head, neck, right arm and right leg pain. Under &ldquo;Interventions in place prior to this fall&rdquo; had &ldquo;Floor mat, Low bed.&rdquo; Under &ldquo;Interventions initiated in response to this fall&rdquo; had &ldquo;Floor mat, Low bed, neuro-checks.&rdquo;<BR/>Record review of Resident #2&rsquo;s Nurses Notes dated 06/18/2025 at 10:55 p.m. by LVN-I revealed resident had returned from the ER with a diagnosis of right knee patella (kneecap) fracture, with knee immobilizer in place.<BR/>Record review of Resident #2&rsquo;s Care Plan initiated 07/03/2022 for &ldquo;The resident is risk for falls r/t Poor communication/comprehension&hellip;.Resident H/O fall out of bed due to self positions to the point of being on the edge&rdquo; initiated 07/03/2022 and last revised 07/07/2023, revealed it was not revised to address the resident&rsquo;s actual fall on 06/18/2025 and no new interventions were listed.<BR/>Record review of Resident #2&rsquo;s other focus areas of Care Plan initiated 07/03/2022 revealed there was no care plan or new interventions which addressed her fall on 06/18/2025.<BR/>Interview with CNA-K on 07/09/2025 at 1:52 p.m. revealed she stated she had completed check and change with Resident #2 about an hour before her fall and stated she put the bed in the lowest position, and the head of bed was just slightly elevated. Then as she was walking down hall with LVN-H to leave at end of her shift, she heard Resident #2 mumbling, looked in her room and saw her on the floor, face down. She stated she also observed the bed was not in the lowest position, and the head of the bed was straight up at 90-degree angle. The fall mat was in place by her bed.<BR/>Interview with LVN-H on 07/10/2025 at 10:40 a.m. revealed she works day shift and was getting ready to leave for the day when she heard Resident #2 talking from her room, and when she went to check on her, found Resident #2 lying on the mat on the floor next to her bed. LVN-H stated she observed that Resident #2&rsquo;s head of bed was up to the full 90 degrees, and the bed was not in lowest position, and stated that Resident #2 had been observed to work the bed controller in the past. LVN H stated she believed Resident #2 had accidentally changed position of bed as she manipulated the bed controller. She stated they always make sure her call light was within reach but does not believe she understands its purpose as Resident #2 will push the button on the call light, but when they answer, she cannot say what she needed or why she activated the light.<BR/>Interview on 07/10/2025 at 5:59 p.m. with LVN-I revealed she works night shift and had just come on duty on 6/18/2025 when she was called into Resident #2&rsquo;s room after she had been found on the floor. She stated Resident #2 was lying on the mat on the floor next to her bed, and that the mat had been in place. However, she noted the bed was not in its lowest position and the head of the bed was in an upright position and stated Resident #2 will take the bed controller and randomly press buttons on it, which can move her bed out of the lowest position. LVN-I stated they have done interventions to keep her from falling again, such as moving the bed controller to the end of the bed to keep her from moving the bed up higher and moving things away from her bed that she can grab, like the drawers out of her dresser.<BR/>Interview with the DON on 07/11/2025 at 8:28 a.m. revealed all acute incidents such as falls are discussed in the morning team meetings and the team discusses actions/interventions needed. She did not remember specifically what was discussed regarding Resident #2&rsquo;s fall on 6/18/2025. The DON stated that the MDS Nurse is responsible for revising the care plan per the quarterly and annual MDS assessments, and the DON and ADONs are responsible for updating care plans for acute changes. The DON did not know why there was no care plan revision done following Resident #2&rsquo;s fall on 06/18/2025 and -stated that could result in staff not being aware of the care needs of the residents, and could result in acute events such as falls happening again.<BR/>During an interview with the Administrator on 07/11/2025 at 10:16 a.m., the Administrator stated that Resident #2&rsquo;s fall on 06/18/2025 was addressed by the team in the morning clinical meeting to review causes of the fall and devise new interventions to prevent other falls in future. The Administrator stated that interventions were put into place, including moving furniture to create a safe space, and moving the bed controller away from Resident #2&rsquo;s reach, so that she could not move the bed out of the recommended low bed position. The Administrator further stated however, that Resident #2&rsquo;s care plan was not revised to include these new interventions to prevent further falls but should have been. She stated that either the MDS Nurse or DON can update the care plan to include new focus areas and interventions after discussion in the morning clinical meeting and did not know why Resident #2&rsquo;s care plan was not revised. The Administrator stated not updating the care plan to include all relevant new information such as interventions put in place to prevent falls, could result in staff not having the needed information to care for the Resident properly.<BR/>Record review of facility policy titled &ldquo;Fall Policy&rdquo;, undated revealed &ldquo;The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as requires&rdquo; and &ldquo;Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall.&rdquo;<BR/>This was determined to be an Immediate Jeopardy (IJ) on 07/11/2025. The Administrator was provided with the IJ template on 07/11/2025 at 10:39 PM. <BR/>On 07/12/2025 the facility provided a plan of removal. The Plan of removal was accepted on 07/12/2025 at 11:33 AM. It is documented as follows:<BR/>The following in-services were initiated by the Regional Compliance nurse and DON on 7/11/25. Any staff member not present or in-serviced on 7/11/25 will not be allowed to assume their duties until in-serviced. <BR/>Direct Staff to include therapy staff.<BR/>1. Implementing interventions to minimize the risk of falls. <BR/>2. Fall Prevention Policy <BR/>3. Reporting all incidents and accidents to the administrator immediately.<BR/>Facility transportation staff was removed from transport duties and counseled by Administrator on 07/11/2025 on Van Driving policy.<BR/>All transportation staff retrained on Incident Reporting Policy to Administrator on 7/11/25 by administrator.<BR/>The medical director was notified of the immediate jeopardy situation on 7/11/25 at 10:30 pm by administrator. <BR/>Ad Hoc QAPI meeting will be held on 7/11/25 to discuss the IJ and review plan of removal. <BR/>Any falls/incidents that occur over the weekend will be reported to the facility administrator and/or DON.<BR/>Monitoring: <BR/>DON and Administrator will review all falls during the morning meeting to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. <BR/>DON and Administrator will review all falls during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. <BR/>Above will be reviewed during the facility monthly QA meeting for no less than 60 days, or until the Administrator determines substantial compliance has been achieved and maintained.<BR/>Incidents involving van transport will be reviewed 5x weekly in morning meeting to determine if there were any incidents. This will be continued for a period of 6 weeks and PRN thereafter as determined by the QAPI committee.<BR/>Verification of the facility&rsquo;s POR for F689 was as follows:<BR/>Record review of an AD Hoc QAPI Contributors signature page dated 07/11/2025 revealed a meeting was held with the Administrator, DON, Medical Director, Social Services, Activity Director and three other employees.<BR/>Record review of an undated, untitled sheet revealed the Medical Director was notified on 07/11/2025 at 11:04 AM of the IJ situation by the Administrator. <BR/>Record review of an Incident/Fall Review Monitoring Tool revealed all falls would be reviewed 5 days per week for 6 weeks.<BR/>Record review of a Falls Review Monitoring Tool revealed the Administrator and the DON would discuss falls and interventions implemented weekly at a SOC (Standard of Care) meeting that was held with the Administrator, DON, and other Interdisciplinary Team members.<BR/>Record review of the QA Monitoring Tool revealed falls and incidents and if interventions were implemented would be reviewed monthly at the QAPI Meetings that will be held on 07/15/2025 and 08/19/2025. <BR/>Record review of the Van Incident Monitoring Tool revealed all incidents involving van transport were reviewed five times a week for 6 weeks by the DON and Administrator. <BR/>Record review of an undated employee list revealed the facility had 89 full time employees and 32 part-time/prn employees for a total of 121 employees.<BR/>Record review of an In-service record log, dated 07/12/2025 revealed all 121 employees had been in-serviced by phone or in person on reporting allegations of abuse/neglect immediately to the administrator; any unsafe conditions must be reported to the administrator immediately; all falls and/or other accidents or unusual occurrences would be reported to the administrator; any unsafe behaviors or incidents that occur on the fan during transport needs to be reported to the administrator and DON immediately; all unsafe behaviors that could lead to a fall must be reported immediately to the administrator; and on the Fall Policy. <BR/>In an interview on 07/12/2025 at 4:23 PM, the Administrator stated the &ldquo;SOC&rdquo; was Standard of Care which was a weekly meeting that was held to discuss resident care.<BR/>Interviews on 07/12/2025 from 4:40 PM to 7:00 PM and 07/13/2025 from 8:30 AM to 4:00 PM with 29 employees out of 121 employees (25 full time employees, 4 prn/part time employees) which consisted of 1 RA (RA W), 2 MA (MA T, MA U), 2 Housekeepers (Housekeeper Q, Housekeeper R), 10 CNAs (CNA L, CNA M, CNA N, CNA O, CNA X, CNA Y, CNA K, CNA BB, CNA AA, CNA Z) 3 of them worked 6 PM to 6 AM shift, 4 LVNs (LVN I, LVN H, LVN J, LVN P) 2 of them worked 6 PM to 6 AM shift), 3 dietary employees (Dietary Aide T, Dietary Supervisor E, and [NAME] S), 1 Activity Director, 1 Van Driver, 2 PTA (PTA EE, PTA CC), 1 OTA (OTA DD) revealed the had received the in-service training as indicated in the POR for F689. All the employees stated they would report any signs of abuse to the Abuse Coordinator who was the Administrator, they had her phone number to contact her. They also stated they would report immediately to the abuse coordinator any falls or unsafe behaviors to the administrator which included any unsafe behaviors when residents were transported in the van. The employees stated they had been in-serviced on the facility&rsquo;s Fall Prevention policy and interventions to minimize falls and provided examples of how that could be done. <BR/>In an interview on 07/13/2025 at 10:41 AM the Van Driver stated she works full time as the van driver; and received training on reporting incidents, on when to pull the van over, on when to report anything to the administrator about unusual behaviors that occurred when a resident was transported, reporting unusual behaviors from residents. Van Driver D said she was also trained to report any falls a resident had to the administrator, the DON and nurse. The Van Driver stated she was also trained to report any signs of abuse or neglect to the administrator immediately. The Van Driver said she received one-on-one training about the fall with Resident #1, was retrained by administrator on transporting residents, and the Administrator rode with her for a whole week in June 2025. Then the administrator rode with her twice a week for four weeks, then the administrator would randomly ride with her. The Van Driver stated she the Administrator was riding with her twice a week for two more weeks. The Van Driver said she would print out daily the calendar of the residents who would be transported; record on the calendar any behaviors from the resident when they were transported and provided the calendar to the administrator at the end of the day. The Van Driver stated she was also in-serviced recently on abuse and neglect; and would report it immediately to the administrator. <BR/>In an interview on 07/13/2025 at 2:03 PM, DON stated they would review in the morning meeting which resident would need an escort when transported to their scheduled appointment. The DON said residents who had falls were reviewed daily in the morning meeting. The DON stated she and the Administrator had in-serviced the employees on Abuse and Neglect, on Falls, who to report to, what to report for abuse or neglect, and fall prevention. The DON stated staff were to report to her or the Administrator if they had witnessed any unsafe behaviors from a resident or when the resident was transported. The DON stated if a resident had a fall, the charge nurse would notify her of the fall. The DON said they would review the falls throughout the day to see how they could be prevented. The DON stated the monitoring would be done with the monitoring tools that were developed and reviewed in the daily morning meeting, the weekly SOC meeting and QAPI meetings. The DON stated they would review which residents need to have an escort or need to have a contracted transport company take a resident to dialysis if needed. The DON said they had an Ad Hoc QAPI meeting on 7/11/2025 with the department heads, the Administrator, the Area Director of Operations; and the Medical Director was informed by the Administrator. The DON said she and the ADON would review the 24-hour summary to see if there were any changes that happened such as falls or behaviors and to see if they were reviewed. The DON stated the resident&rsquo;s dashboard would be reviewed throughout the day for any falls or behaviors that would need to be addressed. The DON said she and the Administrator were reviewing residents who were going to be transported, and it was discussed if the resident needed to have an escort. The DON stated the SOC meeting was held weekly on Fridays, and they would review residents who had a fall or accident to see if any interventions were needed.<BR/>In an interview on 07/13/2025 at 2:23 PM, the Administrator stated the interventions implemented included re-educating all staff on reporting unusual occurrences, and an employee could not return to work unless they received the training. The Administrator said all staff were provided her phone number to contact her to report any abuse or unsafe behaviors. The Administrator stated a monitoring tool was implemented to review all falls in the morning meeting to ensure interventions were implemented and was care planned. The Administrator said the SOC tool would be used weekly to verify the interventions were listed, if the staff knew about the interventions, and would be reviewed at the next QAPI meeting. The Administrator stated a van monitoring tool was implemented to ensure if anything happened during transport was recorded. The Administrator said the monitoring sheet was reviewed daily to determine if a resident needed an escort or need an ambulance to transport them. The Administrator stated the van drivers would turn in the van monitoring tool at the end of the day with notes about if a resident tried to stand up, any issues with their chair, or if they looked weak. The Administrator said the Van Driver was retrained on transporting residents in the van. The Administrator stated after the incident with Resident #1 she rode in the van daily for the first week, then the second week she rode in the van a twice a week. The Administrator stated an Ad Hoc QAPI meeting was held on 07/11/2025 with the department heads and Area Director of Operations. The Administrator said staff were retained about un-safe behaviors to be reported immediately to her or the DON. The Administrator stated when employees see a resident exhibiting behaviors, they were to stay with the resident to make sure they are safe, call for help, then report it to the administrator. The Administrator said they have a clinical care meeting and will follow-up on the entries on the resident&rsquo;s clinical record dashboard for behaviors with instructions for that resident, and the interventions were added to the resident&rsquo;s care plan. The Administrator stated if something happened on the weekend, staff would contact the Administrator. The Administrator said the Van Driver and Activity Director were in-serviced to pull over when a resident did something unsafe in the van and then call her. The Administrator said she a calendar was used with residents who have appointments to determine if a resident needed to have an escort to their appointment. The Administrator stated she and the DON would review all falls to make sure the i

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 2 residents (Residents #1 and #2) reviewed for accidents. 1. The facility failed to identify and address hazards and risk in Resident #1's environment when staff failed to ensure they addressed Resident #1's behavior of unbuckling the seatbelt during transport in the facility van. On 06/13/2025, Resident #1 sustained a fall during van transport, with the seat belt noted to be on the wheelchair but the fastener unlatched, resulting in a laceration to her forehead. 2. The facility failed to identify and address hazards and risk in Resident #2's environment when staff failed to ensure they addressed Resident #2's fall on 06/18/2025. An Immediate Jeopardy (IJ) was identified on 07/11/2025. The IJ template was provided to the facility on [DATE] at 10:39 p.m. While the IJ was removed on 07/13/2025 at 4:20 p.m., the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal. This failure could place residents at risk for accidents injuries, hospitalization and death related to unsafe vehicle transport. The findings included: 1.Record review of Resident #1&rsquo;s admission record dated 07/08/2025 revealed she was a [AGE] year-old woman admitted on [DATE] with re-admission on [DATE], and with diagnoses which included: End-Stage Renal disease (condition where kidneys lose the ability to remove waste and balance fluids in balance requiring dialysis); Syncope (fainting or temporary loss of consciousness) and collapse; Vascular Dementia (impaired cognitive thinking due to constricted blood flow) and Bradycardia (slow heart beat).<BR/>Record review of Resident #1&rsquo;s Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 5, indicating severe cognitive impairment, and was assessed as being dependent for transfers, and had no behavioral symptoms.<BR/>Record review of Resident #1&rsquo;s Care Plan initiated 07/03/2022 revealed a focus area for &ldquo;The resident is risk for falls due to dx [diagnosis] of syncope,&rdquo; and included &ldquo;Resident had action [sic] fall in facility van causing laceration to forehead&rdquo; initiated 07/03/2022 and revised 06/14/2025. There were no interventions listed which addressed the resident&rsquo;s behavior of unbuckling the seat belt and no new interventions for this fall were listed.<BR/>Record review of Resident #1&rsquo;s other focus areas in her Care Plan initiated 07/03/2022, revealed there was no other focus areas for her behavior of trying to stand up during transport or for trying to unbuckle her seatbelt in the facility van during transport.<BR/>Record review of Resident #1&rsquo;s Physician Order Summary Report, dated 07/12/2025, revealed an order initiated on 01/17/2025 for dialysis at 12:05 PM on Monday, Wednesday, and Friday at a local dialysis center.<BR/>Record review of Resident #1&rsquo;s Nurses Notes from 03/11/2025 to 06/12/2025 revealed there was no notation of Resident #1 trying to stand up during transport or for trying to unbuckle her seatbelt in the facility van during transport.<BR/>Record review of Resident #1&rsquo;s Progress Note dated 6/13/2025 at 11:22 a.m. by the DON revealed &ldquo;Resident had a fall. Location: in facility van during transport to dialysis. Cognition/Behavior at Time of Event: Cognitive Impairment. The fall caused a skin tear to above left eyebrow. new/bleeding&hellip;.Administrator received call from Van Driver of resident fall in van. Upon arrival to scene, noted resident on floor of van face down with head partially under 2nd row of seats. Blood noted on floor and on resident&rsquo;s hair. Cream colored emesis (vomit) noted on wc [wheelchair] and unable to check vs [vital signs]. Respirations slow and irregular. 911 called per van driver. Ems arrived and transported to ER&hellip;&rdquo; The MD was notified on 06/13/2025 at 12:02 PM. Resident #1&rsquo;s Responsible Party was notified on 06/13/2025 at 11:52 AM. &ldquo;Interventions in place prior to fall: None, Interventions initiated in response to fall: none.&rdquo;<BR/>Record review of Resident #1&rsquo;s Nurse&rsquo;s Notes dated 06/13/2025 by LVN-H revealed the nurse received a call from the hospital emergency room regarding Resident #1&rsquo;s medication list which was faxed to the hospital and the nurse was informed the resident had another episode of vomiting at the hospital and was intubated (a tube inserted into the mouth and throat to hold open the airway so air can be pushed in and out of the lungs via machine) at that time.<BR/>Record review of Resident #1&rsquo;s Event Nurses&rsquo; Note-Fall, dated 06/13/2025, revealed the resident had an unwitnessed fall in the facility van during transport to dialysis sustaining a skin tear above her left eyebrow. Resident #1&rsquo;s responsible party was notified on 06/13/2025 at 11:52 AM and her physician was notified on 06/13/2025 at 12:02 PM. Under &ldquo;Interventions in place prior to this fall&rdquo; had &ldquo;None of the above&rdquo; was checked. Under &ldquo;Interventions initiated in response to this fall&rdquo; had &ldquo;None of the above&rdquo; checked and no interventions were listed.<BR/>Record review of hospital records dated 6/20/2025 revealed Resident #1 had a CT (Computed tomography &ndash; type of imaging using x-ray techniques to obtain detailed images) of head was completed 06/19/2025 and showed &ldquo;no acute intracranial finding&rdquo;. Further review revealed Resident #1 was treated for and placed on seizure precautions and treated also for sepsis-resolved (condition where the body&rsquo;s responses to infection causes injury to its own tissues and organs), likely secondary to aspiration pneumonia (lung infections caused by inhaling something other than air into your lungs, such as food or vomit), and Paroxysmal Atrial Fibrillation (noted she converted to normal sinus rhythm on 6/16/2025).<BR/>Telephone interview with Family Member #1 on 07/11/2025 at 12:08 p.m. revealed Resident #1 was no longer in hospital and had been moved to a different nursing facility, but was still fighting an infection and very weak. He stated Resident #1 had a history of falls, but expected the facility to know this and take appropriate precautions. He stated he felt the facility should have sent extra staff instead of just the driver to help take care of vulnerable residents.<BR/>During an interview on 07/09/2025 at 3:57 p.m., the Van Driver stated that she loaded Resident #1 in the van on 06/13/2025, leaving facility at 11:16 a.m. and after pulling out onto the road, she heard Resident #1 make a loud noise, and saw in the rear-view mirror that Resident #1 had vomit coming from her mouth. She stated that as she attempted to turn to pull off to the side of road, she saw Resident #1 stiffen up and fall forward out of the wheelchair and land face down on the floor of the van. The Van Driver stated she called the Administrator who told her to call 911. The Van Driver further stated that she had secured Resident #1 securely in her wheelchair into the van with 4 straps that were attached to the L-bar of Resident #1&rsquo;s wheelchair frame, but stated she believed Resident #1 had unbuckled her seatbelt, because she had unbuckled her seatbelt during transport in the past.<BR/>Further interview with the Van Driver on 07/10/2025 at 4:15 p.m. revealed that she stated there were two other prior incidents of Resident #1 removing her seatbelt and trying to stand up in the van. She stated the first incident happened about 2 months prior to the June 13th incident, where Resident #1 took her seatbelt off and she told Resident #1 to keep her seatbelt fastened because she could fall. She stated the second incident happened about 2 weeks prior to the June 13th incident, where Resident #1 attempted to pull herself up to standing by pulling on the seat in front of her during transport. The Van Driver stated she reported one of the incidents to LVN -A, and one incident to the Administrator, who told her to contact therapy to ask what could be done, and therapy told her they could tilt her wheelchair backwards so she couldn&rsquo;t grab things.<BR/>During an interview with LVN-A on 07/10/2025 at 11:44 a.m., she stated that sometime during that first week of June 2025, the Van Driver came to the Nurse&rsquo;s station after returning Resident #1 back to facility from dialysis, and told her, the DON and former ADON, who were all standing at the nurse&rsquo;s station, that Resident #1 had tried to stand up in the van during transport. LVN-A stated she educated Resident #1 about not standing up in the van, that it was dangerous, and she stated Resident #1 denied that she had done that. LVN-A further stated that she did not report the incident to anyone because the DON was standing at the Nurse&rsquo;s station with her when the Van Driver reported the incident and had instructed her to educate Resident #1 on not unbuckling her seatbelt.<BR/>During an interview with the DON on 07/10/2025 at 4:54 p.m., the DON stated she was never made aware of any prior incidents of Resident #1 taking off her seatbelt or trying to stand up out of her wheelchair during van transport. <BR/>Interview on 07/10/2025 at 4:30 p.m. with the Administrator revealed she had inspected the van after the incident and observed vomit on the chest strap when she pulled it out from the retracting device, indicating the chest strap had been in place across Resident #1&rsquo;s chest when she first started to vomit and believed Resident #1 may have pressed down on her abdomen with her hand when she vomited, accidentally pushing on the release button of the seatbelt. When asked about any prior incidents, the Administrator stated that the Van Driver had informed her of an incident where Resident #1 had attempted to slide down out of her wheelchair, could not remember the exact date, but thought it might have been a couple of months prior to the current incident, and that was when she suggested the Van Driver check with therapy to see if wheelchair could be modified. She stated the Van Driver never told her Resident #1 had unbuckled her seatbelt or tried to stand up in van. She stated the Van Driver came back and told her therapy stated the wheelchair could be tilted back slightly, and they agreed that was what they were going to try to do to address the problem. The Administrator further stated that if Resident #1 had intentionally tried to undo her seatbelt or stand up in the van during transport she would expect that to be reported to her, but no one ever had. She stated the team never met to discuss the incident reported to her of Resident #1 trying to slide out of the wheelchair and the intervention they discussed about the therapy assessment of the wheelchair was never care planned but should have been.<BR/>Interview with PT - B on 07/11/2025 at 11:46 a.m. revealed she confirmed a CNA had come down to ask about what could be done about Resident #1 leaning forward in wheelchair and PT-B instructed CNA and Resident #1&rsquo;s family member how to recline the wheelchair. No documentation available as Resident #1 was not on services at this time.<BR/>Interview with the Activity Director on 7/11/2025 at 9:41 a.m. revealed that he also transports residents in the van to recreational activities, but will also transport residents at times to their medical appointments when the primary Van Driver is out sick. He stated the primary Van Driver and he are the only staff who transported residents at the facility. The Activity Director stated he had transported Resident #1 in the van many times and had observed her undo her seatbelt or try to stand up in van during transport several times. The Activity Director further stated he educated Resident #1 not to unbuckle her seat belt, but stated she would get anxious at times and forget. The Activity Director stated he reported this behavior of unbuckling her seatbelt during transport to the primary Van Driver so she could be aware and monitor but did not report the incidents to anyone else.<BR/>During a telephone interview with the Van Driver on 07/11/2025 at 11:54 a.m., she stated that she did not recall the Activity Director ever informing her or warning her about Resident #1&rsquo;s behavior of unbuckling her seatbelt during transport.<BR/>During an interview with the Administrator on 07/11/2025 at 11:46 a.m., the Administrator stated that had she known Resident #1 had incidents of unbuckling her seatbelt in van during transport, she would have assigned an escort to go along with her during transport or contracted with local company for ambulance transportation services for Resident #1.<BR/>2. Record review of Resident #2&rsquo;s admission record dated 07/08/2025 revealed she was an [AGE] year-old woman admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: Vascular Dementia-Severe (impaired cognitive thinking due to constricted blood flow), Schizoaffective Disorder (a mental health condition that includes both symptoms of schizophrenia, such as hallucinations and delusion and mood disorders), and Poly- osteoarthritis (condition where cartilage in multiple joints wears down causing bones to rub against each other leading to pain and stiffness).<BR/>Record review of Resident #2&rsquo;s Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment and she was assessed as needing substantial/maximal assistance for transfers.<BR/>Record review of Resident #2&rsquo;s Nurses Notes dated 06/18/2025 at 6:06 p.m. by LVN-I, revealed the resident had an unwitnessed fall from the low bed in her room onto the floor next to the bed sustaining a skin tear that was 2cm. to her right hand, and complaining of head, neck, right arm and right leg pain. Under &ldquo;Interventions in place prior to this fall&rdquo; had &ldquo;Floor mat, Low bed.&rdquo; Under &ldquo;Interventions initiated in response to this fall&rdquo; had &ldquo;Floor mat, Low bed, neuro-checks.&rdquo;<BR/>Record review of Resident #2&rsquo;s Nurses Notes dated 06/18/2025 at 10:55 p.m. by LVN-I revealed resident had returned from the ER with a diagnosis of right knee patella (kneecap) fracture, with knee immobilizer in place.<BR/>Record review of Resident #2&rsquo;s Care Plan initiated 07/03/2022 for &ldquo;The resident is risk for falls r/t Poor communication/comprehension&hellip;.Resident H/O fall out of bed due to self positions to the point of being on the edge&rdquo; initiated 07/03/2022 and last revised 07/07/2023, revealed it was not revised to address the resident&rsquo;s actual fall on 06/18/2025 and no new interventions were listed.<BR/>Record review of Resident #2&rsquo;s other focus areas of Care Plan initiated 07/03/2022 revealed there was no care plan or new interventions which addressed her fall on 06/18/2025.<BR/>Interview with CNA-K on 07/09/2025 at 1:52 p.m. revealed she stated she had completed check and change with Resident #2 about an hour before her fall and stated she put the bed in the lowest position, and the head of bed was just slightly elevated. Then as she was walking down hall with LVN-H to leave at end of her shift, she heard Resident #2 mumbling, looked in her room and saw her on the floor, face down. She stated she also observed the bed was not in the lowest position, and the head of the bed was straight up at 90-degree angle. The fall mat was in place by her bed.<BR/>Interview with LVN-H on 07/10/2025 at 10:40 a.m. revealed she works day shift and was getting ready to leave for the day when she heard Resident #2 talking from her room, and when she went to check on her, found Resident #2 lying on the mat on the floor next to her bed. LVN-H stated she observed that Resident #2&rsquo;s head of bed was up to the full 90 degrees, and the bed was not in lowest position, and stated that Resident #2 had been observed to work the bed controller in the past. LVN H stated she believed Resident #2 had accidentally changed position of bed as she manipulated the bed controller. She stated they always make sure her call light was within reach but does not believe she understands its purpose as Resident #2 will push the button on the call light, but when they answer, she cannot say what she needed or why she activated the light.<BR/>Interview on 07/10/2025 at 5:59 p.m. with LVN-I revealed she works night shift and had just come on duty on 6/18/2025 when she was called into Resident #2&rsquo;s room after she had been found on the floor. She stated Resident #2 was lying on the mat on the floor next to her bed, and that the mat had been in place. However, she noted the bed was not in its lowest position and the head of the bed was in an upright position and stated Resident #2 will take the bed controller and randomly press buttons on it, which can move her bed out of the lowest position. LVN-I stated they have done interventions to keep her from falling again, such as moving the bed controller to the end of the bed to keep her from moving the bed up higher and moving things away from her bed that she can grab, like the drawers out of her dresser.<BR/>Interview with the DON on 07/11/2025 at 8:28 a.m. revealed all acute incidents such as falls are discussed in the morning team meetings and the team discusses actions/interventions needed. She did not remember specifically what was discussed regarding Resident #2&rsquo;s fall on 6/18/2025. The DON stated that the MDS Nurse is responsible for revising the care plan per the quarterly and annual MDS assessments, and the DON and ADONs are responsible for updating care plans for acute changes. The DON did not know why there was no care plan revision done following Resident #2&rsquo;s fall on 06/18/2025 and -stated that could result in staff not being aware of the care needs of the residents, and could result in acute events such as falls happening again.<BR/>During an interview with the Administrator on 07/11/2025 at 10:16 a.m., the Administrator stated that Resident #2&rsquo;s fall on 06/18/2025 was addressed by the team in the morning clinical meeting to review causes of the fall and devise new interventions to prevent other falls in future. The Administrator stated that interventions were put into place, including moving furniture to create a safe space, and moving the bed controller away from Resident #2&rsquo;s reach, so that she could not move the bed out of the recommended low bed position. The Administrator further stated however, that Resident #2&rsquo;s care plan was not revised to include these new interventions to prevent further falls but should have been. She stated that either the MDS Nurse or DON can update the care plan to include new focus areas and interventions after discussion in the morning clinical meeting and did not know why Resident #2&rsquo;s care plan was not revised. The Administrator stated not updating the care plan to include all relevant new information such as interventions put in place to prevent falls, could result in staff not having the needed information to care for the Resident properly.<BR/>Record review of facility policy titled &ldquo;Fall Policy&rdquo;, undated revealed &ldquo;The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as requires&rdquo; and &ldquo;Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall.&rdquo;<BR/>This was determined to be an Immediate Jeopardy (IJ) on 07/11/2025. The Administrator was provided with the IJ template on 07/11/2025 at 10:39 PM. <BR/>On 07/12/2025 the facility provided a plan of removal. The Plan of removal was accepted on 07/12/2025 at 11:33 AM. It is documented as follows:<BR/>The following in-services were initiated by the Regional Compliance nurse and DON on 7/11/25. Any staff member not present or in-serviced on 7/11/25 will not be allowed to assume their duties until in-serviced. <BR/>Direct Staff to include therapy staff.<BR/>1. Implementing interventions to minimize the risk of falls. <BR/>2. Fall Prevention Policy <BR/>3. Reporting all incidents and accidents to the administrator immediately.<BR/>Facility transportation staff was removed from transport duties and counseled by Administrator on 07/11/2025 on Van Driving policy.<BR/>All transportation staff retrained on Incident Reporting Policy to Administrator on 7/11/25 by administrator.<BR/>The medical director was notified of the immediate jeopardy situation on 7/11/25 at 10:30 pm by administrator. <BR/>Ad Hoc QAPI meeting will be held on 7/11/25 to discuss the IJ and review plan of removal. <BR/>Any falls/incidents that occur over the weekend will be reported to the facility administrator and/or DON.<BR/>Monitoring: <BR/>DON and Administrator will review all falls during the morning meeting to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. <BR/>DON and Administrator will review all falls during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. <BR/>Above will be reviewed during the facility monthly QA meeting for no less than 60 days, or until the Administrator determines substantial compliance has been achieved and maintained.<BR/>Incidents involving van transport will be reviewed 5x weekly in morning meeting to determine if there were any incidents. This will be continued for a period of 6 weeks and PRN thereafter as determined by the QAPI committee.<BR/>Verification of the facility&rsquo;s POR for F689 was as follows:<BR/>Record review of an AD Hoc QAPI Contributors signature page dated 07/11/2025 revealed a meeting was held with the Administrator, DON, Medical Director, Social Services, Activity Director and three other employees.<BR/>Record review of an undated, untitled sheet revealed the Medical Director was notified on 07/11/2025 at 11:04 AM of the IJ situation by the Administrator. <BR/>Record review of an Incident/Fall Review Monitoring Tool revealed all falls would be reviewed 5 days per week for 6 weeks.<BR/>Record review of a Falls Review Monitoring Tool revealed the Administrator and the DON would discuss falls and interventions implemented weekly at a SOC (Standard of Care) meeting that was held with the Administrator, DON, and other Interdisciplinary Team members.<BR/>Record review of the QA Monitoring Tool revealed falls and incidents and if interventions were implemented would be reviewed monthly at the QAPI Meetings that will be held on 07/15/2025 and 08/19/2025. <BR/>Record review of the Van Incident Monitoring Tool revealed all incidents involving van transport were reviewed five times a week for 6 weeks by the DON and Administrator. <BR/>Record review of an undated employee list revealed the facility had 89 full time employees and 32 part-time/prn employees for a total of 121 employees.<BR/>Record review of an In-service record log, dated 07/12/2025 revealed all 121 employees had been in-serviced by phone or in person on reporting allegations of abuse/neglect immediately to the administrator; any unsafe conditions must be reported to the administrator immediately; all falls and/or other accidents or unusual occurrences would be reported to the administrator; any unsafe behaviors or incidents that occur on the fan during transport needs to be reported to the administrator and DON immediately; all unsafe behaviors that could lead to a fall must be reported immediately to the administrator; and on the Fall Policy. <BR/>In an interview on 07/12/2025 at 4:23 PM, the Administrator stated the &ldquo;SOC&rdquo; was Standard of Care which was a weekly meeting that was held to discuss resident care.<BR/>Interviews on 07/12/2025 from 4:40 PM to 7:00 PM and 07/13/2025 from 8:30 AM to 4:00 PM with 29 employees out of 121 employees (25 full time employees, 4 prn/part time employees) which consisted of 1 RA (RA W), 2 MA (MA T, MA U), 2 Housekeepers (Housekeeper Q, Housekeeper R), 10 CNAs (CNA L, CNA M, CNA N, CNA O, CNA X, CNA Y, CNA K, CNA BB, CNA AA, CNA Z) 3 of them worked 6 PM to 6 AM shift, 4 LVNs (LVN I, LVN H, LVN J, LVN P) 2 of them worked 6 PM to 6 AM shift), 3 dietary employees (Dietary Aide T, Dietary Supervisor E, and [NAME] S), 1 Activity Director, 1 Van Driver, 2 PTA (PTA EE, PTA CC), 1 OTA (OTA DD) revealed the had received the in-service training as indicated in the POR for F689. All the employees stated they would report any signs of abuse to the Abuse Coordinator who was the Administrator, they had her phone number to contact her. They also stated they would report immediately to the abuse coordinator any falls or unsafe behaviors to the administrator which included any unsafe behaviors when residents were transported in the van. The employees stated they had been in-serviced on the facility&rsquo;s Fall Prevention policy and interventions to minimize falls and provided examples of how that could be done. <BR/>In an interview on 07/13/2025 at 10:41 AM the Van Driver stated she works full time as the van driver; and received training on reporting incidents, on when to pull the van over, on when to report anything to the administrator about unusual behaviors that occurred when a resident was transported, reporting unusual behaviors from residents. Van Driver D said she was also trained to report any falls a resident had to the administrator, the DON and nurse. The Van Driver stated she was also trained to report any signs of abuse or neglect to the administrator immediately. The Van Driver said she received one-on-one training about the fall with Resident #1, was retrained by administrator on transporting residents, and the Administrator rode with her for a whole week in June 2025. Then the administrator rode with her twice a week for four weeks, then the administrator would randomly ride with her. The Van Driver stated she the Administrator was riding with her twice a week for two more weeks. The Van Driver said she would print out daily the calendar of the residents who would be transported; record on the calendar any behaviors from the resident when they were transported and provided the calendar to the administrator at the end of the day. The Van Driver stated she was also in-serviced recently on abuse and neglect; and would report it immediately to the administrator. <BR/>In an interview on 07/13/2025 at 2:03 PM, DON stated they would review in the morning meeting which resident would need an escort when transported to their scheduled appointment. The DON said residents who had falls were reviewed daily in the morning meeting. The DON stated she and the Administrator had in-serviced the employees on Abuse and Neglect, on Falls, who to report to, what to report for abuse or neglect, and fall prevention. The DON stated staff were to report to her or the Administrator if they had witnessed any unsafe behaviors from a resident or when the resident was transported. The DON stated if a resident had a fall, the charge nurse would notify her of the fall. The DON said they would review the falls throughout the day to see how they could be prevented. The DON stated the monitoring would be done with the monitoring tools that were developed and reviewed in the daily morning meeting, the weekly SOC meeting and QAPI meetings. The DON stated they would review which residents need to have an escort or need to have a contracted transport company take a resident to dialysis if needed. The DON said they had an Ad Hoc QAPI meeting on 7/11/2025 with the department heads, the Administrator, the Area Director of Operations; and the Medical Director was informed by the Administrator. The DON said she and the ADON would review the 24-hour summary to see if there were any changes that happened such as falls or behaviors and to see if they were reviewed. The DON stated the resident&rsquo;s dashboard would be reviewed throughout the day for any falls or behaviors that would need to be addressed. The DON said she and the Administrator were reviewing residents who were going to be transported, and it was discussed if the resident needed to have an escort. The DON stated the SOC meeting was held weekly on Fridays, and they would review residents who had a fall or accident to see if any interventions were needed.<BR/>In an interview on 07/13/2025 at 2:23 PM, the Administrator stated the interventions implemented included re-educating all staff on reporting unusual occurrences, and an employee could not return to work unless they received the training. The Administrator said all staff were provided her phone number to contact her to report any abuse or unsafe behaviors. The Administrator stated a monitoring tool was implemented to review all falls in the morning meeting to ensure interventions were implemented and was care planned. The Administrator said the SOC tool would be used weekly to verify the interventions were listed, if the staff knew about the interventions, and would be reviewed at the next QAPI meeting. The Administrator stated a van monitoring tool was implemented to ensure if anything happened during transport was recorded. The Administrator said the monitoring sheet was reviewed daily to determine if a resident needed an escort or need an ambulance to transport them. The Administrator stated the van drivers would turn in the van monitoring tool at the end of the day with notes about if a resident tried to stand up, any issues with their chair, or if they looked weak. The Administrator said the Van Driver was retrained on transporting residents in the van. The Administrator stated after the incident with Resident #1 she rode in the van daily for the first week, then the second week she rode in the van a twice a week. The Administrator stated an Ad Hoc QAPI meeting was held on 07/11/2025 with the department heads and Area Director of Operations. The Administrator said staff were retained about un-safe behaviors to be reported immediately to her or the DON. The Administrator stated when employees see a resident exhibiting behaviors, they were to stay with the resident to make sure they are safe, call for help, then report it to the administrator. The Administrator said they have a clinical care meeting and will follow-up on the entries on the resident&rsquo;s clinical record dashboard for behaviors with instructions for that resident, and the interventions were added to the resident&rsquo;s care plan. The Administrator stated if something happened on the weekend, staff would contact the Administrator. The Administrator said the Van Driver and Activity Director were in-serviced to pull over when a resident did something unsafe in the van and then call her. The Administrator said she a calendar was used with residents who have appointments to determine if a resident needed to have an escort to their appointment. The Administrator stated she and the DON would review all falls to make sure the i

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident was treated with respect, dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 3 residents (Resident #5) reviewed for dignity, in that:<BR/>The facility failed to ensure Resident #5 was not left exposed during wound care on 4/24/24.<BR/>This failure could place residents at risk of poor self-esteem and decreased self-worth and quality of life. <BR/>Findings include:<BR/>Record review of Resident #5's admission Record, dated 4/20/24, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, and Depression. <BR/>Record review of Resident #5's quarterly MDS assessment, dated 2/26/24, revealed the resident had a BIMS score of 00, which indicated severe cognitive impairment.<BR/>Record review of Resident #5's Care Plan, revised 4/20/24, revealed: The resident has a pressure ulcer or potential for pressure ulcer development . Administer wound care as ordered .<BR/>Record review of Resident #5's Order Summary Report, dated 4/26/24, revealed an order for wound care as follows: Cleanse stage IV sacral wound with vashe (Wound Cleanser). Apply collagen and calcium alginate with silver to wound bed. Paint peri-wound with skin prep. Secure with silicone dressing QD and PRN every day shift for wound care.<BR/>Observation of wound care to the sacrum for Resident #5 on 4/24/24 at 7:12 AM revealed LVN C approached Resident #5 and explained the procedure. Further observation revealed after removing the resident's dressing, LVN C walked away from Resident #15, leaving the resident's buttocks and sacral wound exposed, to retrieve the trash can. LVN C returned with the trash can and continued with the treatment.<BR/>During an attempted interview on 4/27/24 at 12:53 PM, Resident #5 did not respond to investigator's questions. <BR/>During an interview on 4/27/24 at 1:45 PM, LVN D stated Resident #5 was not supposed to be left exposed during wound care. LVN D further stated the resident should have been covered and given privacy during care. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated she expected nurses to provide privacy during wound care to preserve the resident's privacy and dignity. <BR/>Record review of the facility's policy, titled, Resident Rights, revised 11/28/16, reflected: The resident has a right to a dignified existence . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life . The facility must protect and promote the rights of the resident . Respect and dignity -The resident has a right to be treated with respect and dignity .Privacy and confidentiality -The resident has a right to personal privacy .1. Personal privacy includes accommodations, medical treatment . personal care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodations of residents needs for 2 of 2 residents (Resident #5 and Resident #15) reviewed for accommodations of needs, in that.<BR/>The facility failed to ensure Resident #5, and Resident #15 were able to press the call light when assistance was needed.<BR/>This deficient practice could place residents at risk of not receiving care or attention when needed.<BR/>Findings included:<BR/>Record review of Resident #5's admission Record, dated 4/20/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, Muscle Weakness, Abnormal Posture, Muscle Wasting and Atrophy (decrease in size or wasting away of a body part or tissue), Pain, and Depression. <BR/>Record review of Resident #5's MDS assessment, dated 2/26/24, revealed the resident had a BIMS score of 00, suggesting severe cognitive impairment. Further review of this assessment revealed Resident #15 functional limitation in range of motion to bilateral upper and lower extremities, was dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for all self-care and dependent for mobility.<BR/>Record review of Resident #5's Care Plan, dated 1/24/23, revealed the following focus area last revised on 6/21/23: The resident is at risk for falls .Interventions .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed .The resident needs a safe environment with .a working and reachable call light . Further review of this document revealed the following focus area last revised on 11/4/23: Resident has a communication problem r/t to cog/comm deficit, such as expressing words, emotions, spontaneous speech and needs time to communicate basic needs .Goal: Resident will be able to make basic needs known by allowing time for her to express herself and emotions on a daily basis .Interventions .Ensure/provide a safe environment: Call light in reach .Monitor effectiveness of communication strategies and assistive devices .<BR/>During observation and interview on 4/20/24 at 6:23 pm, Resident #5 was seen lying in bed with family at bedside. Resident #5 was awake, alert, and her upper limbs were contracted across her chest. Interview with resident was attempted but answers were unintelligible. Resident #5 slightly moved left hand but was unable to press call light when asked by the investigator to press the button. Resident #5's family member said she was unable to press the call light herself and believed the facility staff were aware of this. <BR/>During an interview on 4/22/24 at 11:28 am, LVN D said Resident #5 was not able to press the call light. <BR/>During an interview on 4/22/24 at 12:10 pm, CNA D said Resident #5 was not able to press the call light button. CNA D further stated that Resident #5 was checked on and repositioned every two hours.<BR/>During an interview on 4/27/24 at 12:47 pm, LVN A said she did not believe Resident #5, cognitively and physically, was able to press the call light. <BR/>Record review of Resident #15's admission Record dated 4/23/24 revealed the resident was re-admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), COPD (lung diseases that block airflow and make it difficult to breathe) , Cognitive Communication Deficit, Dysphagia (difficulty swallowing) , Functional Quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition ) , Pressure ulcer of sacral region Stage 4, Depression and Anxiety. <BR/>Record review of Resident #15's MDS assessment dated [DATE] revealed a BIMS score of 5, suggesting severe cognitive impairment. Further review of this assessment revealed Resident #15 functional limitation in range of motion to bilateral upper and lower extremities; was dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for all self-care and Dependent for mobility.<BR/>Record review of Resident #15's Care Plan, dated 3/8/23, revealed the following focus area last revised on 9/27/23: The resident is at risk for falls r/t recent admit to hospital and now with increased weakness and decreased mobility skills .Interventions .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Further review of this document revealed the following focus area last revised on 4/11/23: The resident has a communication problem r/t she is hared [sic] of hearing and speaker must adjust tone to be heard .Goal: The resident will be able to make basic needs known by on a daily basis .Interventions .Ensure/provide a safe environment: Call light in reach .Monitor effectiveness of communication strategies and assistive devices .<BR/>Observation and atteBased 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 residents needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 11 residents (Resident #5 and Resident #15) reviewed for accommodations of needs.<BR/>The facility failed to ensure Resident #5 and Resident #15 were able to press the call light when assistance was needed.<BR/>This deficient practice could place residents at risk of not receiving care or attention when needed.<BR/>Findings include:<BR/>1. Record review of Resident #5's admission Record, dated 4/20/24, reflected the resident was admitted to the facility on [DATE]. Resident #5 had diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, Muscle Weakness, Abnormal Posture, Muscle Wasting and Atrophy (decrease in size or wasting away of a body part or tissue), Pain, and Depression. <BR/>Record review of Resident #5's quarterly MDS assessment, dated 2/26/24, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Resident #5 functional limitation in range of motion to bilateral upper and lower extremities, was dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for all self-care and dependent for mobility.<BR/>Record review of Resident #5's Care Plan, dated 1/24/23, reflected the following focus area last revised on 6/21/23: The resident is at risk for falls .Interventions .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed .The resident needs a safe environment with .a working and reachable call light . Further review of this document revealed the following focus area last revised on 11/4/23: Resident has a communication problem r/t to cog/comm deficit, such as expressing words, emotions, spontaneous speech and needs time to communicate basic needs .Goal: Resident will be able to make basic needs known by allowing time for her to express herself and emotions on a daily basis .Interventions .Ensure/provide a safe environment: Call light in reach .Monitor effectiveness of communication strategies and assistive devices <BR/>During observation and interview on 4/20/24 at 6:23 PM, Resident #5 was seen lying in bed with family at the bedside. Resident #5 was awake, alert and her upper limbs were contracted across her chest. Interview with the resident was attempted but answers were unintelligible. Resident #5 slightly moved their left hand but was unable to press the call light when asked by the State Surveyor to press the button. Resident #5's family member said she was unable to press the push button call light herself and believed the facility staff were aware of this. Resident #5's family member further stated it would have been better for the resident to have a flat call light. <BR/>During an interview on 4/22/24 at 11:28 AM, LVN D said Resident #5 was not able to press the push button call light. LVN D further stated a soft call light would have been better for Resident #5 was but did the facility did not have any. <BR/>During an interview on 4/22/24 at 12:10 PM, CNA D said Resident #5 was not able to press the call light button. CNA D further stated Resident #5 was checked on and repositioned every two hours.<BR/>During an interview on 4/27/24 at 12:47 PM, LVN A said she did not believe Resident #5, cognitively and physically, was able to press the call light. <BR/>2. Record review of Resident #15's admission Record, dated 4/23/24, reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), COPD (lung diseases that block airflow and make it difficult to breathe) , Cognitive Communication Deficit, Dysphagia (difficulty swallowing) , Functional Quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition ) , Pressure ulcer of sacral region Stage 4, Depression and Anxiety. <BR/>Record review of Resident #15's quarterly MDS assessment, dated 3/15/24, reflected a BIMS score of 5, which indicated severe cognitive impairment. Resident #15's functional limitation in range of motion to bilateral upper and lower extremities; was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers was required for the resident to complete the activity) for all self-care and dependent for mobility.<BR/>Record review of Resident #15's Care Plan, dated 3/8/23, reflected the following focus area last revised on 9/27/23, reflected: The resident is at risk for falls r/t recent admit to hospital and now with increased weakness and decreased mobility skills .Interventions .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Further review of this document revealed the following focus area last revised on 4/11/23: The resident has a communication problem r/t she is hared [sic] of hearing and speaker must adjust tone to be heard .Goal: The resident will be able to make basic needs known by on a daily basis .Interventions .Ensure/provide a safe environment: Call light in reach .Monitor effectiveness of communication strategies and assistive devices <BR/>Observation and attempted interview on 4/25/24 at 5:24 PM revealed Resident #15 was seen lying in bed. She was awake, alert, and her arms were crossed across her chest, right arm appeared contracted across her chest and left hand was observed with severe edema (swelling) and appeared to have limited range of motion. Interview with the resident was attempted but Resident #15 did not respond to questions. Resident #15 was unable to press the call light when asked. <BR/>During an interview on 4/27/24 at 12:47 PM, LVN A said all staff should have been checking for residents' ability to press the call light button. LVN A further stated if a resident was unable to press the push button call light button, they were given a soft call light (a special device used for residents with limited ROM) they could press when assistance was needed. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON said interventions for Resident #5 and Resident #15 included: rounding every 2 hours, turning every 2 hours and CNAs were sent to check on the residents more often because they had a higher acuity and needed more assistance than others. The DON said Resident #5 and Resident #15 were able to press the call light button but refused to do so. <BR/>Record review of the facility's policy, titled Resident Rights, revised 11/28/16, reflected: . Respect and dignity - 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs .mpted interview on 4/25/24 at 5:24 pm revealed Resident #15 was seen lying in bed. She was awake, alert, and her arms were crossed across her chest, right arm appeared contracted across her chest and left hand was observed with severe edema and appeared to have limited range of motion. Interview with resident was attempted but Resident #15 did not respond to questions. Resident #15 was unable to press the call light when asked. <BR/>During an interview on 4/27/24 at 12:47 pm, LVN A said all staff should have been checking for residents' ability to press the call light button. LVN A further stated that if a resident was unable to press the call light button, they were given a soft call light (a special device used for residents with limited ROM). <BR/>During an interview on 4/27/24 at 6:32 pm, the DON said she had not evaluated Resident #5's and Resident #15's ability to press the call light button. She added that interventions for Resident #5 and Resident #15 included: rounding every 2 hours, turning every 2 hours and CNAs were sent to check on the residents more often because they have a higher acuity and need more assistance than others. <BR/>Record review of the facility's policy, titled, Resident Rights, revised 11/28/16, revealed: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality . The facility must provide equal access to quality care regardless of diagnosis, severity of condition . Planning and implementing care - d. The right to receive the services and/or items included in the plan of care .3. The planning process must-- b. Include an assessment of the resident's strengths and needs . Respect and dignity - 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the a comprehensive care plan was developed within seven days of the comprehensive assessment and review and revise the care plan after each assessment for 1 of 12 residents (Resident #15) reviewed for care plans. <BR/>The facility failed to ensure Resident #15's care plan was revised to reflect edema to left hand with elevation. <BR/>These failures could place residents at risk of current needs not being met. <BR/>Findings included:<BR/>Record review of Resident #15's admission Record, dated 4/23/24, reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), COPD (lung diseases that block airflow and make it difficult to breathe) , Cognitive Communication Deficit, Dysphagia (difficulty swallowing) , Functional Quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition ) , Pressure ulcer of sacral region Stage 4, Depression and Anxiety. <BR/>Record review of Resident #15's quarterly MDS assessment, dated 3/15/24, reflected a BIMS score of 5, which indicated severe cognitive impairment. Resident #15's functional limitation in range of motion to bilateral upper and lower extremities; was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) for all self-care and Dependent for mobility.<BR/>Record review of Resident #15's Progress Notes reflected:<BR/>Effective Date: 03/11/2024 20:08 [8:08 pm] .Note Text: resident has 3+ edema to left arm no warmth or redness noted VS within normal limits informed NP .orders to elevate arm .Author: [LVN H]<BR/>Effective Date: 03/13/2024 16:03 [4:03 pm] .Note Text: New order per [NP] Xray to left hand .due to swelling .Author: [ADON A]<BR/>Effective Date: 03/14/2024 12:52 [12:52 pm] .Note Text .New orders received to start keflex 500 mg po bid x 10 days for cellulitis, keep left hand elevated on pillows .Author: [LVN C]<BR/>Effective Date: 04/09/2024 09:20 [9:20 am] .Note Text: Left hand swollen .Author: [LVN E]<BR/>Record review of Resident #15's Care Plan last reviewed 3/29/24, did not address edema and elevation of left arm. <BR/>Record review of Resident #15's Order Summary Report, dated 4/26/24, reflected: elevate left arm, dated 3/11/24. <BR/>During an interview on 4/27/24 at 12:47 PM, LVN A stated care plans were completed and updated by herself and RN A (MDS Coordinators). LVN A further stated care plans were completed quarterly when the MDS assessment was completed and PRN if there were changes in condition, services and/or needs. LVN A stated care plans were updated as soon as possible. LVN A further stated the facility had morning meetings and if changes were reported, she tried to update the appropriate care plans during the meeting. LVN A stated the facility also had daily nursing meetings with the DON, ADONs, Administrator and an the MDS nurse and standard of care meetings. LVN A stated she knew Resident #15's hand was swollen and when she saw it top of her stomach, she assumed it was elevated. LVN A further stated she was not aware Resident #15 had an order for her left arm to be elevated. LVN A stated she was not going to say whether or not Resident #15's left arm edema should have been care planned because the facility's care plans were liberalized/generalized. LVN A further stated yes, it should have been care planned. LVN A stated the left arm edema and elevation for Resident #15 was not care planned, she further stated she did not know why it had not been care planned. <BR/>During interview on 4/27/24 at 2:17 PM, RN A stated the nurses on working on the floor were responsible for updating care plans with acute changes to the resident's conditions. RN A further stated the facility had a morning meeting every day and changes to the resident condition/orders were shared at this meeting. RN A stated she and LVN A were mainly responsible for admissions assessments, quarterly assessments and care plans. RN A further stated the MDS Coordinators (LVN A and RN A) updated care plans, but care plans were updated for acute changes in condition by the floor nurses. RN A stated updates were done when changes happened, and added there was not a timeframe, but the goal was to update the care plans immediately. RN A further stated she was not aware Resident #15's edema to left arm and that her care plan had not been updated to reflect the edema and elevation to her left arm, stating the floor nurse should have updated Resident #15's care plan. RN A stated this change should have been shared in the morning meeting, and she did not remember the edema/elevation to Resident #15's left arm being discussed in the morning meetings. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated she expected care plans to be updated the day the change occurred. The DON stated the MDS, and charge nurses were responsible for updating care plans quarterly and when there were changes to orders. <BR/>Record review of the facility's, undated, policy, titled Comprehensive Care Planning, read: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life .The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented .revised based on changing goals, preferences and needs of the resident and in response to current interventions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #15) reviewed for pain management. <BR/>The facility failed to adequately assess and treat Resident #15's pain.<BR/>This failure could place residents at risk for unnecessary pain, discomfort and decreased quality of life.<BR/>Findings include:<BR/>Record review of Resident #15's admission Record, dated 4/23/24, reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning), Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), cognitive communication deficit, Pressure ulcer of sacral region Stage 4 and Anxiety. <BR/>Record review of Resident #15's quarterly MDS assessment, dated 2/13/24, reflected a BIMS score of 99, which indicated the resident was unable to complete the interview. Resident #15 had an unhealed Stage 4 pressure ulcer present upon admission/entry or re-entry and was taking an Opioid. <BR/>Record review of Resident #15's quarterly MDS assessment, dated 3/15/24, reflected a BIMS score of 5, which indicated severe cognitive impairment. Resident #15 received PRN medications or was offered and declined and had an unhealed Stage 4 pressure ulcer present upon admission/entry or re-entry. <BR/>Record review of Resident #15's Care Plan, reviewed 3/29/24, reflected: The resident has a pressure ulcer .1. Stage IV left gluteal wound- present on admission. 2. Excoriation to peri-rectal area and inner thighs with treatment in place .Observe for s/s of c/o pain and medicate with pain medication as ordered <BR/>Record review of Resident #15's Weekly Ulcer Assessment, dated 4/23/24, for the resident's left gluteal fold stage IV pressure ulcer reflected there was no pain associated with this wound. <BR/>Record review of Resident #15's Order Summary Report, dated 4/26/24, reflected an order for wound care as follows: Cleanse stage IV left gluteal wound with hibiclens, rinse with normal saline Pat dry with 4X4 gauze. Apply collagen/silver then hydrofera blue to wound bed. Skin prep peri-wound and Cover with silicone dressing QOD and PRN. one time a day every Tue, Thu, Sat for Wound healing. Further review reflected an order, dated 3/7/23, HYDROcodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for PAIN .Give 2 Tablets to Equal 10-650MG, the date discontinued was not listed. <BR/>Record review of Resident #15's Progress Notes reflected an entry, dated 3/8/24, which read: Note Text .NP here on rounds and orders were obtained to DC Norco d/t no use in last 60 days.<BR/>Record review of Resident #15's Order Summary, dated 4/26/24, revealed Resident #15 did not have an order for pain medication. <BR/>Record review of Resident #15's orders reflected an order, dated 4/27/24 at 9:06 AM, for Tylenol Oral Tablet 325 MG, Give 2 tablet by mouth every 6 hours as needed for pain.<BR/>Observation of wound care for Resident #15 on 4/26/24 at 9:59 AM revealed LVN C approached the resident and informed her she would be providing wound care to the resident's left gluteal area. Further observation revealed LVN C did not assess the resident's pain prior to the start of the wound care procedure. During the procedure, while cleaning Resident #15's left gluteal area wound, the resident yelled, [NAME], [NAME], [NAME], and, hurry up. LVN C continued to provide wound care to Resident #15's left gluteal area and did not ask the resident if she had pain. LVN C did not complete a pain assessment during any part of the procedure. <BR/>During an observation of wound care for Resident #15 on 4/27/24 at 9:38 AM revealed RN B approached the resident and informed the resident she would be providing wound care to the resident's left gluteal area. Further observation revealed RN B did not assess the resident's pain prior to the wound care procedure. During the procedure, while cleaning Resident #15's left gluteal area wound, the resident yelled, ou, ou, it hurts. RN B continued to provide wound care to the resident's left gluteal area and did not ask the resident if she had pain, but said she was almost done. RN B did not complete a pain assessment during any part of the procedure. <BR/>During an interview with LVN C on 4/24/24 at 9:20 AM, LVN C stated she provided wound care for the facility and the floor nurses provided wound care in her absence. LVN C stated she was responsible for weekly ulcer assessments, and further stated she documented wound details on the residents' weekly ulcer assessments every Monday. LVN C stated she started the wound care position about nine months ago, and further stated she had not received training or skills check-off while at the facility. <BR/>During an interview with LVN C on 4/26/24 at 10:14 AM, LVN C stated Resident #15 did not have any medications ordered for pain. <BR/>During an interview with RN B on 4/27/24 at 10:14 AM, RN B stated Resident #15 had Acetaminophen 325 mg X2 ordered for pain, which was administered at 9:15 AM. <BR/>During an interview with LVN C on 4/27/24 at 2:09 PM, LVN C stated Resident #15 was usually asked about pain prior to wound care and if the resident had pain, Tylenol was administered. LVN C stated she thought Resident #15 had an order for Tylenol PRN but did not have an order for pain medication during wound care. <BR/>During an interview with the DON on 4/27/24 at 6:32 PM, the DON stated she was unsure if Resident #15 was assessed for pain management, and further stated all residents with pressure ulcers usually had something ordered for pain. The DON stated she expected nurses to follow wound care orders, infection control practices and provide privacy. <BR/>Record review of the facility's, undated, policy, titled Dressing Change Checklist, reflected, Verifies Treatment: . Determines need to pre-medicate for pain. If necessary, verify pain medication order and allow appropriate time for medication to be effective <BR/>Record review of the facility's policy, titled, Pain Management, Assessment Scale, revised 05/25/2016, reflected .Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility . Procedure 1. Assess resident's physical symptoms of pain, physical complaints .14. The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plans will be maintained for the management of the resident's pain

Based on observation, interview and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 6 out of 23 days (4/3/24, 4/4/24, 4/8/24, 4/9/24, 4/14/24, and 4/18/24) reviewed for sufficient nursing staff.<BR/>The facility failed to have sufficient staff available to provide resident care on from 6:00 PM - 6:00 AM on 4/3/24, 4/4/24, 4/8/24, 4/9/24, 4/14/24 and 4/18/24.<BR/>This failure could put residents at risk of not receiving necessary care to maintain their highest practicable physical, mental and psychosocial wellbeing.<BR/>Findings include:<BR/>Record review of the facility's Direct Care Reports reflected the number of CNAs scheduled for the 6:00 PM - 6:00 AM shift was:<BR/>4/3/24 - 4 CNAs<BR/>4/4/24 - 2 CNAs<BR/>4/8/24 - 1 CNA (6:00 PM - 10:00 PM) and 3 (6:00 PM - 6:00 AM)<BR/>4/9/24 - 1 CNA (6:00 PM - 10:00 PM) and 3 (6:00 PM - 6:00 AM)<BR/>4/14/24 - 4 CNAs<BR/>4/18/24 - 4 CNAs<BR/>Further review of the Direct Care Reports reflected the census was:<BR/>4/3/24 - 108 residents<BR/>4/4/24 - 108 residents<BR/>4/8/24 - 110 residents<BR/>4/9/24 - 110 residents<BR/>4/14/24 - 108 residents<BR/>4/18/24 - 107 residents<BR/>Record review of facility's staff time punches reflected on:<BR/>4/3/24 <BR/>o <BR/>1 CNA 8:36 PM - 4:48 AM<BR/>o <BR/>1 CNA 6:04 PM - 6:05 AM<BR/>o <BR/>1 CNA 5:34 PM - 6:06 AM<BR/>4/4/24<BR/>o <BR/>1 CNA 6:23 PM - 5:49 AM<BR/>o <BR/>1 CNA 5:46 PM - 5:57 AM<BR/>o <BR/>1 CNA 6:04 PM - 6:05 AM<BR/>o <BR/>1 CNA 6:00 PM - 10:00 PM<BR/>o <BR/>1 CNA 5:27 PM - 6:19 AM<BR/>4/8/24<BR/>o <BR/>1 CNA 6:31 PM - 6:12 AM<BR/>o <BR/>1 CNA 5:47 PM - 5:57 AM<BR/>o <BR/>1 CNA 5:49 PM - 6:00 AM<BR/>4/9/24<BR/>o <BR/>1 CNA 1:02 PM - 9:51 PM<BR/>o <BR/>1 CNA 6:24 PM - 6:01 AM<BR/>o <BR/>1 CNA 5:51 PM - 5:55 AM<BR/>o <BR/>1 CNA 6:46 PM - 10:11 PM<BR/>o <BR/>1 CNA 5:54 PM - 6:01 AM<BR/>4/14/24<BR/>o <BR/>1 CNA 9:40 PM - 4:53 AM<BR/>o <BR/>1 CNA 5:54 PM - 5:53 AM<BR/>o <BR/>1 CNA 6:08 PM - 5:54 AM<BR/>o <BR/>1 CNA 6:00 PM - 6:05 AM<BR/>o <BR/>1 CNA 4:40 PM - 6:23 AM<BR/>4/18/24<BR/>o <BR/>1 CNA 6:22 PM - 5:54 AM<BR/>o <BR/>1 CNA 10:11 PM - 6:03 AM<BR/>o <BR/>1 CNA 6:18 PM - 10:06 PM<BR/>o <BR/>1 CNA 6:01 PM - 6:01 AM<BR/>Record review of Resident Grievances reflected:<BR/>2/22/24 - .Resident states his call light is not answered timely especially at night.<BR/>2/22/24 - .Pressed the call light and after 15 minutes of waiting family member went to hall for assistance .She is concerned that the facility is understaffed.<BR/>3/5/24 - Resident's daughter said her Mother voices that is taking a long time for her call light to be answered .<BR/>Record review of Resident Council Grievances revealed:<BR/>2/27/24 - .Food cold .Meal trays are not being served timely - residents sit for a while before they get their food .<BR/>2/27/24 - .Call lights not answered timely .<BR/>3/26/24 - .Food cold .call lights not answered timely .trays not always delivered timely .<BR/>Record review of Resident Advisory Council Minutes reflected:<BR/>2/26/24 - Food continues to be cold .Are the meal trays delivered timely? No sit for a while before we get our food .Are call lights being answered in a timely manner? Takes a while 30 minutes to hour .Are medications received timely? Not always .<BR/>3/25/24 - .Food continues to be cold .Are call lights answered in a timely manner? Takes a while 30 minutes to 1 hour. CNA states that they are doing two halls .<BR/>During observation on 4/19/24 at 10:15 PM revealed there were three staff members outside in the parking lot smoking. <BR/>During observation on 4/19/24 at 10:23 PM revealed there was 1 CNA per wing and one nurse in.<BR/>During observation on 4/19/24 at 10:36 PM revealed there was 1 LVN and 1 CNA for 37 residents in the. <BR/>During an interview on 4/19/24 at 11:10 PM, CNA A said on 4/16/24 Resident #5's family member was upset because there were no staff on the wing and her mother needed to be changed. CNA A said the same family member was upset on 4/15/24 because the dinner trays were sitting in the C wing hallway for approximately 40 minutes. <BR/>During observation and interview on 4/20/24 at 12:29 PM revealed Resident #4 lying in bed and the call light was on. Resident #4 said the light had been on for approximately 20 minutes because she needed to use the bathroom. Resident #4 said sometimes it took up to 1 and half hours for staff to respond at night, adding most of the time there was only one nurse and one CNA for 4 halls at night. Resident #4 said the food was always cold. <BR/>During observation on 4/25/24 at 1:58 PM revealed the call light for room D2/3 was already on, further observation revealed there were two nurses and one MA sitting at the nurses' station and several staff walking around, which included two staff on D wing talking in the hallway. The call light on D wing was answered at 2:19 PM. <BR/>During an interview on 4/20/24 at 5:52 PM the DON said the facility assessment was the closest thing the facility had to a staffing policy. <BR/>During an interview on 4/21/24 at 6:23 PM, Resident #5's family member said the facility did not have enough help on the floor. She further stated meals were often late, sometimes over an hour the tray carts were left in the C wing hallway and the facility did not have enough staff to deliver trays or at times only had one staff that had to do it all. <BR/>During interview on 4/22/24 at 11:28 AM, LVN D said some weekends were less staffed, so nurses were busier and were unable to complete their documentation. LVN D further stated when there were only two nurses on, they each took two wings and although they were able to complete all nursing tasks, it was hard to complete documentation. LVN D said there was not enough staff to feed residents before their food got cold. LVN D further stated for example she worked the 6 AM-6 PM shift and sometimes she was alone from 5 PM-6 PM and she had six residents to feed so sometimes some residents were not fed until 7-730 PM. LVN D said lunch was scheduled for 12 PM but sometimes the meals did not come out until after 1 PM. <BR/>Observation and interview on 4/22/24 at 12:29 PM revealed Resident #4 was lying in bed, she said her call light was on because she needed to use the bathroom. Resident #4 further stated the call light had been on for approximately 20 minutes and there was only one CNA. Further observation revealed Resident #4's lunch tray was not delivered until 12:41 PM. <BR/>Observation on 4/26/24 at 8:38 am revealed the breakfast trays on A wing were still on the cart in the hallway. <BR/>During an interview on 4/23/34 at 2:07 PM, Resident #2 said sometimes the food was room temperature and the trays were not delivered on time. Resident #2 said he did not know if the facility had enough staff to get food delivered while it was still hot. Resident #2 said one time he pressed his call light at 2:30 AM and it was not answered until 6 AM but could not remember when this was. Resident #2 further stated the facility did not have enough staff in general, adding sometimes the night shift were busy and did not administer medications until 9 PM.<BR/>During an interview on 4/23/24 at 2:32 PM, Resident #3 said the wound care nurse was not able to complete treatments when she was working on the floor. Resident #3 further stated the facility was very short staffed and only had 1 nurse and 1 CNA in the 100, 200, and 300 halls per 12-hour shift. Resident #3 said she did not think this was safe for residents if there was an emergency. Resident #3 said 1 CNA for 40 residents was a lot and if she needed assistance it took approximately 45 minutes sometimes for someone to respond. <BR/>During an interview on 4/23/24 at 10:10 PM, LVN C said she worked 20 hours yesterday, 4/22/24, because there was no one else to cover. <BR/>During interview on 4/24/24 at 9:20 AM, LVN C said she worked on the floor and was responsible for wound care. LVN C further stated she was responsible for approximately 35 residents, and 25 wound care treatments during her night shift. LVN C said she asked to stay late, come in early, or work overtime very often, probably about twice per week. LVN C said her schedule was supposed to be 8 am-5 pm Monday - Friday but had been working 6 pm-6 am for about a month because the facility needed more nurses at night. <BR/>During an interview on 4/24/24 at 2:55 PM, CNA B said there was 1 LVN and 1 CNA in the and she was responsible for three hallways with approximately 37 residents.<BR/>During an interview on 4/27/24 at 3:57 PM, the Administrator said the facility had a basic staffing pattern, adding the residents in the did not require as much assistance and residents on the side required more assistance, because they had a higher level of need. The Administrator further stated the residents on C and D wings seemed to require more assistance with care, so they tried to shift more assistance to that side. The Administrator said there was usually one nurse, 1 CNA and 1 MA on and 2-3 nurses, 2 CNAs on C and D wings, one on A wing, and one on E wing, which included weekends. The Administrator said the staffing numbers listed on the Direct Care Report were the minimum needed to provide care for the entire facility. The Administrator said the facility had an on-call nurse who helped cover shifts as need, she further stated at times staff were asked to stay over and asked others if they could come in early. The Administrator said nursing management covered as needed. The Administrator said she had concerns about staffing brought to her attention by staff, residents, and families. <BR/>During interview on 4/27/24 at 6:13 AM, LVN F said she did not arrive to the facility until 6:30 PM on 4/23/24. LVN F further stated she tried to call in, but the facility did not have anyone to cover her shift. LVN F said the shift was pretty busy until approximately 10-11 PM, adding there were a lot of call lights going off, showers, and residents being put to bed. LVN F said that was why she administered medications late on 4/23/24. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON said residents had complained about call lights taking too long to be answered, food being served late and cold. The DON further stated she believed there was enough staff to serve food to resident before it got cold but sometimes the management team needed to assist. The DON said in there were 2 CNAs each wing, except D wing because it did not have as many residents, and three nurses during the day on side #1 and in side #2, there was one nurse, one CNA and there were 2 MAs, one on each side. The DON said at night staffing levels were the same for the CNAs with one nurse on each side. The DON said staffing needs were reassessed daily and they were always evaluating staffing and the acuity of each hall. The DON further stated staffing depended on the acuity of the residents and the goal was to always have 2 CNAs both shifts on A and E wings due to the high acuity of resident needs. The DON said the facility had an on-call nurse that reached out to management, nurses, and CNAs for help when there were call-ins/shortages. The DON further stated this did not happen often, but it did happen. The DON said she had concerns about staffing brought to her attention by staff, residents, and families. The DON said the facility did not have a policy regarding call lights, but her expectation was they were answered in a timely manner. The DON stated 22 minutes was probably too long to respond to a call light. <BR/>Record review of the facility assessment revealed it did not address staffing needs. <BR/>Record review of Appropriate Nurse Staffing Levels for U.S. Nursing Homes (06/29/2020), www.ncbi.nlm.nih.gov/pmc/srticles/PMC7328494 was assessed on 07/12/2023 indicated US nursing homes are required to have sufficient nursing staff with the appropriate competencies to assure resident safety and attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident .nursing homes must take into account the resident acuity to assure they have adequate staff levels to meet the needs of residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the medication error rate was not five percent or greater. The facility had a medication error rate of 16% based on 5 errors out of 30 opportunities, which involved 2 of 4 residents (Resident #17 and Resident #18) reviewed for medication errors.<BR/>1. <BR/>LVN F failed to administer medications as ordered to Resident #17 by administering Trazadone (a treatment for Depression) and Nortriptyline (a treatment for Depression)1 hour and 54 minutes after the scheduled time and not administering Melatonin (a treatment for Insomnia).<BR/>2. <BR/>LVN F failed to administer a medication as ordered to Resident #18 by administering Donepezil (a treatment for Dementia) 3 hours after the scheduled time and Trazadone (a treatment for Bipolar Disorder) 2 hours after the scheduled time. <BR/>These failures could place residents at risk of not receiving the desired therapeutic effect of their medications.<BR/>Findings include:<BR/>1. Record review of Resident #17's admission Record, dated 4/24/24, reflected the resident admitted to the facility on [DATE]. Resident #17 had diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Schizoaffective Disorder (a combination of symptoms of schizophrenia and mood disorder), Major Depressive Disorder (mental health disorder characterized by persistently depressed mood) and Insomnia (common sleep disorder). <BR/>Record review of Resident #17's Order Summary Report, dated 4/24/24, reflected: Melatonin Oral Tablet 10 MG (Melatonin) Give 1 tablet . by mouth in the evening for Insomnia; Nortriptyline HCI capsule 25 MG Give 1 capsule by mouth at bedtime related to Major Depressive Disorder; Trazodone HCI Tablet 50 MG Give 1 tablet by mouth at bedtime related to Major Depressive Disorder.<BR/>Record review of Resident #17's Medication Audit Report, dated 4/25/24, reflected: Melatonin was scheduled for 7:00 PM and was administered on 4/23/24 at 9:59 PM; Trazadone was scheduled for 8:00 PM and was administered on 4/23/24 at 9:54 PM; Nortriptyline was scheduled for 8:00 PM and was administered on 4/23/24 at 9:54 PM. <BR/>Observation on 4/23/24 beginning at 9:53 PM revealed, LVN F compared blister packs to Resident #17's MAR (medications were already in a medication cup prior to medication pass) and checking them off on the MAR. The MAR reflected red for Melatonin, Trazadone, and Nortriptyline which indicated late medication administrations on the EMR. Further observation revealed Melatonin was not administered. LVN F stated the red in the MAR indicated the medication administration was late. LVN F said she only had Melatonin 5 mg tablets and order called for 1 10 mg tablet so she would have to administer 2, 5 mg tablets. LVN F said she was not going to administer the melatonin because there were only 5 mg tablets available. LVN F administered the medications to Resident #17 at 9:58 PM. <BR/>2. Record review of Resident #18's admission Record, dated 4/24/24, reflected the resident admitted to the facility on [DATE]. Resident #18 had diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning) , Schizoaffective Disorder (a combination of symptoms of schizophrenia and mood disorder), Major Depressive Disorder (mental health disorder characterized by persistently depressed mood), and Bipolar Disorder ( disorder associated with episodes of mood swings ranging from depressive lows to manic highs). <BR/>Record review of Resident #18's Order Summary Report, dated 4/24/24, reflected: Donepezil HCI Tablet 5 MG Give 1 tablet by mouth at bedtime related to Unspecified Dementia and Trazodone HCI Tablet 50 MG Give 1 tablet by mouth at bedtime for insomnia related to Bipolar Disorder.<BR/>Record review of Resident #18's Medication Audit Report, dated 4/25/24, reflected: Donepezil was scheduled for 7:00 PM and was administered on 4/23/24 at 10:00 PM and Trazadone was scheduled for 8:00 PM and was administered on 4/23/24 at 10:00 PM.<BR/>Observation on 4/23/24 beginning at 9:59 PM revealed, LVN F compared blister packs to Resident #18's MAR and checked them off on the MAR. MAR reflected red for Donepezil and Trazadone which indicated late medication administrations on the EMR. LVN F administered the medications to Resident #18 at 10:03 PM. <BR/>During interview on 4/25/24 at 12:50 PM, the DON said the medication administration times for AM and PM was a 4-hour block from 6:30 AM to 10:30 AM and 6:30 PM to 10:30 PM. The DON further stated if a resident was ordered one 10 mg tablet of a medications and the medication was available in 5 mg tablets, she would have expected a nurse to administer two 5 mg tablets of the medication. <BR/>During interview on 4/27/24 at 6:13 AM, LVN F said medications were late because the MA took the medication cart, and she did not arrive to the facility until 6:30 PM on 4/23/24. LVN F said the shift was pretty busy until approximately 10-11 PM, and there were a lot of call lights going off, showers, and residents being put to bed. LVN F said that was why she administered medications late on 4/23/24. LVN F further stated the medications were not administered late and were just documented later. LVN F said she was an LVN and knew she could have given two 5 mg tablets of Melatonin to Resident #17, but the order said to give one tablet. LVN F further stated if she did not administer a medication, she normally did not check it off on the MAR and entered a progress note which reflected the reason the medication was not administered. <BR/>During interview on 4/27/24 at 6:32 PM, the DON said medications were documented after administration because staff needed to ensure the residents received medications/treatments before they were documented. The DON further stated administration should not be documented before medications/treatments were completed because residents could refuse. The DON said medications should be administered within one hour of the scheduled time, one hour before or one hour after, unless it was liberalized time.<BR/>Record review of the facility's policy titled, Medication Administration Procedures revised 10/25/17, reflected the following: .administer the medication and immediately chart doses administered on the medication administration record. It is recommended that medication be charted immediately after administration .20. The 10 rights of medication should always be adhered to . 5. Right time . 7. Right documentation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 3 of 10 residents (Resident #7, Resident #11,, and Resident #15) reviewed for dietary services.needs, in that:<BR/>1. <BR/>The facility failed to ensure Resident #7 did not received a health shake, or a red glass as prescribed on 4/22/24.<BR/>2. <BR/>The facility failed to ensure Resident #11 did not received the appropriate portion size of pureed spaghetti and meatballs and a red glass on 4/20/24. <BR/>3. <BR/>The facility failed to ensure Resident #15 did not received a house shake on 4/25/24 or red glass on 4/25/24 and 4/26/24 . <BR/>This These deficient practices could place residents at risk for poor food intake, weight loss, and not having their nutritional needs met.<BR/>Findings includedd:<BR/>1. Record review of Resident #7's admission Record, dated 4/25/24, revealed reflected the resident was admitted to the facility on [DATE]. Resident #7 had with diagnoses that which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Iron Deficiency Anemia (occurs when the body does not have enough iron), Anxiety, Major Depressive Disorder (mental health disorder characterized by persistently depressed mood), Muscle Wasting, and Weight Loss . <BR/>Record review of Resident #7's quarterly MDS assessment, dated 3/25/24, revealed reflected the resident had a BIMS score of 10, suggesting which indicated moderate cognitive impairment. <BR/>Record review of Resident #7's Progress Notes revealedreflected: Effective Date: 03/30/2024 08:02 [8:02 am] . Note Text .On a Mech Soft Diet, Red Glass Program . Provided a Health Shake with meals d/t weight loss .Review of chart indicates p. o. intake is fair to good - expect weight to stabilize with addition of a House Shake with all meals. Continue with same plan fo [sic] care . Author .Dietitian <BR/>Record review of Resident #7's Order Summary, dated 4/20/24, revealedreflected: Regular diet Mechanical Soft texture, Regular consistency, Red Glass Program, start date 7/6/23 and Health Shake with meals, start date 3/15/24. <BR/>Record review of Resident #7's meal ticket, dated 4/22/24, revealed reflected diet was Regular/Mechanical Soft .Health Shake . <BR/>During observation and interview on 4/22/24 at 12:42 PM, Resident #7 was sitting on the side of the bed eating lunch. Further observation revealed there was no Health Shake or red glass. Resident #7 confirmed stated he did not receive a Health Shake or red glass. <BR/>2. Record review of Resident #11's admission Record, dated 4/22/24, revealed reflected the resident was a re-admitted to the facility on [DATE]. Resident #11 had with diagnoses that which included: Type 2 diabetes - condition in which the body has trouble controlling blood sugar and using it for energy. Dysphagia (difficulty swallowing), Malnutrition, Anxiety, Muscle Wasting, and Cognitive Communication Deficit. <BR/>Record review of Resident #11's quarterly MDS assessment, dated 2/26/24, revealed reflected the resident had a BIMS score of 7, suggesting which indicated severe cognitive impairment. <BR/>Record review of Resident #11's Progress Notes revealedreflected: Effective Date: 02/26/2024 18:35 [6:35 pm] . Start Date: 2/26/2024 per .FNP resident to continue on Puree texture, resident does not tolerate mech soft <BR/>Record review of Resident #11's Order Summary, dated 4/22/24, revealedreflected: Regular diet Pureed texture, Nectar consistency, for Dysphagia, start date 2/26/24. <BR/>Record review of Resident #11's meal ticket, dated 4/20/24, revealed reflected diet was Regular/Puree .Entr&eacute;e 1 # 6 Sc P Spaghetti with Meatballs .Red Glass . <BR/>During observation and interview on 4/20/24 at 5:06 PM revealed, Resident #11 was sitting in the annex dining room. Resident #11 was asked by investigator the State Surveyor if this portion was enough for him, but he did not respond. <BR/>During interview on 4/20/24 at 5:19 PM, the DON said it was hard for her to say if Resident #11's entr&eacute;e portion seemed enough for him . <BR/>Observation and interview on 4/20/22 at 5:23 PM revealed the puree entr&eacute;e was served with a blue scoop and the regular entr&eacute;e was served with a black scoop . [NAME] A said the regular entr&eacute;e was served with a 6 oz scoop and the puree entr&eacute;e was served with a 3 oz . <BR/>During interview on 4/27/24 at 5:31 PM, [NAME] A said he used a blue scoop, 3 oz, to serve the spaghetti with meatballs entr&eacute;e on 4/20/24. [NAME] A further stated that was the scoop used for purees all of the time. [NAME] A said he was unable to say if the blue 3 oz scoop was a #6. He further stated he used a black scoop to serve the puree. <BR/>Record review of the facility's Recipes to Scale, dated 4/21/24, revealedreflected: Saturday, April 20, 2024 - Supper .Spaghetti with Meatballs .Serve: #6 scoop <BR/>Record review of the facility's, undated, Disher Scoop Sizes, Colors and Yields, undated, revealedreflected the #6 scoop was white and yielded 2/3 cup, the blue scoop was a #16 and yielded &frac14; cup. <BR/>3. Record review of Resident #15's admission Record, dated 4/23/24, revealed reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had with diagnoses that which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), cognitive communication deficit, Pressure ulcer of sacral region Stage 4, Anxiety. <BR/>Record review of Resident #15's quarterly MDS assessment, dated 3/15/24, revealed reflected a BIMS score of 5, suggesting which indicated severe cognitive impairment.<BR/>Record review of Resident #15's Progress Notes revealedreflected: Effective Date: 04/18/2024 . Note Text .On a Mech Soft Diet, Super Cereal with breakfast, House Shake with supper. HS snack <BR/>Record review of Resident #15's meal ticket, dated 4/25/24 , revealed reflected diet was Regular/Mechanical Soft .Health Shake <BR/>Record review of Resident #15's Order Summary Report, dated 4/26/24, revealedreflected: Regular diet Mechanical Soft texture, Regular consistency, start date 8/14/23 and House Shake in the evening .W /Supper. <BR/>During observation and interview on 4/25/24 at 5:24 PM revealed, Resident #15 was lying in bed with a dinner tray at the bedside. Further observation revealed there was no Health Shake on the tray. CNA, I confirmed stated Resident #15 had not received a house shake with her dinner. <BR/>During an interview on 4/27/24 at 2:49 pm, the DFN said did not remember what size scoop was used to serve the spaghetti with meatballs puree. The DFN further stated a #6 scoop was 5 oz and he was not sure why a 3 oz scoop was used to serve the puree. The DFN said the spaghetti with meatballs recipe was reviewed with [NAME] A. <BR/>Attempted interview with the RD Call attempted by phone on 4/25/24 at 11:46 pm to RDwas unsuccessful. <BR/>Record review of the facility's policy, titled Preparation of Foods, dated 2012, revealedreflected: .2. All food . will be attractively served at the proper temperature and in a form to meet the individual needs of the resident .5. Food will be cut, chopped, ground or pureed to meet individual needs of the resident <BR/>Record review of the facility's policy, titled Red Glass and Fortified Food Program, dated 2012, revealed: .The red glass program uses the presence of a red glass on the resident's meal tray to alert facility staff to which residents may have had a weight loss and/or need additional monitoring and encouragement to complete meals and fluids. Dietary will provide the red glass .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure meals were prepared in a form designed to meet individual needs for 1 of 10 residents (Resident #6) reviewed for dietary services. <BR/>The facility failed to ensure Resident #6 was served mechanical ground meat as prescribed. <BR/>These deficient practices could place residents at risk for poor food intake, weight loss and not having their nutritional needs met.<BR/>Findings included:<BR/>Record review of Resident #6's admission Record, dated 4/20/24, reflected the resident was admitted to the facility on [DATE]. Resident #6 had diagnoses which included: Hypokalemia (low potassium levels in the bloodstream), Malnutrition, Weakness, Muscle Wasting and Atrophy (decrease in size or wasting away of a body part or tissue), Dysphagia (difficulty swallowing), Cognitive Communication Deficit, Altered Mental Status, Tachycardia (elevated heart rate over 100 beats per minute), Hypertension (high blood pressure) and Anxiety. <BR/>Record review of Resident #6's comprehensive MDS assessment, dated 1/31/24, reflected the resident had a BIMS score of 99, which indicated the resident was unable to complete the interview. Resident #6 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating, had complaints of difficulty or pain with swallowing, had obvious or likely cavity or broken natural teeth, and did not have a mechanically altered or therapeutic diet. <BR/>Record review of Resident #6's Progress Notes reflected: Effective Date: 03/26/2024 14:10 [2:10 pm] . Note Text .RP called and made aware of diet changes d/t resident voicing having trouble chewing meats. Author: [LVN B]<BR/>Record review of Resident #6's Order Summary, dated 4/25/24, reflected: Regular diet Regular with Mechanical Ground Meat texture, Regular consistency, start date 3/26/24. <BR/>Record review of Resident #6's meal ticket, dated 4/22/24, reflected diet was Regular/Regular. <BR/>During observation and interview on 4/22/24 at 12:20 PM revealed Resident #6 was sitting in the dining room, she was served a whole piece of chicken fried steak that had not been cut up or ground. Resident #6 said the meat was hard and was not cut up. Resident #6 further stated she had no teeth and it was hard for her to eat meat. <BR/>Attempted interview with the RD attempted by phone on 4/25/24 at 11:46 pm was unsuccessful. <BR/>During an interview on 4/27/24 at 1:58 pm, LVN B said she remembered receiving the order for Resident #6's diet change. LVN B further stated she completed a dietary slip and submitted it to the dietary department to inform them of the change. <BR/>During an interview on 4/27/24 at 2:49 pm, the DFN said mechanical ground was ground with sauce. The DFN said he was not aware Resident #6 was ordered a mechanical ground meat diet. <BR/>During interview on 4/27/24 at 5:31 PM, [NAME] A said mechanical ground is a shredded meal, it should be ground or cut up, he added he choose to cut it up because it looked more appetizing. [NAME] A said he was not aware Resident #6 was ordered a mechanical ground meat diet. <BR/>Record review of the facility's policy, titled Preparation of Foods, dated 2012, reflected: .2. All food . will be attractively served at the proper temperature and in a form to meet the individual needs of the resident .5. Food will be cut, chopped, ground or pureed to meet individual needs of the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident medical records are kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 2 of 2 residents (Residents #5 and #15) reviewed for accuracy of records, in that:<BR/>1. The facility failed to ensure Resident #5's wound care and treatments as ordered by the physician were documented.<BR/>2. The facility failed to ensure Resident #15's wound care and treatments as ordered by the physician were documented.<BR/>These deficient practices could place residents at risk for improper care due to inaccurate records.<BR/>The findings were:<BR/>1. Record review of Resident #5's admission Record, dated 4/20/24, reflected the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, and Depression. <BR/>Record review of Resident #5's quarterly MDS assessment, dated 2/26/24, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Further review revelaed the resident had an unhealed Stage 4 pressure ulcer present upon admission/entry or re-entry.<BR/>Record review of Resident #5's Order Summary Report, dated 4/26/24, reflected an order for wound care as follows: Cleanse stage IV sacral wound with vashe. Apply collagen and calcium alginate with silver to wound bed. Paint peri-wound with skin prep. Secure with silicone dressing QD and PRN every day shift for wound care.<BR/>Record review of Resident #5's April WAR reflected the resident did not receive wound care on the following days: 4/5/24, 4/6/24, 4/15/24, 4/17/24 and 4/21/24. <BR/>2. Record review of Resident #15's admission Record, dated 4/23/24, reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning), Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), cognitive communication deficit, Pressure ulcer of sacral region Stage 4, and Anxiety. <BR/>Record review of Resident #15's quarterly MDS assessment, dated 3/15/24, reflected a BIMS score of 5, which indicated severe cognitive impairment Resident #15 had an unhealed Stage 4 pressure ulcer present upon admission/entry or re-entry. <BR/>Record review of Resident #15's Care Plan, reviewed 3/29/24, reflected: The resident has a pressure ulcer .1. Stage IV left gluteal wound- present on admission .Interventions .Administer treatments as ordered <BR/>Record review of Resident #15's Order Summary Report, dated 4/26/24, reflected an order for wound care as follows: Cleanse stage IV left gluteal wound with hibiclens, rinse with normal saline Pat dry with 4X4 gauze. Apply COLLAGEN/SILVER THEN hydrofera blue to wound bed. Skin prep peri-wound and Cover with silicone dressing QOD and PRN. one time a day every Tue, Thu, Sat for Wound healing. <BR/>Record review of Resident #15's March WAR reflected the resident did not receive wound care on the following days: 3/21/24 and 3/25/24.<BR/>Record review of Resident #15's April WAR reflected the resident did not receive wound care on 4/6/24.<BR/>Record review of Resident #15's Progress Note, dated 2/28/24, and authored by the NP, reflected: Multivitamin q day, Vitamin C 500 mg BID x30 days, Zinc 50 mg x14 days for wound healing. <BR/>Observation on 4/26/24 at 9:59 AM revealed Resident #15 was in bed. Resident #15 had Stage IV pressure injury to the left upper gluteal area.<BR/>During an interview on 4/26/24 at 3:15 PM, the DON said the ADONs audited the records daily and she tried to audit weekly. She added the facility held a stand-up meeting where the ADONs brought their audit sheets and were asked if they had any missed medications/treatments, and they answered no. The DON said she was not aware of Resident #15's missed treatments in March and April. <BR/>During an interview on 4/24/24 at 9:20 AM, LVN C said she audited the Wound Care Administration Records when she was in the office but not when she was working on the floor. She added she thought the last time she audited them was last Friday, 4/19/24. LVN C said she was not aware of the missed treatments in April for Resident #5 and March and April for Resident #15 and did not remember if she worked on 3/21/24, 3/25/24, 4/5/24, 4/6/24, 4/15/24, 4/17/24 and 4/21/24. She added she was responsible for ensuring wound care was completed as ordered and the floor nurses were responsible for providing wound care in her absence. LVN C stated blanks in the WAR meant the treatment were either not completed or were not signed off after completion. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated herself and LVN C were responsible for ensuring wound care was completed. She further stated LVN C ran a missed treatment report daily and a 72-hour report on Mondays, she added this report was reviewed in the morning meetings. The DON said she was not aware of missed treatments for Resident #5 and Resident #15. The DON stated when LVN C was asked if there were any missed treatments during the morning meeting, LVN C answered no every time. The DON said blanks in the WAR meant the treatments were either not completed or not documented after completion. <BR/>Record review of the facility's, undated, document titled Dressing Change Checklist reflected: Dressing Removal: Washes hands prior to applying gloves, when changing gloves and upon removal of gloves throughout dressing procedure . cleanses wound per orders and facility policy (working from center of wound to outside of wound) <BR/>Record review of the facility's policy, titled Fundamentals of Infection Control Precautions, dated 2018, reflected: .Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene . Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . Before and after changing a dressing .Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections .Recommended techniques for washing hands with soap and water include .rubbing hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers .Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Residents #5 and #15) reviewed for infection control, in that:<BR/>1. LVN C failed to maintain infection control practices when performing wound care for Resident #5.<BR/>2. LVN C and RN B failed to maintain infection control practices when performing wound care for Resident #15.<BR/>These deficient practices could place residents at risk for delayed wound healing and infection.<BR/>The findings were:<BR/>1. Record review of Resident #5's admission Record, dated 4/20/24, reflected the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, and Depression. <BR/>Record review of Resident #5's quarterly MDS assessment, dated 2/26/24, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Further review revealed the resident had an unhealed Stage 4 pressure ulcer present upon admission/entry or re-entry.<BR/>Record review of Resident #5's Order Summary Report, dated 4/26/24, reflected an order for wound care as follows: Cleanse stage IV sacral wound with vashe. Apply collagen and calcium alginate with silver to wound bed. Paint peri-wound with skin prep. Secure with silicone dressing QD and PRN every day shift for wound care.<BR/>Observation of wound care for Resident #5 on 4/24/24 at 7:12 AM revealed LVN C started to gather treatment supplies, then left the treatment cart to retrieve the laptop computer, upon returning to the treatment cart LVN C did not wash or sanitize hands prior to preparing tray and supplies. Further observation revealed LVN C donned gloves after gathering all treatment supplies without washing or sanitizing her hands and proceeded to don gown. <BR/>2. Record review of Resident #15's admission Record, dated 4/23/24, reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning), Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), cognitive communication deficit, Pressure ulcer of sacral region Stage 4, and Anxiety. <BR/>Record review of Resident #15's quarterly MDS assessment, dated 3/15/24, reflected a BIMS score of 5, which indicated severe cognitive impairment Resident #15 had an unhealed Stage 4 pressure ulcer present upon admission/entry or re-entry. <BR/>Record review of Resident #15's Care Plan, reviewed 3/29/24, reflected: The resident has a pressure ulcer .1. Stage IV left gluteal wound- present on admission .Interventions .Administer treatments as ordered <BR/>Record review of Resident #15's Order Summary Report, dated 4/26/24, reflected an order for wound care as follows: Cleanse stage IV left gluteal wound with hibiclens, rinse with normal saline Pat dry with 4X4 gauze. Apply COLLAGEN/SILVER THEN hydrofera blue to wound bed. Skin prep peri-wound and Cover with silicone dressing QOD and PRN. one time a day every Tue, Thu, Sat for Wound healing. <BR/>Record review of Resident #15's Progress Note, dated 2/28/24, and authored by the NP, reflected: Multivitamin q day, Vitamin C 500 mg BID x30 days, Zinc 50 mg x14 days for wound healing. <BR/>Observation on 4/26/24 at 9:59 AM revealed Resident #15 was in bed. Resident #15 had Stage IV pressure injury to the left upper gluteal area.<BR/>Observation of wound care to the left gluteal area for Resident #15, on 4/27/24 at 9:38 AM, revealed RN B approached Resident #15 and explained the procedure. Further observation revealed RN B entered the bathroom and washed her hands for 5 seconds and donned gloves. RN B proceeded to clean Resident #15's peri-wound area and then the inside of the wound. RN B removed gloves after applying silicone dressing and donned new gloves without washing or sanitizing her hands. <BR/>During an interview on 4/27/24 at 10:14 AM, RN B stated she knew it was recommended to wash hands for a total of 20-30 seconds to prevent infections and she washed her hands for approximately 10 seconds. RN B further stated she had received wound care and infection control training approximately 2 years ago when she started working at the facility. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated she expected nurses provide wound care according to physician orders and maintain infection control to promote wound healing. <BR/>Record review of the facility's, undated, document titled Dressing Change Checklist reflected: Dressing Removal: Washes hands prior to applying gloves, when changing gloves and upon removal of gloves throughout dressing procedure . cleanses wound per orders and facility policy (working from center of wound to outside of wound) <BR/>Record review of the facility's policy titled, Fundamentals of Infection Control Precautions, dated 2018, reflected: .Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene . Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . Before and after changing a dressing .Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections .Recommended techniques for washing hands with soap and water include .rubbing hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers .Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the a comprehensive care plan was developed within seven days of the comprehensive assessment and review and revise the care plan after each assessment for 1 of 12 residents (Resident #15) reviewed for care plans. <BR/>The facility failed to ensure Resident #15's care plan was revised to reflect edema to left hand with elevation. <BR/>These failures could place residents at risk of current needs not being met. <BR/>Findings included:<BR/>Record review of Resident #15's admission Record, dated 4/23/24, reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), COPD (lung diseases that block airflow and make it difficult to breathe) , Cognitive Communication Deficit, Dysphagia (difficulty swallowing) , Functional Quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition ) , Pressure ulcer of sacral region Stage 4, Depression and Anxiety. <BR/>Record review of Resident #15's quarterly MDS assessment, dated 3/15/24, reflected a BIMS score of 5, which indicated severe cognitive impairment. Resident #15's functional limitation in range of motion to bilateral upper and lower extremities; was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) for all self-care and Dependent for mobility.<BR/>Record review of Resident #15's Progress Notes reflected:<BR/>Effective Date: 03/11/2024 20:08 [8:08 pm] .Note Text: resident has 3+ edema to left arm no warmth or redness noted VS within normal limits informed NP .orders to elevate arm .Author: [LVN H]<BR/>Effective Date: 03/13/2024 16:03 [4:03 pm] .Note Text: New order per [NP] Xray to left hand .due to swelling .Author: [ADON A]<BR/>Effective Date: 03/14/2024 12:52 [12:52 pm] .Note Text .New orders received to start keflex 500 mg po bid x 10 days for cellulitis, keep left hand elevated on pillows .Author: [LVN C]<BR/>Effective Date: 04/09/2024 09:20 [9:20 am] .Note Text: Left hand swollen .Author: [LVN E]<BR/>Record review of Resident #15's Care Plan last reviewed 3/29/24, did not address edema and elevation of left arm. <BR/>Record review of Resident #15's Order Summary Report, dated 4/26/24, reflected: elevate left arm, dated 3/11/24. <BR/>During an interview on 4/27/24 at 12:47 PM, LVN A stated care plans were completed and updated by herself and RN A (MDS Coordinators). LVN A further stated care plans were completed quarterly when the MDS assessment was completed and PRN if there were changes in condition, services and/or needs. LVN A stated care plans were updated as soon as possible. LVN A further stated the facility had morning meetings and if changes were reported, she tried to update the appropriate care plans during the meeting. LVN A stated the facility also had daily nursing meetings with the DON, ADONs, Administrator and an the MDS nurse and standard of care meetings. LVN A stated she knew Resident #15's hand was swollen and when she saw it top of her stomach, she assumed it was elevated. LVN A further stated she was not aware Resident #15 had an order for her left arm to be elevated. LVN A stated she was not going to say whether or not Resident #15's left arm edema should have been care planned because the facility's care plans were liberalized/generalized. LVN A further stated yes, it should have been care planned. LVN A stated the left arm edema and elevation for Resident #15 was not care planned, she further stated she did not know why it had not been care planned. <BR/>During interview on 4/27/24 at 2:17 PM, RN A stated the nurses on working on the floor were responsible for updating care plans with acute changes to the resident's conditions. RN A further stated the facility had a morning meeting every day and changes to the resident condition/orders were shared at this meeting. RN A stated she and LVN A were mainly responsible for admissions assessments, quarterly assessments and care plans. RN A further stated the MDS Coordinators (LVN A and RN A) updated care plans, but care plans were updated for acute changes in condition by the floor nurses. RN A stated updates were done when changes happened, and added there was not a timeframe, but the goal was to update the care plans immediately. RN A further stated she was not aware Resident #15's edema to left arm and that her care plan had not been updated to reflect the edema and elevation to her left arm, stating the floor nurse should have updated Resident #15's care plan. RN A stated this change should have been shared in the morning meeting, and she did not remember the edema/elevation to Resident #15's left arm being discussed in the morning meetings. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated she expected care plans to be updated the day the change occurred. The DON stated the MDS, and charge nurses were responsible for updating care plans quarterly and when there were changes to orders. <BR/>Record review of the facility's, undated, policy, titled Comprehensive Care Planning, read: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life .The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented .revised based on changing goals, preferences and needs of the resident and in response to current interventions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 12 residents (Resident #12) reviewed for care plans. <BR/>The facility failed to ensure Resident #12's care plan was revised to reflect prescribed diet and weight loss. <BR/>These failures could place residents at risk of current needs not being met. <BR/>Findings included:<BR/>Record review of Resident #12's admission Record, dated 4/22/24, reflected the resident was admitted to the facility on [DATE]. Resident #12 had diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning) , Malnutrition, Dysphagia (difficulty swallowing) , Cognitive Communication Deficit, Depression and GERD (digestive disease in which stomach acid or bile irritates the food pipe lining) . <BR/>Record review of Resident #12's quarterly MDS assessment, dated 1/3/24, reflected the resident had a BIMS score of 99, which indicated the resident was unable to complete the interview. Resident #12 weighed 147 pounds, a weight loss of 5% or more, was not on physician-prescribed weight-loss regimen and was on a mechanically altered and therapeutic diet. <BR/>Record review of Resident #12's Care Plan, dated 12/20/17, reflected the following focus area last revised on 6/3/23: Potential for weight loss due to impaired cognition with Dementia, Depression, edentulous status without the use of his dentures currently. DX: GERD and Malnutrition .Goal: Resident will maintain stable weight and adequate nutrition by consuming 75-100% of meals X 3 per day with diet and liquids at most lenient texture and with compliance to diet as ordered x90 days .Target date:4/9/24 <BR/>Record review of Resident #12's Order Summary, dated 4/20/24, reflected: Regular diet Mechanical Soft texture, Nectar consistency, Red Glass Program, Pur&eacute;ed meats with gravy, no straw. Magic cup with lunch for Per MBS study 2/13/23 related to Unspecified Protein-Calorie Malnutrition, start date 7/6/23; Readycare 2.0 four times a day for Weight Loss give 90CC, start date 2/27/24; Super Cereal in the morning for with breakfast, start date 10/25/23. <BR/>Record review of the facility's Weight and Vitals Summary, dated, 4/20/24, reflected Resident #12 weighed 145.6 lbs on 1/5/24 a 14.8% weight loss compared to 7/10/23 (170.8 lbs), 148.4 lbs on 1/12/24 a 13.1% weight loss compared to 7/10/23 (170.8 lbs), 143.4 lbs on 1/19/24 a 11.8% weight loss compared to 8/1/23 (162.2 lbs), 144.4 lbs on 2/2/24 a 10.3% weight loss compared to 8/11/23 (161 lbs), 144.4 lbs on 2/6/24 a 10.3% weight loss compared to 8/11/23 (161 lbs), and 144.4 lbs on 2/9/24 a 10.3% weight loss compared to 8/11/23 (161 lbs).<BR/>Record review of Resident #12's Progress Notes reflected:<BR/>Effective Date: 01/10/2024 09:31 [9:31 am] Type: Dietary Note .Note Text: Wt's 147.2 lbs, 145.6 lbs - loss of 11.6 lbs/90 days (7.38%), 25.2 lbs/180 days (14.75%). On a Mech Soft Diet, Nectar Thick Liquids, Pureed Meats with gravy, no straw, Super Cereal in a.m. with breakfast, Magic Cup with lunch . Red Glass Program. Provided a House Shake after meals and at bedtime d/t weight loss .Current diet, nutritional supplements and p. o. intake areadequate [sic] as evidenced by fairly stable weekly weights past 4 weeks. Recommend continuing with same plan of care - goal is no significant weight changes next 30 days. Author .Dietitian<BR/>Effective Date: 01/22/2024 18:28 [6:28 pm] Type: Nursing . Note Text: Contacted [NP] due to resident [sic] 5LBS wight [sic] loss in a week, did inform weight loss may have been due to resdient [sic] having a resp infection, will continue to monitor and weigh resdient [sic] weekly Author: [ADON A] Assistant Director of Nursing<BR/>Effective Date: 02/26/2024 10:16 [10:16 am] Type: Dietary Note .Note Text: Wt's 145.6 lbs, 144.4 lbs - loss of 17.8 lbs/180 days (10.97%). On a Mech Soft Diet, Nectar Thick Liquids, Super Cereal in a.m., pureed meats with gravy, no straw . Magic Cup with lunch. Red glass Program. Provided a House Shake after meals and at bedtime .Review of chart indicates p. o. intake is good for most meals, however, continued weight loss trend noted. Recommend the following: .House Shake after meals and at bedtime. Provide 90ml ReadyCare 2.0 or Med Pass 2.0 QID with med pass. Goal is no further weight loss. Author .Dietitian<BR/>Effective Date: 03/30/2024 07:18 [7:18 am] Type: Dietary Note . Note Text: Wt's 144.4 lbs, 142 lbs - loss of 17.4 lbs/180 days (10.92%). On a Mech Soft Diet, Nectar Thick Liquids, Pureed Meats with gravy, no straw, Magic Cup with lunch .Red Glass Program. Provided 90ml ReadyCare 2.0 QID . Review of chart indicates 2.24 RD recommendations are in place and weight has stabilized as evidenced by most recent weekly weight of 142 lbs. Recommend continuing with same plan of care . Author .Dietitian <BR/>Effective Date: 04/18/2024 11 :08 [11:08 am] Type: Dietary Note . Note Text: Wt's 142 lbs, 141 lbs - loss of 16.2 lbs/180 days (10.31 %). On a Mech Soft Diet, Nectar Thick Liquids, Super Cereal with breakfast, Pureed Meats with gravy, no straw, Magic Cup with lunch . Red Glass Program. Provided 90ml ReadyCare 2.0 QID .Current diet, nutritional supplements and p. o. intake are adequate as evidenced by fairly stable weight past 90 days. Recommend continuing with same plan of care . Author .Dietitian <BR/>During an interview on 4/27/24 at 12:47 PM, LVN A stated care plans were completed and updated by herself and RN A (MDS Coordinators). LVN A further stated care plans were completed quarterly when the MDS assessment was completed and PRN if there were changes in condition, services and/or needs. LVN A stated care plans were updated as soon as possible. LVN A further stated the facility had morning meetings and if changes were reported, she tried to update the appropriate care plans during the meeting. LVN A stated the facility also had daily nursing meetings with the DON, ADONs, Administrator and an the MDS nurse and standard of care meetings. LVN A stated care plans were supposed to reflect diet as ordered and stated Resident #12's diet was not included in the resident's care plan. <BR/>During interview on 4/27/24 at 2:17 PM, RN A stated the nurses on working on the floor were responsible for updating care plans with acute changes to the resident's conditions. RN A further stated the facility had a morning meeting every day and changes to the resident condition/orders were shared at this meeting. RN A stated she and LVN A were mainly responsible for admissions assessments, quarterly assessments and care plans. RN A further stated the MDS Coordinators (LVN A and RN A) updated care plans, but care plans were updated for acute changes in condition by the floor nurses. RN A stated updates were done when changes happened, and added there was not a timeframe, but the goal was to update the care plans immediately. RN A stated she not aware Resident #12's care plan had not been updated to reflect his weight loss and diet orders. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated diet orders were to be care planned. The DON further stated she expected care plans to be updated the day the change occurred. The DON stated the MDS, and charge nurses were responsible for updating care plans quarterly and when there were changes to orders. <BR/>Record review of the facility's, undated, policy, titled Comprehensive Care Planning, read: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life .The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented .revised based on changing goals, preferences and needs of the resident and in response to current interventions <BR/>Record review of the facility's policy, titled Red Glass and Fortified Food Program, dated 2012, revealed: .The red glass program uses the presence of a red glass on the resident's meal tray to alert facility staff to which residents may have had a weight loss and/or need additional monitoring and encouragement to complete meals and fluids. Dietary will provide the red glass .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one resident (#70) out of 2 residents reviewed who received enteral feedings in that:<BR/>Resident #70's head of the bed not kept at 30 degrees while his enteral feeding was infusing.<BR/>This deficient practice affects residents who receive enteral feeding and could result in aspiration pneumonia.<BR/>The findings included:<BR/>Record review of Resident #70's electronic face sheet dated 10/12/2023 reflected he was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. His diagnoses included: cerebral infarction (area of brain tissue that dies as a result of localized lack of oxygen due to the cessation of blood flow), dysphagia (difficulty swallowing) and hemiplegia and hemiparesis side (complete paralysis affecting one side of the body) and hemiparesis (partial weakness affecting one side of the body) following cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting left non-dominant side.<BR/>Record review of Resident #70's significant change in status MDS assessment dated [DATE] reflected he scored a 99 on his BIMS which signified he was severely cognitively impaired. Further review reflected he required extensive assistance with his ADL's and he received enteral feedings through a gastrostomy tube ( tube that is inserted in the stomach for feeding and medications).<BR/>Record review of Resident #70's comprehensive care plan revised dated 09/01/2023 reflected Focus .resident requires tube feeding .Interventions .the resident needs the HOB elevated at least 30 degrees during and thirty minutes after tube feed.<BR/>Record review of Resident #70's Active orders as of: 10/12/2023 Enteral Feed Order two times a day NOVASOURCE RENAL @ 50ML/HR X 22 HOURS Active 10/06/2023 <BR/>Observation on 10/12/2023 at 08:10 a.m. of Resident #70 revealed he was lying in bed in his room and the head of his bed was almost flat and his enteral feeding was infusing at 50 ml/hr. He made gurgling sounds which signified he had saliva or mucus collecting in his throat or chest. The surveyor retrieved LVN C and she stated the head of Resident #70's bed was up when she performed her rounds earlier. She then raised the head of his bed up to at least 30 degrees and stated he had pneumonia and required suctioning. <BR/>Further interview on 10/12/2023 at 08:15 a.m. with LVN C, she stated Resident #70's condition could worsen with aspiration with the feeding infusing while his head of bed was down lower than 30 degrees. She did not know how it happened.<BR/>Interview on 10/13/2023 at 10:53 a.m. with LVN A, she stated Resident #70 was on hospice care and his condition had deteriorated in the last couple of months. She stated Hospice discontinued his enteral feedings now. She stated Resident #70's HOB needed to be elevated at least 30 degrees when his enteral feeding infused. She stated if the HOB was not elevated during feedings that Resident #70 could aspirate.<BR/>Record review of the facility policy and procedure titled Gastrostomy Tube Care revised date February 13, 2007 reflected Place the resident in semi-Fowler's position (a position in which the individual lies on their back in bed with the head of the bed elevated at 30-45 degrees) during feeding .maintain the resident in a semi to high-Fowler's (60 to 90 degree) position for 45-60 minutes following a feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident was treated with respect, dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 3 residents (Resident #5) reviewed for dignity, in that:<BR/>The facility failed to ensure Resident #5 was not left exposed during wound care on 4/24/24.<BR/>This failure could place residents at risk of poor self-esteem and decreased self-worth and quality of life. <BR/>Findings include:<BR/>Record review of Resident #5's admission Record, dated 4/20/24, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, and Depression. <BR/>Record review of Resident #5's quarterly MDS assessment, dated 2/26/24, revealed the resident had a BIMS score of 00, which indicated severe cognitive impairment.<BR/>Record review of Resident #5's Care Plan, revised 4/20/24, revealed: The resident has a pressure ulcer or potential for pressure ulcer development . Administer wound care as ordered .<BR/>Record review of Resident #5's Order Summary Report, dated 4/26/24, revealed an order for wound care as follows: Cleanse stage IV sacral wound with vashe (Wound Cleanser). Apply collagen and calcium alginate with silver to wound bed. Paint peri-wound with skin prep. Secure with silicone dressing QD and PRN every day shift for wound care.<BR/>Observation of wound care to the sacrum for Resident #5 on 4/24/24 at 7:12 AM revealed LVN C approached Resident #5 and explained the procedure. Further observation revealed after removing the resident's dressing, LVN C walked away from Resident #15, leaving the resident's buttocks and sacral wound exposed, to retrieve the trash can. LVN C returned with the trash can and continued with the treatment.<BR/>During an attempted interview on 4/27/24 at 12:53 PM, Resident #5 did not respond to investigator's questions. <BR/>During an interview on 4/27/24 at 1:45 PM, LVN D stated Resident #5 was not supposed to be left exposed during wound care. LVN D further stated the resident should have been covered and given privacy during care. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated she expected nurses to provide privacy during wound care to preserve the resident's privacy and dignity. <BR/>Record review of the facility's policy, titled, Resident Rights, revised 11/28/16, reflected: The resident has a right to a dignified existence . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life . The facility must protect and promote the rights of the resident . Respect and dignity -The resident has a right to be treated with respect and dignity .Privacy and confidentiality -The resident has a right to personal privacy .1. Personal privacy includes accommodations, medical treatment . personal care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodations of residents needs for 2 of 2 residents (Resident #5 and Resident #15) reviewed for accommodations of needs, in that.<BR/>The facility failed to ensure Resident #5, and Resident #15 were able to press the call light when assistance was needed.<BR/>This deficient practice could place residents at risk of not receiving care or attention when needed.<BR/>Findings included:<BR/>Record review of Resident #5's admission Record, dated 4/20/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, Muscle Weakness, Abnormal Posture, Muscle Wasting and Atrophy (decrease in size or wasting away of a body part or tissue), Pain, and Depression. <BR/>Record review of Resident #5's MDS assessment, dated 2/26/24, revealed the resident had a BIMS score of 00, suggesting severe cognitive impairment. Further review of this assessment revealed Resident #15 functional limitation in range of motion to bilateral upper and lower extremities, was dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for all self-care and dependent for mobility.<BR/>Record review of Resident #5's Care Plan, dated 1/24/23, revealed the following focus area last revised on 6/21/23: The resident is at risk for falls .Interventions .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed .The resident needs a safe environment with .a working and reachable call light . Further review of this document revealed the following focus area last revised on 11/4/23: Resident has a communication problem r/t to cog/comm deficit, such as expressing words, emotions, spontaneous speech and needs time to communicate basic needs .Goal: Resident will be able to make basic needs known by allowing time for her to express herself and emotions on a daily basis .Interventions .Ensure/provide a safe environment: Call light in reach .Monitor effectiveness of communication strategies and assistive devices .<BR/>During observation and interview on 4/20/24 at 6:23 pm, Resident #5 was seen lying in bed with family at bedside. Resident #5 was awake, alert, and her upper limbs were contracted across her chest. Interview with resident was attempted but answers were unintelligible. Resident #5 slightly moved left hand but was unable to press call light when asked by the investigator to press the button. Resident #5's family member said she was unable to press the call light herself and believed the facility staff were aware of this. <BR/>During an interview on 4/22/24 at 11:28 am, LVN D said Resident #5 was not able to press the call light. <BR/>During an interview on 4/22/24 at 12:10 pm, CNA D said Resident #5 was not able to press the call light button. CNA D further stated that Resident #5 was checked on and repositioned every two hours.<BR/>During an interview on 4/27/24 at 12:47 pm, LVN A said she did not believe Resident #5, cognitively and physically, was able to press the call light. <BR/>Record review of Resident #15's admission Record dated 4/23/24 revealed the resident was re-admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), COPD (lung diseases that block airflow and make it difficult to breathe) , Cognitive Communication Deficit, Dysphagia (difficulty swallowing) , Functional Quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition ) , Pressure ulcer of sacral region Stage 4, Depression and Anxiety. <BR/>Record review of Resident #15's MDS assessment dated [DATE] revealed a BIMS score of 5, suggesting severe cognitive impairment. Further review of this assessment revealed Resident #15 functional limitation in range of motion to bilateral upper and lower extremities; was dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for all self-care and Dependent for mobility.<BR/>Record review of Resident #15's Care Plan, dated 3/8/23, revealed the following focus area last revised on 9/27/23: The resident is at risk for falls r/t recent admit to hospital and now with increased weakness and decreased mobility skills .Interventions .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Further review of this document revealed the following focus area last revised on 4/11/23: The resident has a communication problem r/t she is hared [sic] of hearing and speaker must adjust tone to be heard .Goal: The resident will be able to make basic needs known by on a daily basis .Interventions .Ensure/provide a safe environment: Call light in reach .Monitor effectiveness of communication strategies and assistive devices .<BR/>Observation and atteBased 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 residents needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 11 residents (Resident #5 and Resident #15) reviewed for accommodations of needs.<BR/>The facility failed to ensure Resident #5 and Resident #15 were able to press the call light when assistance was needed.<BR/>This deficient practice could place residents at risk of not receiving care or attention when needed.<BR/>Findings include:<BR/>1. Record review of Resident #5's admission Record, dated 4/20/24, reflected the resident was admitted to the facility on [DATE]. Resident #5 had diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, Muscle Weakness, Abnormal Posture, Muscle Wasting and Atrophy (decrease in size or wasting away of a body part or tissue), Pain, and Depression. <BR/>Record review of Resident #5's quarterly MDS assessment, dated 2/26/24, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Resident #5 functional limitation in range of motion to bilateral upper and lower extremities, was dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for all self-care and dependent for mobility.<BR/>Record review of Resident #5's Care Plan, dated 1/24/23, reflected the following focus area last revised on 6/21/23: The resident is at risk for falls .Interventions .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed .The resident needs a safe environment with .a working and reachable call light . Further review of this document revealed the following focus area last revised on 11/4/23: Resident has a communication problem r/t to cog/comm deficit, such as expressing words, emotions, spontaneous speech and needs time to communicate basic needs .Goal: Resident will be able to make basic needs known by allowing time for her to express herself and emotions on a daily basis .Interventions .Ensure/provide a safe environment: Call light in reach .Monitor effectiveness of communication strategies and assistive devices <BR/>During observation and interview on 4/20/24 at 6:23 PM, Resident #5 was seen lying in bed with family at the bedside. Resident #5 was awake, alert and her upper limbs were contracted across her chest. Interview with the resident was attempted but answers were unintelligible. Resident #5 slightly moved their left hand but was unable to press the call light when asked by the State Surveyor to press the button. Resident #5's family member said she was unable to press the push button call light herself and believed the facility staff were aware of this. Resident #5's family member further stated it would have been better for the resident to have a flat call light. <BR/>During an interview on 4/22/24 at 11:28 AM, LVN D said Resident #5 was not able to press the push button call light. LVN D further stated a soft call light would have been better for Resident #5 was but did the facility did not have any. <BR/>During an interview on 4/22/24 at 12:10 PM, CNA D said Resident #5 was not able to press the call light button. CNA D further stated Resident #5 was checked on and repositioned every two hours.<BR/>During an interview on 4/27/24 at 12:47 PM, LVN A said she did not believe Resident #5, cognitively and physically, was able to press the call light. <BR/>2. Record review of Resident #15's admission Record, dated 4/23/24, reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), COPD (lung diseases that block airflow and make it difficult to breathe) , Cognitive Communication Deficit, Dysphagia (difficulty swallowing) , Functional Quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition ) , Pressure ulcer of sacral region Stage 4, Depression and Anxiety. <BR/>Record review of Resident #15's quarterly MDS assessment, dated 3/15/24, reflected a BIMS score of 5, which indicated severe cognitive impairment. Resident #15's functional limitation in range of motion to bilateral upper and lower extremities; was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers was required for the resident to complete the activity) for all self-care and dependent for mobility.<BR/>Record review of Resident #15's Care Plan, dated 3/8/23, reflected the following focus area last revised on 9/27/23, reflected: The resident is at risk for falls r/t recent admit to hospital and now with increased weakness and decreased mobility skills .Interventions .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Further review of this document revealed the following focus area last revised on 4/11/23: The resident has a communication problem r/t she is hared [sic] of hearing and speaker must adjust tone to be heard .Goal: The resident will be able to make basic needs known by on a daily basis .Interventions .Ensure/provide a safe environment: Call light in reach .Monitor effectiveness of communication strategies and assistive devices <BR/>Observation and attempted interview on 4/25/24 at 5:24 PM revealed Resident #15 was seen lying in bed. She was awake, alert, and her arms were crossed across her chest, right arm appeared contracted across her chest and left hand was observed with severe edema (swelling) and appeared to have limited range of motion. Interview with the resident was attempted but Resident #15 did not respond to questions. Resident #15 was unable to press the call light when asked. <BR/>During an interview on 4/27/24 at 12:47 PM, LVN A said all staff should have been checking for residents' ability to press the call light button. LVN A further stated if a resident was unable to press the push button call light button, they were given a soft call light (a special device used for residents with limited ROM) they could press when assistance was needed. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON said interventions for Resident #5 and Resident #15 included: rounding every 2 hours, turning every 2 hours and CNAs were sent to check on the residents more often because they had a higher acuity and needed more assistance than others. The DON said Resident #5 and Resident #15 were able to press the call light button but refused to do so. <BR/>Record review of the facility's policy, titled Resident Rights, revised 11/28/16, reflected: . Respect and dignity - 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs .mpted interview on 4/25/24 at 5:24 pm revealed Resident #15 was seen lying in bed. She was awake, alert, and her arms were crossed across her chest, right arm appeared contracted across her chest and left hand was observed with severe edema and appeared to have limited range of motion. Interview with resident was attempted but Resident #15 did not respond to questions. Resident #15 was unable to press the call light when asked. <BR/>During an interview on 4/27/24 at 12:47 pm, LVN A said all staff should have been checking for residents' ability to press the call light button. LVN A further stated that if a resident was unable to press the call light button, they were given a soft call light (a special device used for residents with limited ROM). <BR/>During an interview on 4/27/24 at 6:32 pm, the DON said she had not evaluated Resident #5's and Resident #15's ability to press the call light button. She added that interventions for Resident #5 and Resident #15 included: rounding every 2 hours, turning every 2 hours and CNAs were sent to check on the residents more often because they have a higher acuity and need more assistance than others. <BR/>Record review of the facility's policy, titled, Resident Rights, revised 11/28/16, revealed: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality . The facility must provide equal access to quality care regardless of diagnosis, severity of condition . Planning and implementing care - d. The right to receive the services and/or items included in the plan of care .3. The planning process must-- b. Include an assessment of the resident's strengths and needs . Respect and dignity - 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were 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 and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Residents #1) of 1 resident reviewed for abuse, neglect, and misappropriation of property, in that;<BR/>The facility failed to report an allegation of abuse made on 09/19/2023 for Resident #1 in accordance with State law, requiring all alleged violations be reported immediately but not later than 2 hours if the alleged violation involves abuse OR results in serious bodily injury.<BR/>This failure could place residents at risk for not having incidents reported as required and continued abuse and neglect which could result in diminished quality of life.<BR/>The findings included: <BR/>Record review of Resident #1's face sheet dated 09/28/2023 revealed Resident #1 had an initial admission on [DATE] and was re-admitted on [DATE] with diagnoses that included dementia, aphasia, and lack of coordination. <BR/>Record review of Resident #1's Annual MDS, dated [DATE], revealed the resident had a BIMS score of 99, which indicated the individual chooses not to participate, or gave a nonsensical response. Further review revealed Resident #1's required extensive physical assistance of one person for transfers and bed mobility.<BR/>Record review of Resident #1's Care Plan, last review date 09/26/2023, revealed a focus area Resident with decreased vision related to age and Intervention adapt environment to resident individual needs to ensure that resident able to recognize objects/own environment. Further review revealed a focus area Resident has need for assist for mobility. Does have dx of muscle weakness, abnormal posture, and lack of coordination.<BR/>Record review in TULIP (an online system for submitting long-term care licensure applications) revealed a self-report indicating that on 09/19/2023 at approximately 5:15 am, the Interim Administrator was contacted by Charge Nurse (LVN H) that Resident #2 was alleging to her that over the weekend, CNA I was providing care to his roommate and he heard her state to Resident #2, don't touch me like that again you son of a bitch or I will knock the shit out of you. Further review revealed the report filed regarding Resident #1 by the Administrator was dated 09/20/2023, one day following the incident. <BR/>Record review of a screen shot of an email addressed to HHSC Complaint and Incident Intake, provided by the Administrator as evidence she attempted to report within the required time frame revealed draft saved at Tuesday 8:22 am and we couldn't send your .<BR/>An attempted interview with Resident #1 on 09/27/2023 at 2:05 p.m., revealed Resident #1 was non-interviewable.<BR/>During an interview with Resident #2 on 09/27/2023 at 2:08 p.m. Resident #2 revealed that CNA I had alleged that Resident #1 grabbed her in the private area. Resident #2 revealed this was not however witnessed but knows Resident #1 sleeps with his hands at his sides so could have possibly grabbed CNA I when she tried to assist with care. Resident #2 then state that CNA I called Resident #1 a son of a bitch and added threatened to knock the shit out of Resident #1.<BR/>During an interview with LVN H on 09/29/2023 at 3:08 p.m., LVN H revealed at 5:15 a.m. near the end of her shift on, Tuesday, 09/19/2023, Resident #2 reported to LVN H that the skinny little CNA that worked this past weekend was changing Resident #1 and called Resident #1 a son of a bitch. Resident #2 alleged that CNA I then said she would knock the shit out of you, towards Resident #1. LVN H stated that the residents called CNA I a skinny little CNA. <BR/>During an interview with the Administrator on 09/29/2023 at 3:08 p.m., the Administrator stated she had been unaware the email had not gone through to HHSC until the following day, 09/20/2023 when she found the email in her drafts. The Administrator stated that is when she was able to file a report and receive confirmation and start her investigation.<BR/>Record review of the facility's policy titled, Abuse/Neglect, rev 3/29/18, revealed, E. Reporting: 3. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the a comprehensive care plan was developed within seven days of the comprehensive assessment and review and revise the care plan after each assessment for 1 of 12 residents (Resident #15) reviewed for care plans. <BR/>The facility failed to ensure Resident #15's care plan was revised to reflect edema to left hand with elevation. <BR/>These failures could place residents at risk of current needs not being met. <BR/>Findings included:<BR/>Record review of Resident #15's admission Record, dated 4/23/24, reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), COPD (lung diseases that block airflow and make it difficult to breathe) , Cognitive Communication Deficit, Dysphagia (difficulty swallowing) , Functional Quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition ) , Pressure ulcer of sacral region Stage 4, Depression and Anxiety. <BR/>Record review of Resident #15's quarterly MDS assessment, dated 3/15/24, reflected a BIMS score of 5, which indicated severe cognitive impairment. Resident #15's functional limitation in range of motion to bilateral upper and lower extremities; was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) for all self-care and Dependent for mobility.<BR/>Record review of Resident #15's Progress Notes reflected:<BR/>Effective Date: 03/11/2024 20:08 [8:08 pm] .Note Text: resident has 3+ edema to left arm no warmth or redness noted VS within normal limits informed NP .orders to elevate arm .Author: [LVN H]<BR/>Effective Date: 03/13/2024 16:03 [4:03 pm] .Note Text: New order per [NP] Xray to left hand .due to swelling .Author: [ADON A]<BR/>Effective Date: 03/14/2024 12:52 [12:52 pm] .Note Text .New orders received to start keflex 500 mg po bid x 10 days for cellulitis, keep left hand elevated on pillows .Author: [LVN C]<BR/>Effective Date: 04/09/2024 09:20 [9:20 am] .Note Text: Left hand swollen .Author: [LVN E]<BR/>Record review of Resident #15's Care Plan last reviewed 3/29/24, did not address edema and elevation of left arm. <BR/>Record review of Resident #15's Order Summary Report, dated 4/26/24, reflected: elevate left arm, dated 3/11/24. <BR/>During an interview on 4/27/24 at 12:47 PM, LVN A stated care plans were completed and updated by herself and RN A (MDS Coordinators). LVN A further stated care plans were completed quarterly when the MDS assessment was completed and PRN if there were changes in condition, services and/or needs. LVN A stated care plans were updated as soon as possible. LVN A further stated the facility had morning meetings and if changes were reported, she tried to update the appropriate care plans during the meeting. LVN A stated the facility also had daily nursing meetings with the DON, ADONs, Administrator and an the MDS nurse and standard of care meetings. LVN A stated she knew Resident #15's hand was swollen and when she saw it top of her stomach, she assumed it was elevated. LVN A further stated she was not aware Resident #15 had an order for her left arm to be elevated. LVN A stated she was not going to say whether or not Resident #15's left arm edema should have been care planned because the facility's care plans were liberalized/generalized. LVN A further stated yes, it should have been care planned. LVN A stated the left arm edema and elevation for Resident #15 was not care planned, she further stated she did not know why it had not been care planned. <BR/>During interview on 4/27/24 at 2:17 PM, RN A stated the nurses on working on the floor were responsible for updating care plans with acute changes to the resident's conditions. RN A further stated the facility had a morning meeting every day and changes to the resident condition/orders were shared at this meeting. RN A stated she and LVN A were mainly responsible for admissions assessments, quarterly assessments and care plans. RN A further stated the MDS Coordinators (LVN A and RN A) updated care plans, but care plans were updated for acute changes in condition by the floor nurses. RN A stated updates were done when changes happened, and added there was not a timeframe, but the goal was to update the care plans immediately. RN A further stated she was not aware Resident #15's edema to left arm and that her care plan had not been updated to reflect the edema and elevation to her left arm, stating the floor nurse should have updated Resident #15's care plan. RN A stated this change should have been shared in the morning meeting, and she did not remember the edema/elevation to Resident #15's left arm being discussed in the morning meetings. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated she expected care plans to be updated the day the change occurred. The DON stated the MDS, and charge nurses were responsible for updating care plans quarterly and when there were changes to orders. <BR/>Record review of the facility's, undated, policy, titled Comprehensive Care Planning, read: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life .The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented .revised based on changing goals, preferences and needs of the resident and in response to current interventions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 3 residents reviewed for accuracy of assessments. <BR/>The facility failed to ensure Resident #1 was coded on his Quarterly MDS assessment, signed as completed on 02/11/2025, for a fall with major injury that occurred on 01/12/2025.<BR/>This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. <BR/>The findings included:<BR/>Record review of Resident #1's admission Record, dated 04/17/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE].<BR/>Record review of Resident #1's Diagnosis Report, dated 04/17/2025, reflected a primary and admitting diagnosis of Hemiplegia (partial to complete loss of muscle function of one side of the body) and Hemiparesis (muscle weakness of one side of the body) following an unspecified cerebrovascular disease (a group of conditions that affect the blood flow and blood vessels in the brain) affecting the left non-dominant side, epilepsy (a brain disorder that causes seizures), and other reduced mobility. <BR/>Record review of Resident #1's Nursing Note, dated 01/12/2025 at 09:31 p.m. by LPN A, reflected Resident #1 had an unwitnessed fall in his room on 01/12/2024. LPN A noted the fall caused a fracture to Left leg.<BR/>Record review of Resident #1's Fall Nurses Note 12hr, signed 01/17/2025 with effective date 01/15/2025 by LPN A, reflected Resident #1 sustained a fracture to his left leg with swelling and a brace applied for intervention. <BR/>Record review of Resident #1's Quarterly MDS, signed as completed on 02/11/2025 by the RN Assessment Coordinator B, reflected assessment observation end date of 01/29/2025. Resident #1 had a BIMS score of 10 indicating he was mildly impaired, he required substantial/maximal assistance for transferring from lying to sitting on the side of the bed or sitting to standing; and he had two or more falls since admission/entry or reentry or the prior assessment with no injury. He was documented as had no major injury since admission/entry or reentry or prior assessment. The assessment description for major injury included bone fractures. <BR/>An observation and interview with Resident #1 on 04/17/2025 at 04:25 p.m., revealed Resident #1 was lying in his bed with his head and shoulders slighted elevated watching television. Resident #1 appeared clean and groomed. His call light, a side table, and a bedside urinal bottle were in reach. The resident had two grab bars attached to both sides of his upper bed. Resident #1 revealed he had fallen a couple times at the facility. He stated on one fall he broke his leg. He stated staff responded okay and he felt safe at the facility. He revealed he continued to go to therapy. <BR/>During an interview on 04/17/2025 at 05:55 p.m., RN Assessment Coordinator B stated for falls, the DON would discuss the falls that were active or historical with the care team. She stated the DON was also responsible for care planning and assigning the interventions for a resident. She stated the facility had not had a DON since around Thanksgiving of the prior year, and the new DON had just started. She stated without a DON, the responsibility had fallen to the ADONs. She stated she and the other facility MDS Assessment Coordinator were responsible for ensuring the accuracy of the MDS Assessments; however, she stated they had to go off the information they could see, and they did not have a system in place to manually track the facility falls. She revealed when completing an MDS assessment there was a tab in the EMR that would trigger for any active or historical falls the resident being assessed had. She revealed when the information on a fall or incident was not completed or still open, then that fall history would not pull into the information they used to complete the assessments. She stated a missed fall on the MDS assessment would not have impacted the resident's care in the slightest if the care plan was updated with the interventions enacted for that fall.<BR/>During an interview and record review on 04/17/2025 at 06:21 p.m., RN Assessment Coordinator B stated in the EMR, when reviewing the risk management tab, it showed a resident's active incidents and, on another page, the closed incidents. Record review of Resident #1's Historical Incidents Report, undated and accessed on 04/17/2025 by RN Assessment Coordinator B, revealed Resident #1 had a fall incident on 01/12/2025 at 08:05 p.m. The incident was noted as closed on 03/11/2025 at 02:50 p.m. RN Assessment Coordinator B stated she assumed Resident #1's fall on 01/12/2025 was not closed until 03/11/2025 because they were unable to determine his injury. <BR/>During an interview on 04/17/2025 at 07:13 p.m., the DON stated she had just started working at the facility on 04/09/2025. She stated it would be the MDS Coordinator's responsibility to ensure the MDS assessments were accurate. She stated an RN was required to review a completed MDS assessment and sign it to indicate the assessment was accurate and complete. She stated if an MDS assessment was not accurate for fall history, but the care plan was updated with the appropriate interventions following the fall, then the inaccuracy in the assessment would not impact the resident's care. <BR/>During an interview on 04/17/2025 at 07:18 p.m., the ADMIN revealed every weekday morning she would go over the incidents and accidents that occurred during the night with the care team, and then the care team would also have a stand down meeting at the end of the day to discuss anything that happened during that day. She stated she also believed incidents and accidents would appear on the staff's dashboard when they logged into the EMR. She stated during the care team discussions, they discussed what happened, interventions, and the necessity to update the care plan. She stated the MDS Coordinators were supposed to attend both daily meetings. She stated she believed it was the MDS Consultant's responsibility to initially catch MDS errors, but the facility also had a compliance nurse. She stated the MDS Coordinator would sign the MDS Assessments, but then the MDS Consultant would check them. She stated she was unsure if the MDS Consultant checked every MDS Assessment. The ADMIN stated the DON would normally be the person responsible for completing the facility incident documentation in the EMR, but in the absence of the DON, the compliance nurse was working on them. She stated the compliance nurse would have been able to see if any incidents were still open and she was usually at the facility weekly or able to do them offsite. The ADMIN stated the compliance nurse was able to communicate with the ADONs if there were any sections of an incident report that needed completion. The ADMIN revealed that if the care plan was updated appropriately after a resident fall, then an inaccurate MDS Assessment would not impact the residents care but may impact the facility's reimbursement for that care. <BR/>Record review of facility policy, Resident Assessment, noted as a section of the Nursing Policy & Procedure Manual 2003, revealed 7. Each assessment will be conducted or coordinate with the appropriate participation of health professionals. Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 out of 1 resident (Resident #4) reviewed for indwelling catheters.<BR/>Resident #4's indwelling catheter collection bag was lying on the floor of the resident's room, not in a protective container, and was not secured to prevent pulling and/or tugging to the urethra. <BR/>This failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections.<BR/>The findings included: <BR/>Record review of Resident #4's electronic face sheet revealed the resident was [AGE] years of age and was admitted to the facility on [DATE]. Further review revealed Resident #4's diagnoses included: <BR/>-Urinary Tract Infection (UTI) (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract. The infections can affect several parts of the urinary tract, but the most common type is a bladder infection (cystitis). Kidney infection (pyelonephritis) is another type of UTI). <BR/>-Chronic Kidney Disease Stage 4 (kidneys are moderately or severely damaged and are not working as well as they should to filter waste from your blood. Waste products may build up in your blood and cause other health problems, such as: High blood pressure. Anemia (not enough red blood cells in your body). <BR/>-Anemia in Chronic Kidney Disease (Anemia of chronic renal disease, also known as anemia of chronic kidney disease (CKD), is a form of normocytic, normochromic, hyperproliferative anemia. It is frequently associated with poor outcomes in chronic kidney disease and confers an increased mortality risk).<BR/>-Benign prostatic hyperplasia with lower urinary tract symptoms (the urinary stream may be weak, or stop and start. In some cases, it can lead to infection, bladder stones, and reduced kidney function).<BR/>Record review of Resident #4's Order Summary Report, printed 9/15/2023 revealed, ensure foley bag is in privacy bag while in bed or w/c every shift (effective date 9/1/2023).<BR/>Record review of Resident #4's Care Plan, dated 9/6/2023, stated, (Resident #4) has Foley Catheter with dx of Obstructive & Reflux Uropathy due to Dx of BPH . (Resident #4) will be free from catheter-related trauma through review date Interventions included,'.'. Ensure tubing is anchored to (Resident'#4's) leg or linens so that tubing is not pulling on the urethra .Check tubing for kinks and maintain the drainage bag off the floor.<BR/>Review of Resident'#4's 5 day MDS assessment dated [DATE] revealed, BIMS: 99 and PHQ9: 99. Further review revealed ADLs: Totally dependent 2+ person assist for the following - Bed mobility, transfer, Dressing, Toilet use. Further review of (Section H- Bowel and Bladder - H0100 Appliances) denied the presence of an indwelling catheter. <BR/>Observation and attempted interview on 9/14/2023 at 12:34 PM. Resident #4 was observed lying in bed, asleep, through his open door. Resident #4 did not respond to an attempted interview. Further observation revealed Residen'#4's catheter bag was exposed and lying on the floor. A photograph was subsequently taken and the resident's call light was pushed by this investigator. <BR/>Interview and observation on 9/14/2023at 12:40 PM, Charge Nurse, LVN C, was asked what appeared to be of concern while observing Resident #4. The LVN C responded that Resident'#4's catheter bag was on the floor and also not in a protective container. This investigator asked how this deficient practice could be of concern to which the LVN C responded that it was n infection control problem. This investigator asked the LVN C if Resident #4 had any types of infections such as ESBL, CDIFF, or UTI to which the LVN C responded that Resident #4 did not. <BR/>Interview on 9/15/2023 at 9:47 AM., the DON was informed of this investigator's findings and shown a photograph of Resident #4's catheter bag resting on the floor. The DON confirmed the catheter bag on the floor was an infection control concern and said staff had been in-serviced regarding these findings. <BR/>Record review of facility policy, Catheter Care, revised 2/13/2007, stated, Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Keep tubing off floor and minimize friction or movement at insertion site. <BR/>A record review of the CDC's website (assessed 9/15/2023) https://www.cdc.gov/infectioncontrol/guidelines/cauti/recommendations.html#I , accessed 09/07/2023, Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) revealed, Proper Techniques for Urinary Catheter Insertion .Properly secure indwelling catheters after insertion to prevent movement and urethral traction .Proper Techniques for Urinary Catheter Maintenance .Maintain unobstructed urine flow .Keep the collecting bag below the level of the bladder at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Residents #5 and #15) reviewed for infection control, in that:<BR/>1. LVN C failed to maintain infection control practices when performing wound care for Resident #5.<BR/>2. LVN C and RN B failed to maintain infection control practices when performing wound care for Resident #15.<BR/>These deficient practices could place residents at risk for delayed wound healing and infection.<BR/>The findings were:<BR/>1. Record review of Resident #5's admission Record, dated 4/20/24, reflected the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, and Depression. <BR/>Record review of Resident #5's quarterly MDS assessment, dated 2/26/24, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Further review revealed the resident had an unhealed Stage 4 pressure ulcer present upon admission/entry or re-entry.<BR/>Record review of Resident #5's Order Summary Report, dated 4/26/24, reflected an order for wound care as follows: Cleanse stage IV sacral wound with vashe. Apply collagen and calcium alginate with silver to wound bed. Paint peri-wound with skin prep. Secure with silicone dressing QD and PRN every day shift for wound care.<BR/>Observation of wound care for Resident #5 on 4/24/24 at 7:12 AM revealed LVN C started to gather treatment supplies, then left the treatment cart to retrieve the laptop computer, upon returning to the treatment cart LVN C did not wash or sanitize hands prior to preparing tray and supplies. Further observation revealed LVN C donned gloves after gathering all treatment supplies without washing or sanitizing her hands and proceeded to don gown. <BR/>2. Record review of Resident #15's admission Record, dated 4/23/24, reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning), Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), cognitive communication deficit, Pressure ulcer of sacral region Stage 4, and Anxiety. <BR/>Record review of Resident #15's quarterly MDS assessment, dated 3/15/24, reflected a BIMS score of 5, which indicated severe cognitive impairment Resident #15 had an unhealed Stage 4 pressure ulcer present upon admission/entry or re-entry. <BR/>Record review of Resident #15's Care Plan, reviewed 3/29/24, reflected: The resident has a pressure ulcer .1. Stage IV left gluteal wound- present on admission .Interventions .Administer treatments as ordered <BR/>Record review of Resident #15's Order Summary Report, dated 4/26/24, reflected an order for wound care as follows: Cleanse stage IV left gluteal wound with hibiclens, rinse with normal saline Pat dry with 4X4 gauze. Apply COLLAGEN/SILVER THEN hydrofera blue to wound bed. Skin prep peri-wound and Cover with silicone dressing QOD and PRN. one time a day every Tue, Thu, Sat for Wound healing. <BR/>Record review of Resident #15's Progress Note, dated 2/28/24, and authored by the NP, reflected: Multivitamin q day, Vitamin C 500 mg BID x30 days, Zinc 50 mg x14 days for wound healing. <BR/>Observation on 4/26/24 at 9:59 AM revealed Resident #15 was in bed. Resident #15 had Stage IV pressure injury to the left upper gluteal area.<BR/>Observation of wound care to the left gluteal area for Resident #15, on 4/27/24 at 9:38 AM, revealed RN B approached Resident #15 and explained the procedure. Further observation revealed RN B entered the bathroom and washed her hands for 5 seconds and donned gloves. RN B proceeded to clean Resident #15's peri-wound area and then the inside of the wound. RN B removed gloves after applying silicone dressing and donned new gloves without washing or sanitizing her hands. <BR/>During an interview on 4/27/24 at 10:14 AM, RN B stated she knew it was recommended to wash hands for a total of 20-30 seconds to prevent infections and she washed her hands for approximately 10 seconds. RN B further stated she had received wound care and infection control training approximately 2 years ago when she started working at the facility. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated she expected nurses provide wound care according to physician orders and maintain infection control to promote wound healing. <BR/>Record review of the facility's, undated, document titled Dressing Change Checklist reflected: Dressing Removal: Washes hands prior to applying gloves, when changing gloves and upon removal of gloves throughout dressing procedure . cleanses wound per orders and facility policy (working from center of wound to outside of wound) <BR/>Record review of the facility's policy titled, Fundamentals of Infection Control Precautions, dated 2018, reflected: .Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene . Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . Before and after changing a dressing .Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections .Recommended techniques for washing hands with soap and water include .rubbing hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers .Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident medical records are kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 2 of 2 residents (Residents #5 and #15) reviewed for accuracy of records, in that:<BR/>1. The facility failed to ensure Resident #5's wound care and treatments as ordered by the physician were documented.<BR/>2. The facility failed to ensure Resident #15's wound care and treatments as ordered by the physician were documented.<BR/>These deficient practices could place residents at risk for improper care due to inaccurate records.<BR/>The findings were:<BR/>1. Record review of Resident #5's admission Record, dated 4/20/24, reflected the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, and Depression. <BR/>Record review of Resident #5's quarterly MDS assessment, dated 2/26/24, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Further review revelaed the resident had an unhealed Stage 4 pressure ulcer present upon admission/entry or re-entry.<BR/>Record review of Resident #5's Order Summary Report, dated 4/26/24, reflected an order for wound care as follows: Cleanse stage IV sacral wound with vashe. Apply collagen and calcium alginate with silver to wound bed. Paint peri-wound with skin prep. Secure with silicone dressing QD and PRN every day shift for wound care.<BR/>Record review of Resident #5's April WAR reflected the resident did not receive wound care on the following days: 4/5/24, 4/6/24, 4/15/24, 4/17/24 and 4/21/24. <BR/>2. Record review of Resident #15's admission Record, dated 4/23/24, reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning), Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), cognitive communication deficit, Pressure ulcer of sacral region Stage 4, and Anxiety. <BR/>Record review of Resident #15's quarterly MDS assessment, dated 3/15/24, reflected a BIMS score of 5, which indicated severe cognitive impairment Resident #15 had an unhealed Stage 4 pressure ulcer present upon admission/entry or re-entry. <BR/>Record review of Resident #15's Care Plan, reviewed 3/29/24, reflected: The resident has a pressure ulcer .1. Stage IV left gluteal wound- present on admission .Interventions .Administer treatments as ordered <BR/>Record review of Resident #15's Order Summary Report, dated 4/26/24, reflected an order for wound care as follows: Cleanse stage IV left gluteal wound with hibiclens, rinse with normal saline Pat dry with 4X4 gauze. Apply COLLAGEN/SILVER THEN hydrofera blue to wound bed. Skin prep peri-wound and Cover with silicone dressing QOD and PRN. one time a day every Tue, Thu, Sat for Wound healing. <BR/>Record review of Resident #15's March WAR reflected the resident did not receive wound care on the following days: 3/21/24 and 3/25/24.<BR/>Record review of Resident #15's April WAR reflected the resident did not receive wound care on 4/6/24.<BR/>Record review of Resident #15's Progress Note, dated 2/28/24, and authored by the NP, reflected: Multivitamin q day, Vitamin C 500 mg BID x30 days, Zinc 50 mg x14 days for wound healing. <BR/>Observation on 4/26/24 at 9:59 AM revealed Resident #15 was in bed. Resident #15 had Stage IV pressure injury to the left upper gluteal area.<BR/>During an interview on 4/26/24 at 3:15 PM, the DON said the ADONs audited the records daily and she tried to audit weekly. She added the facility held a stand-up meeting where the ADONs brought their audit sheets and were asked if they had any missed medications/treatments, and they answered no. The DON said she was not aware of Resident #15's missed treatments in March and April. <BR/>During an interview on 4/24/24 at 9:20 AM, LVN C said she audited the Wound Care Administration Records when she was in the office but not when she was working on the floor. She added she thought the last time she audited them was last Friday, 4/19/24. LVN C said she was not aware of the missed treatments in April for Resident #5 and March and April for Resident #15 and did not remember if she worked on 3/21/24, 3/25/24, 4/5/24, 4/6/24, 4/15/24, 4/17/24 and 4/21/24. She added she was responsible for ensuring wound care was completed as ordered and the floor nurses were responsible for providing wound care in her absence. LVN C stated blanks in the WAR meant the treatment were either not completed or were not signed off after completion. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated herself and LVN C were responsible for ensuring wound care was completed. She further stated LVN C ran a missed treatment report daily and a 72-hour report on Mondays, she added this report was reviewed in the morning meetings. The DON said she was not aware of missed treatments for Resident #5 and Resident #15. The DON stated when LVN C was asked if there were any missed treatments during the morning meeting, LVN C answered no every time. The DON said blanks in the WAR meant the treatments were either not completed or not documented after completion. <BR/>Record review of the facility's, undated, document titled Dressing Change Checklist reflected: Dressing Removal: Washes hands prior to applying gloves, when changing gloves and upon removal of gloves throughout dressing procedure . cleanses wound per orders and facility policy (working from center of wound to outside of wound) <BR/>Record review of the facility's policy, titled Fundamentals of Infection Control Precautions, dated 2018, reflected: .Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene . Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . Before and after changing a dressing .Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections .Recommended techniques for washing hands with soap and water include .rubbing hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers .Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 (Resident #84) of 21 residents and 2 of 8 resident halls (Halls A and 300) reviewed for maintaining a safe, clean, comfortable, and homelike environment, in that: <BR/>1. Resident #84's wheelchair was visibly soiled with substances that appeared to be crumbs, dust, and residue of dried liquids. <BR/>2. A storage closet on the 300 Hall was unlocked and contained hazardous materials. <BR/>3. A shower room on Hall A was soiled with a smear of odorous brown substance on the wall. <BR/>These failures could place residents at risk of living in an unsanitary and uncomfortable environment and diminished quality of life. <BR/>The findings were: <BR/>1. Record review of Resident #84's face sheet, dated 08/26/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses including Other Seizures, Cerebral Infarction due to Unspecified Occlusion or Stenosis of Unspecified Cerebral Artery, and Personal History of Traumatic Brain Injury. <BR/>Record review of Resident #84's Quarterly MDS, dated [DATE], revealed a BIMS score of 12 which indicated the resident had moderate cognitive impairment. Further review revealed Resident #84 required extensive assistance from facility staff to perform activities of daily living. <BR/>Record review of Resident #84's care plan, revised 11/13/2018, revealed a focus, Resident [#84] has a physical mobility deficit [related to] recent admit to hospital and now with increased weakness and decreased mobility skills, and interventions, Appropriate assistive device to be used for mobility and locomotion. Resident requires [wheelchair]. He requires supervision assist X 1 staff at times . Resident is mobile using [wheelchair]. He requires supervision assist X 1 staff (at times) on and off unit. <BR/>Observation on 08/24/2022 at 5:52 p.m. revealed Resident #84's wheelchair was visibly soiled with substances that appeared to be crumbs, dust, and residue of dried liquids. <BR/>During an interview with Resident #84, at the same time as the observation, Resident #84 indicated he was aware his wheelchair was soiled and disliked that it was soiled. <BR/>During an interview with LVN G on 08/24/2022 at 5:55 p.m., LVN G confirmed that Resident #84's wheelchair was soiled and stated it would be cleaned. <BR/>During an interview with the Administrator on 08/25/2022 at 5:30 p.m., the Administrator confirmed resident wheelchairs should be maintained for cleanliness. <BR/>2. Observation on 08/23/2022 at 12:12 p.m. revealed an unlocked storage closet on Hall 300 which contained three unsecured spray bottles with liquid. Bottle #1 was labeled odor counteractant with warnings do not drink and may cause eye irritation. Bottle #2 was labeled multi-surface cleaner with warnings danger and keep out of reach of children. Bottle #3 was labeled disinfecting heavy-duty acid bathroom cleaner with warnings keep out of reach of children and hazard to humans and domestic animals. Two empty spray bottles with similar warning on the labels were observed with the three bottles containing liquid. <BR/>During an interview with Housekeeper D on 08/23/2022 at 12:18 p.m., Housekeeper D confirmed the storage closet on Hall 300 was unlocked and contained three unsecured bottles with liquid and warnings on their labels. Housekeeper D stated that the closet was always unlocked and that she stored and retrieved her housekeeping cart in the closet at each of her shifts. <BR/>3. Observation on 08/23/2022 at 12:32 p.m. of the shower room on Hall A revealed the wall was soiled with a smear of odorous brown substance. <BR/>During an interview with CNA E on 08/23/2022 at 12:35 p.m., CNA E confirmed the wall of the shower room on Hall A was soiled with a smear of odorous brown substance. <BR/>During an interview with the Administrator on 08/25/2022 at 5:30 p.m., the Administrator confirmed hazardous substances should be secured and resident shower rooms should not be soiled. <BR/>Record review of the facility's policy titled, Sanitation Assurance Program - Overview, dated 2021, revealed, 2. Daily Cleaning/Disinfecting Process d. Shower Rooms.<BR/>Record review of the facility's policy titled, Social Services Manual 2003, revised 11/28/2016, revealed, Safe Environment - The resident has a right to a safe, clean, comfortable and homelike environment .<BR/>Record review of the facility's policy titled, Resident Rights, revised 11/28/2016, revealed, Safe Environment - The resident has a right to a safe, clean, comfortable and homelike environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 12 residents (Resident #12) reviewed for care plans. <BR/>The facility failed to ensure Resident #12's care plan was revised to reflect prescribed diet and weight loss. <BR/>These failures could place residents at risk of current needs not being met. <BR/>Findings included:<BR/>Record review of Resident #12's admission Record, dated 4/22/24, reflected the resident was admitted to the facility on [DATE]. Resident #12 had diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning) , Malnutrition, Dysphagia (difficulty swallowing) , Cognitive Communication Deficit, Depression and GERD (digestive disease in which stomach acid or bile irritates the food pipe lining) . <BR/>Record review of Resident #12's quarterly MDS assessment, dated 1/3/24, reflected the resident had a BIMS score of 99, which indicated the resident was unable to complete the interview. Resident #12 weighed 147 pounds, a weight loss of 5% or more, was not on physician-prescribed weight-loss regimen and was on a mechanically altered and therapeutic diet. <BR/>Record review of Resident #12's Care Plan, dated 12/20/17, reflected the following focus area last revised on 6/3/23: Potential for weight loss due to impaired cognition with Dementia, Depression, edentulous status without the use of his dentures currently. DX: GERD and Malnutrition .Goal: Resident will maintain stable weight and adequate nutrition by consuming 75-100% of meals X 3 per day with diet and liquids at most lenient texture and with compliance to diet as ordered x90 days .Target date:4/9/24 <BR/>Record review of Resident #12's Order Summary, dated 4/20/24, reflected: Regular diet Mechanical Soft texture, Nectar consistency, Red Glass Program, Pur&eacute;ed meats with gravy, no straw. Magic cup with lunch for Per MBS study 2/13/23 related to Unspecified Protein-Calorie Malnutrition, start date 7/6/23; Readycare 2.0 four times a day for Weight Loss give 90CC, start date 2/27/24; Super Cereal in the morning for with breakfast, start date 10/25/23. <BR/>Record review of the facility's Weight and Vitals Summary, dated, 4/20/24, reflected Resident #12 weighed 145.6 lbs on 1/5/24 a 14.8% weight loss compared to 7/10/23 (170.8 lbs), 148.4 lbs on 1/12/24 a 13.1% weight loss compared to 7/10/23 (170.8 lbs), 143.4 lbs on 1/19/24 a 11.8% weight loss compared to 8/1/23 (162.2 lbs), 144.4 lbs on 2/2/24 a 10.3% weight loss compared to 8/11/23 (161 lbs), 144.4 lbs on 2/6/24 a 10.3% weight loss compared to 8/11/23 (161 lbs), and 144.4 lbs on 2/9/24 a 10.3% weight loss compared to 8/11/23 (161 lbs).<BR/>Record review of Resident #12's Progress Notes reflected:<BR/>Effective Date: 01/10/2024 09:31 [9:31 am] Type: Dietary Note .Note Text: Wt's 147.2 lbs, 145.6 lbs - loss of 11.6 lbs/90 days (7.38%), 25.2 lbs/180 days (14.75%). On a Mech Soft Diet, Nectar Thick Liquids, Pureed Meats with gravy, no straw, Super Cereal in a.m. with breakfast, Magic Cup with lunch . Red Glass Program. Provided a House Shake after meals and at bedtime d/t weight loss .Current diet, nutritional supplements and p. o. intake areadequate [sic] as evidenced by fairly stable weekly weights past 4 weeks. Recommend continuing with same plan of care - goal is no significant weight changes next 30 days. Author .Dietitian<BR/>Effective Date: 01/22/2024 18:28 [6:28 pm] Type: Nursing . Note Text: Contacted [NP] due to resident [sic] 5LBS wight [sic] loss in a week, did inform weight loss may have been due to resdient [sic] having a resp infection, will continue to monitor and weigh resdient [sic] weekly Author: [ADON A] Assistant Director of Nursing<BR/>Effective Date: 02/26/2024 10:16 [10:16 am] Type: Dietary Note .Note Text: Wt's 145.6 lbs, 144.4 lbs - loss of 17.8 lbs/180 days (10.97%). On a Mech Soft Diet, Nectar Thick Liquids, Super Cereal in a.m., pureed meats with gravy, no straw . Magic Cup with lunch. Red glass Program. Provided a House Shake after meals and at bedtime .Review of chart indicates p. o. intake is good for most meals, however, continued weight loss trend noted. Recommend the following: .House Shake after meals and at bedtime. Provide 90ml ReadyCare 2.0 or Med Pass 2.0 QID with med pass. Goal is no further weight loss. Author .Dietitian<BR/>Effective Date: 03/30/2024 07:18 [7:18 am] Type: Dietary Note . Note Text: Wt's 144.4 lbs, 142 lbs - loss of 17.4 lbs/180 days (10.92%). On a Mech Soft Diet, Nectar Thick Liquids, Pureed Meats with gravy, no straw, Magic Cup with lunch .Red Glass Program. Provided 90ml ReadyCare 2.0 QID . Review of chart indicates 2.24 RD recommendations are in place and weight has stabilized as evidenced by most recent weekly weight of 142 lbs. Recommend continuing with same plan of care . Author .Dietitian <BR/>Effective Date: 04/18/2024 11 :08 [11:08 am] Type: Dietary Note . Note Text: Wt's 142 lbs, 141 lbs - loss of 16.2 lbs/180 days (10.31 %). On a Mech Soft Diet, Nectar Thick Liquids, Super Cereal with breakfast, Pureed Meats with gravy, no straw, Magic Cup with lunch . Red Glass Program. Provided 90ml ReadyCare 2.0 QID .Current diet, nutritional supplements and p. o. intake are adequate as evidenced by fairly stable weight past 90 days. Recommend continuing with same plan of care . Author .Dietitian <BR/>During an interview on 4/27/24 at 12:47 PM, LVN A stated care plans were completed and updated by herself and RN A (MDS Coordinators). LVN A further stated care plans were completed quarterly when the MDS assessment was completed and PRN if there were changes in condition, services and/or needs. LVN A stated care plans were updated as soon as possible. LVN A further stated the facility had morning meetings and if changes were reported, she tried to update the appropriate care plans during the meeting. LVN A stated the facility also had daily nursing meetings with the DON, ADONs, Administrator and an the MDS nurse and standard of care meetings. LVN A stated care plans were supposed to reflect diet as ordered and stated Resident #12's diet was not included in the resident's care plan. <BR/>During interview on 4/27/24 at 2:17 PM, RN A stated the nurses on working on the floor were responsible for updating care plans with acute changes to the resident's conditions. RN A further stated the facility had a morning meeting every day and changes to the resident condition/orders were shared at this meeting. RN A stated she and LVN A were mainly responsible for admissions assessments, quarterly assessments and care plans. RN A further stated the MDS Coordinators (LVN A and RN A) updated care plans, but care plans were updated for acute changes in condition by the floor nurses. RN A stated updates were done when changes happened, and added there was not a timeframe, but the goal was to update the care plans immediately. RN A stated she not aware Resident #12's care plan had not been updated to reflect his weight loss and diet orders. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated diet orders were to be care planned. The DON further stated she expected care plans to be updated the day the change occurred. The DON stated the MDS, and charge nurses were responsible for updating care plans quarterly and when there were changes to orders. <BR/>Record review of the facility's, undated, policy, titled Comprehensive Care Planning, read: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life .The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented .revised based on changing goals, preferences and needs of the resident and in response to current interventions <BR/>Record review of the facility's policy, titled Red Glass and Fortified Food Program, dated 2012, revealed: .The red glass program uses the presence of a red glass on the resident's meal tray to alert facility staff to which residents may have had a weight loss and/or need additional monitoring and encouragement to complete meals and fluids. Dietary will provide the red glass .

Based on observation and interview the facility failed to post the current nurse staffing information for 1 of 1 facility reviewed for postings.<BR/>The facility failed to ensure the nurse staffing information was posted upon entrance on 4/19/24 and 4/20/24.<BR/>This deficient practice could place residents at risk by not providing adequate staffing information to ensure resident care needs were met.<BR/>Findings included:<BR/>Observation on 4/19/24 at 10:23 PM, revealed a posting which detailed nurse staffing information for 4/19/24 was not available at the entrance #1. Further observation revealed a posting detailing nurse staffing information for 4/19/24 was not available at the entrance #2.<BR/>Observation on 4/20/24 at 2:51 PM, revealed a posting detailing nurse staffing information for 4/20/24 was not available at the entrance #1. Further observation revealed a posting detailing nurse staffing information for 4/20/24 was not available at the entrance #2.<BR/>Observation and interview on 4/20/24 at 3:15 PM, revealed the staffing pattern was not posted. The DON stated the staffing pattern was not posted and the staffing pattern was supposed to be posted on the entrance #1 bulletin board. The DON further stated ADON B was responsible for posting the staffing patterns. <BR/>During an interview on 4/25/24 at 4:43 PM, ADON B stated the nurse staffing pattern postings within the facility were her responsibility. ADON B further stated she was off and did not know who was responsible for the postings in her absence.<BR/>During an interview on 4/20/24 at 5:52 PM, the DON said the facility did not have a staffing policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 3 residents reviewed for accuracy of assessments. <BR/>The facility failed to ensure Resident #1 was coded on his Quarterly MDS assessment, signed as completed on 02/11/2025, for a fall with major injury that occurred on 01/12/2025.<BR/>This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. <BR/>The findings included:<BR/>Record review of Resident #1's admission Record, dated 04/17/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE].<BR/>Record review of Resident #1's Diagnosis Report, dated 04/17/2025, reflected a primary and admitting diagnosis of Hemiplegia (partial to complete loss of muscle function of one side of the body) and Hemiparesis (muscle weakness of one side of the body) following an unspecified cerebrovascular disease (a group of conditions that affect the blood flow and blood vessels in the brain) affecting the left non-dominant side, epilepsy (a brain disorder that causes seizures), and other reduced mobility. <BR/>Record review of Resident #1's Nursing Note, dated 01/12/2025 at 09:31 p.m. by LPN A, reflected Resident #1 had an unwitnessed fall in his room on 01/12/2024. LPN A noted the fall caused a fracture to Left leg.<BR/>Record review of Resident #1's Fall Nurses Note 12hr, signed 01/17/2025 with effective date 01/15/2025 by LPN A, reflected Resident #1 sustained a fracture to his left leg with swelling and a brace applied for intervention. <BR/>Record review of Resident #1's Quarterly MDS, signed as completed on 02/11/2025 by the RN Assessment Coordinator B, reflected assessment observation end date of 01/29/2025. Resident #1 had a BIMS score of 10 indicating he was mildly impaired, he required substantial/maximal assistance for transferring from lying to sitting on the side of the bed or sitting to standing; and he had two or more falls since admission/entry or reentry or the prior assessment with no injury. He was documented as had no major injury since admission/entry or reentry or prior assessment. The assessment description for major injury included bone fractures. <BR/>An observation and interview with Resident #1 on 04/17/2025 at 04:25 p.m., revealed Resident #1 was lying in his bed with his head and shoulders slighted elevated watching television. Resident #1 appeared clean and groomed. His call light, a side table, and a bedside urinal bottle were in reach. The resident had two grab bars attached to both sides of his upper bed. Resident #1 revealed he had fallen a couple times at the facility. He stated on one fall he broke his leg. He stated staff responded okay and he felt safe at the facility. He revealed he continued to go to therapy. <BR/>During an interview on 04/17/2025 at 05:55 p.m., RN Assessment Coordinator B stated for falls, the DON would discuss the falls that were active or historical with the care team. She stated the DON was also responsible for care planning and assigning the interventions for a resident. She stated the facility had not had a DON since around Thanksgiving of the prior year, and the new DON had just started. She stated without a DON, the responsibility had fallen to the ADONs. She stated she and the other facility MDS Assessment Coordinator were responsible for ensuring the accuracy of the MDS Assessments; however, she stated they had to go off the information they could see, and they did not have a system in place to manually track the facility falls. She revealed when completing an MDS assessment there was a tab in the EMR that would trigger for any active or historical falls the resident being assessed had. She revealed when the information on a fall or incident was not completed or still open, then that fall history would not pull into the information they used to complete the assessments. She stated a missed fall on the MDS assessment would not have impacted the resident's care in the slightest if the care plan was updated with the interventions enacted for that fall.<BR/>During an interview and record review on 04/17/2025 at 06:21 p.m., RN Assessment Coordinator B stated in the EMR, when reviewing the risk management tab, it showed a resident's active incidents and, on another page, the closed incidents. Record review of Resident #1's Historical Incidents Report, undated and accessed on 04/17/2025 by RN Assessment Coordinator B, revealed Resident #1 had a fall incident on 01/12/2025 at 08:05 p.m. The incident was noted as closed on 03/11/2025 at 02:50 p.m. RN Assessment Coordinator B stated she assumed Resident #1's fall on 01/12/2025 was not closed until 03/11/2025 because they were unable to determine his injury. <BR/>During an interview on 04/17/2025 at 07:13 p.m., the DON stated she had just started working at the facility on 04/09/2025. She stated it would be the MDS Coordinator's responsibility to ensure the MDS assessments were accurate. She stated an RN was required to review a completed MDS assessment and sign it to indicate the assessment was accurate and complete. She stated if an MDS assessment was not accurate for fall history, but the care plan was updated with the appropriate interventions following the fall, then the inaccuracy in the assessment would not impact the resident's care. <BR/>During an interview on 04/17/2025 at 07:18 p.m., the ADMIN revealed every weekday morning she would go over the incidents and accidents that occurred during the night with the care team, and then the care team would also have a stand down meeting at the end of the day to discuss anything that happened during that day. She stated she also believed incidents and accidents would appear on the staff's dashboard when they logged into the EMR. She stated during the care team discussions, they discussed what happened, interventions, and the necessity to update the care plan. She stated the MDS Coordinators were supposed to attend both daily meetings. She stated she believed it was the MDS Consultant's responsibility to initially catch MDS errors, but the facility also had a compliance nurse. She stated the MDS Coordinator would sign the MDS Assessments, but then the MDS Consultant would check them. She stated she was unsure if the MDS Consultant checked every MDS Assessment. The ADMIN stated the DON would normally be the person responsible for completing the facility incident documentation in the EMR, but in the absence of the DON, the compliance nurse was working on them. She stated the compliance nurse would have been able to see if any incidents were still open and she was usually at the facility weekly or able to do them offsite. The ADMIN stated the compliance nurse was able to communicate with the ADONs if there were any sections of an incident report that needed completion. The ADMIN revealed that if the care plan was updated appropriately after a resident fall, then an inaccurate MDS Assessment would not impact the residents care but may impact the facility's reimbursement for that care. <BR/>Record review of facility policy, Resident Assessment, noted as a section of the Nursing Policy & Procedure Manual 2003, revealed 7. Each assessment will be conducted or coordinate with the appropriate participation of health professionals. Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living for 1 (Resident #52) of 21 residents reviewed, in that: <BR/>Resident #52 did not receive assistance needed for personal grooming. <BR/>This failure could lead to embarrassment, diminished self-worth, and diminished quality of life. <BR/>The findings were: <BR/>Record review of Resident #52's face sheet, dated 08/26/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses including Muscle Weakness Generalized, Other Chronic Pain, and Anxiety Disorder. <BR/>Record review of Resident #52's comprehensive MDS, dated [DATE], revealed a BIMS score of 7 which indicated severe cognitive impairment. Further review revealed the resident required extensive assistance with personal hygiene. <BR/>Record review of Resident #52's care plan, revised 08/07/2022, revealed a focus, The resident [#52] is dependent for ADL [activities of daily living] care tasks, a goal, Resident will be clean, well groomed ., and intervention, Resident [#52] requires extensive assist x 1 staff for personal hygiene tasks.<BR/>Observation on 08/23/2022 at 10:42 a.m. revealed Resident #52 had approximately 10 individual hairs on her chin which were approximately 1 to 1 &frac12; inch long. <BR/>During an interview with Resident #52, at the same time as the observation, Resident #52 stated she wanted to remove the hair on her chin and indicated having chin hair bothered her by stating, I know it looks awful. <BR/>During an interview with CNA C, on 08/23/2022 at 10:45 a.m., CNA C confirmed that Resident #52 had approximately 10 individual hairs on her chin which were approximately 1 to 1 &frac12; inch long. CNA C reported that hair removal was part of shower/bath duties performed by CNAs stated she was unaware why the task had not been completed, and indicated having unwanted facial hair, especially for a female resident, could cause embarrassment and loss of dignity. <BR/>During an interview with the DON on 08/26/2022 at 1:30 p.m., the DON confirmed residents should receive assistance needed to perform activities of daily living, including grooming and maintenance of personal hygiene. <BR/>Record review of the facility policy, Shaving, Electric/Safety Razors, dated 2003, revealed, Shaving .It is usually done as a part of daily personal hygeine .Goals: 1. The resident will experience cleanliness and comfort.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 3 the residents (Resident # 18) reviewed for oxygen use.<BR/>The facility failed to ensure Residents #18's, oxygen tubing and mask was bagged and stored off the floor. <BR/>This failure could place residents who received oxygen therapy at risk for an increase in respiratory complications.<BR/>The findings were:<BR/>Record review of Resident #18's face sheet dated 12/03/2024 revealed a [AGE] year-old male admitted to the facility initially on 12/12/2019 and re-admitted on [DATE], and with diagnoses that included: Dementia (a group of symptoms affecting memory, thinking and social abilities) and Chronic Obstructive Pulmonary Disease (lung disease that blocks air flow and makes it difficult to breathe). <BR/>Record review of Resident #18's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating intact cognition.<BR/>Record review of Resident #18's Physician Order Summary dated 12/03/2024 revealed an order for O2 [oxygen] at nasal cannula 2-3 liters apply at night and PRN as needed for shortness of breath.<BR/>Observations on12/03/2024 at 11:34 a.m and 12/04/2024 at 8:10 a.m. inside Resident #18's room, revealed Resident #18's oxygen tubing and nasal cannula were laying coiled loosely on the top of his oxygen concentrator not bagged, and his oxygen/nebulizer mask was lying on the floor behind the oxygen concentrator.<BR/>During an interview with Resident #18 on 12/03/2024 at 11:36 a.m., Resident #18 stated that he only used oxygen at night and sometimes received nebulizer treatments. He further stated that the Nurse's change out the tubing every Sunday. <BR/>A second observation on 12/04/2024 at 8:10a.m. inside Resident #18's room with LVN I, revealed Resident #18's oxygen tubing and nasal cannula were still loosely coiled around the top of his oxygen concentrator, and the mask was still lying on the floor behind the oxygen concentrator.<BR/>In an interview with LVN I on 12/04/2024 at 8:10 a.m., LVN I stated that Resident #18 used oxygen supplementation at night and as needed, and stated the oxygen tubing and mask should be stored in a plastic bag, not on the floor to prevent damage to the tubing and cross contamination. He stated he did not administer the oxygen during the day to Resident #18 and did not know why the tubing and mask were not placed in plastic bag for storage,<BR/>During an interview with the RCN on 12/04/2024 at 1:55 p.m. the RCN stated oxygen tubing/mask should always be stored in a plastic bag, so that it stays clean and off the floor, and to prevent cross-contamination. She stated that it was the responsibility of the administering Nurse and all the Nurse's working with Resident #18 to ensure that the oxygen tubing/mask was stored correctly in a plastic bag after use. The RCN provided a copy of the facility policy titled Oxygen Administration revised February 13, 2007, but noted that it did not address proper storage of oxygen tubing/masks, and that she did not have any other policy addressing storage of oxygen tubing and masks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. <BR/>The facility failed to transport Resident #1 to a scheduled appointment with an oncologist, MD F as ordered on 02/10/2025. <BR/>This failure could place residents at risk for not receiving appropriate care and treatment and or a decline in their health. <BR/>Findings included: <BR/>Record review of Resident #1's admission Record, dated 02/13/2025, reflected Resident #1 was a [AGE] year-old male. He was admitted on [DATE]. MD G was noted as Resident #1's attending physician.<BR/>Record review of Resident #1 Diagnosis Report, dated 02/13/2025, reflected Resident #1 was noted to have diagnoses including secondary malignant neoplasm (a cancerous tumor either caused by a prior cancer treatment or a tumor unrelated and in a new location from a prior cancer) of unspecified site, squamous cell carcinoma (a type of skin cancer) of skin of scalp and neck, unilateral paralysis of vocal cords (a condition in which one vocal cord cannot move or has limited movement) and larynx (voice box), and localized enlarged lymph nodes (swollen clusters of immune system cells). <BR/>Record review of Resident #1's admission MDS, signed as completed on 11/17/2024, reflected Resident #1 had a BIMS score of 13, indicating he was cognitively intact. He was documented as requiring substantial/maximal assistance with sit to stand, chair/bed-to-chair transfers, and car transfers. He used a wheelchair and required supervision or touching assistance when wheeling 50 feet with two turns and 150 feet. His active diagnoses included cancer. <BR/>Record review of Resident #1's Care Plan, dated as last review completed 01/24/2025, reflected Resident #1 had a communication problem r/t paralysis of left side vocal cords due to localized enlarged lymph nodes resulting in squamous cell carcinoma of left side of neck. Resident also with mets [Metastasis; a process by which cancer cells spread to other parts of the body] to chest. Interventions included: Anticipate and meet needs., initiated 11/09/2024.<BR/>Record review of Resident #1's Progress Notes reflected: <BR/>- A Nursing Progress Note, effective date 02/04/2025 at 03:05 p.m. by LPN C, [Oncologist Office Manager] with [MD F] called at this time and appt for this resident was made for Monday 2/10/25 @ 2:00PM[sic]. <BR/>- A Nursing Progress Note, effective date 02/10/2025 at 03:48 p.m. by ADON A, CONTACTED [MD F] REGARDING SCHEDULING RESIDENT APPOINMENT [sic] NO ANSWER VM WAS LEFT WITH CONTACT INFO. <BR/>Record review of Resident #1's Order Recap Report, dated 02/13/2024 with order dates 11/08/2024 - 02/28/2025, reflected an order, order dated 02/04/2025 with start date 02/10/2025 and end date 02/11/2025, ordered by MD G, [MD F] called at this time and appt for this resident was made for Monday 2/10/25 @ 2:00PM one time only for 1 Day. Order status was noted to be documented as Completed. <BR/>Record review of Resident #1's 2/1/2025 - 2/28/2025 Treatment Administration Record, dated as printed on 02/13/2025, reflected the order [MD F] called at this time and appt for this resident was made for Monday 2/10/25 @ 2:00PM one time only for 1 Day. The order was documented as Administered by LPN E on 02/10/2025 at 10:32 a.m.<BR/>During an interview on 02/13/2025 at 10:21 p.m., Resident #1's RP stated Resident #1 had missed an oncology appointment due to the transportation not having been scheduled. Resident #1's RP stated Resident #1 had cancer that had not progressed far but was virulent (rapidly harmful), which indicated Resident #1 could not miss any of his cancer treatment appointments. <BR/>During an interview on 02/13/2025 at 12:04 p.m., Resident #1 reported the facility had canceled prior appointments he was scheduled due to lack of transportation. Resident #1 stated he believed he missed two appointments but was not sure. Resident #1 stated the facility was aware he missed his appointments and felt that the facility was not good about taking him to his appointments. <BR/>During an interview on 02/13/2025 at 02:00 p.m., the Transportation Nurse stated the facility procedure for scheduling resident appointments was for the nurses on Resident #1's side of the facility to first put in the order for the appointment and then they would also put in the appointment on the appointments calendar. The Transportation Nurse stated she was made aware of upcoming appointments by reviewing the appointment calendar and she would also be knowledgeable of scheduled appointments she had scheduled herself. She stated she was unaware of Resident #1 having had missed any appointments scheduled in January or February (of 2025). <BR/>During an interview on 02/13/2025 at 02:15 p.m., LPN E stated the facility procedure for scheduling resident appointments was for the nurse who received the appointment to put in the appointment order once scheduled and then to put the appointment on the appointment calendar. LPN E stated it was the responsibility of the nursing staff to correctly schedule appointments and that the appointment calendar was specifically for transportation scheduling. LPN E stated she was Resident #1's nurse on the day he had a scheduled radiation appointment, 02/10/2025. She stated she notified her nursing aides and reminded Resident #1 of his appointment that morning so he would be ready for transportation at 01:00 p.m. She stated he was ready, dressed, and with his paperwork for the appointment prepared prior to her leaving for a lunch break. She said that when she returned from her lunch break, she was asked by ADON A why Resident #1 missed his appointment. She stated at that time she verified that the resident's appointment was ordered, which she had already marked as completed prior to her break. She stated she also checked the appointment calendar and found that his appointment on the calendar was no longer present. She stated she remembered his appointment having been on the calendar earlier that morning but that she had been previously observed that appointments could be deleted or disappear. She did not state that she had reported her observations of appointments having been deleted. She stated she did not know for certain how Resident #1's appointment did not show on the appointment calendar once reviewed following his missed 02/10/2025 appointment. <BR/>During an interview on 02/13/2025 at 02:29 p.m., ADON B stated she was aware Resident #1 missed his radiology appointment. She stated a radiology appointment was pretty important for the Resident's care and that a resident should not miss any appointments unless there was an outlying reason. <BR/>During an interview on 02/13/2025 at 02:41 p.m., the Oncologist Office Manager for MD F confirmed Resident #1 missed his scheduled 02/10/2025 appointment. She stated MD F was unavailable for interview; however, she stated that the 02/10/2025 appointment was Resident #1's first appointment with MD F which meant the doctor would not be able to estimate the impact on Resident #1's health for having a 8-day delay in appointment visits. <BR/>Attempted interview on 02/13/2025 at 03:20 p.m. with MD G, Resident #1's primary physician. MD G's office staff member reported he was unavailable for interview.<BR/>During an interview on 02/13/2025 at 03:33 p.m., ADON A stated she was aware Resident #1 recently missed an appointment. ADON A stated she was not sure of what caused the missed appointment. ADON A stated her understanding was that the appointment was not on the appointment calendar and the van driver would have then not been aware of the appointment. She stated Resident #1 was ready to go to his appointment but between 01:30 p.m. and 02:00 p.m., he did not get picked up by transportation. She stated she believed LPN E was on break during that time. ADON A stated that appointments were communicated to nursing staff through the 24-hour report, the Medication Administration Report which shows the appointment order, and on the transportation calendar. ADON A stated she was unsure if the transportation nurse had access to the 24-hour report but did have access to the transportation calendar. ADON A stated following Resident #1's missed appointment, she spoke with LPN E and re-educated LPN E on her responsibility to ensure the residents leave for their scheduled appointments. <BR/>During an interview on 02/13/2025 at 04:38 p.m., the ADMIN stated she and the ADONs review the transportation calendar each morning during their morning meeting. The ADMIN revealed she believed access to the transportation calendar was restricted to only the nursing staff and department managers. She stated appointments could be rescheduled and or deleted but was unsure how to view a report to show that information. She stated nursing staff would typically make appointments and they were to then put the appointment in the transportation calendar, which would communicate the scheduled appointment with the transportation nurse. The ADMIN stated the facility did not have a formal procedure or monitoring report to ensure that scheduled appointments were put both into the resident's orders and onto the transportation calendar. The ADMIN stated that the facility's biggest confusion was that scheduled appointments needed to be in both places and if an appointment was not on the transportation calendar, there would be a miscommunication. The ADMIN stated every appointment was important and Resident #1's condition could worsen if he was not making his appointments. <BR/>Record review of facility policy Appointments, labeled as part of Nursing Policy & Procedure Manual 2003, reflected The facility will assist with outside facility resident appointments to ensure the resident attends any scheduled appointment., and under procedure, 2. If facility transportation is to be used, the staff member responsible for transportation will be notified to schedule the appointment.

**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 and the facility provided food that accommodated resident allergies, intolerances, and preferences for 1 of 15 residents (Resident #16) reviewed for dietary services.<BR/>The facility failed to ensure Resident #16's was not served he was allergic to and was served onions with the meal. <BR/>This deficient practice could place residents at-risk by contributing to poor intake, weight loss and/or allergic reaction.<BR/>Findings include:<BR/>Record review of Resident #16's admission Record, dated 4/24/24, reflected the resident was re-admitted to the <BR/>facility on 8/21/20. Resident #16 had diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), Muscle Wasting and Hypertension (high blood pressure).<BR/>Record review of Resident #16's quarterly MDS assessment, dated 2/15/24, reflected the resident had a BIMS score of 12, which indicated moderately impaired cognition. <BR/>Record review of Resident #16's Order Summary, dated 4/24/24, reflected the resident had an allergy to onions. <BR/>Record review of Resident #16's Care Plan, revised 12/1/21, reflected: Resident is allergic to .onion .Resident will not receive known allergens .Do NOT administer food/medications/materials known to be allergens <BR/>Observation of Resident #16's dinner plate on 4/24/24 at 5:30 PM revealed the residents plate contained chicken salad on a lettuce leaf, a deviled egg, vegetables and peaches. <BR/>During an interview on 4/25/24 at 1:55 PM, Resident #16 said she was served chicken salad for dinner but could not eat it because she saw onions in it. Resident #16 further stated she asked for an alternate meal but was not brought anything else, so she ate [NAME] and crackers. Resident #16 said when she ingested onions she broke out in hives. <BR/>During an interview on 4/27/24 at 5:31 PM, [NAME] A said he believed he did use onions in the chicken salad. [NAME] A further stated he was not told there was a resident with an onion allergy and was not aware Resident #16 had an allergy to onions. <BR/>Record review of the facility's Recipes to Scale, dated 4/25/24, reflected: .Chicken salad on Lettuce Leaf .Onion Yellow Jumbo <BR/>Record review of the facility's policy, titled Preparation of Foods, dated 2012, reflected: .2. All food . will be attractively served .in a form to meet the individual needs of the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 3 residents reviewed for accuracy of assessments. <BR/>The facility failed to ensure Resident #1 was coded on his Quarterly MDS assessment, signed as completed on 02/11/2025, for a fall with major injury that occurred on 01/12/2025.<BR/>This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. <BR/>The findings included:<BR/>Record review of Resident #1's admission Record, dated 04/17/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE].<BR/>Record review of Resident #1's Diagnosis Report, dated 04/17/2025, reflected a primary and admitting diagnosis of Hemiplegia (partial to complete loss of muscle function of one side of the body) and Hemiparesis (muscle weakness of one side of the body) following an unspecified cerebrovascular disease (a group of conditions that affect the blood flow and blood vessels in the brain) affecting the left non-dominant side, epilepsy (a brain disorder that causes seizures), and other reduced mobility. <BR/>Record review of Resident #1's Nursing Note, dated 01/12/2025 at 09:31 p.m. by LPN A, reflected Resident #1 had an unwitnessed fall in his room on 01/12/2024. LPN A noted the fall caused a fracture to Left leg.<BR/>Record review of Resident #1's Fall Nurses Note 12hr, signed 01/17/2025 with effective date 01/15/2025 by LPN A, reflected Resident #1 sustained a fracture to his left leg with swelling and a brace applied for intervention. <BR/>Record review of Resident #1's Quarterly MDS, signed as completed on 02/11/2025 by the RN Assessment Coordinator B, reflected assessment observation end date of 01/29/2025. Resident #1 had a BIMS score of 10 indicating he was mildly impaired, he required substantial/maximal assistance for transferring from lying to sitting on the side of the bed or sitting to standing; and he had two or more falls since admission/entry or reentry or the prior assessment with no injury. He was documented as had no major injury since admission/entry or reentry or prior assessment. The assessment description for major injury included bone fractures. <BR/>An observation and interview with Resident #1 on 04/17/2025 at 04:25 p.m., revealed Resident #1 was lying in his bed with his head and shoulders slighted elevated watching television. Resident #1 appeared clean and groomed. His call light, a side table, and a bedside urinal bottle were in reach. The resident had two grab bars attached to both sides of his upper bed. Resident #1 revealed he had fallen a couple times at the facility. He stated on one fall he broke his leg. He stated staff responded okay and he felt safe at the facility. He revealed he continued to go to therapy. <BR/>During an interview on 04/17/2025 at 05:55 p.m., RN Assessment Coordinator B stated for falls, the DON would discuss the falls that were active or historical with the care team. She stated the DON was also responsible for care planning and assigning the interventions for a resident. She stated the facility had not had a DON since around Thanksgiving of the prior year, and the new DON had just started. She stated without a DON, the responsibility had fallen to the ADONs. She stated she and the other facility MDS Assessment Coordinator were responsible for ensuring the accuracy of the MDS Assessments; however, she stated they had to go off the information they could see, and they did not have a system in place to manually track the facility falls. She revealed when completing an MDS assessment there was a tab in the EMR that would trigger for any active or historical falls the resident being assessed had. She revealed when the information on a fall or incident was not completed or still open, then that fall history would not pull into the information they used to complete the assessments. She stated a missed fall on the MDS assessment would not have impacted the resident's care in the slightest if the care plan was updated with the interventions enacted for that fall.<BR/>During an interview and record review on 04/17/2025 at 06:21 p.m., RN Assessment Coordinator B stated in the EMR, when reviewing the risk management tab, it showed a resident's active incidents and, on another page, the closed incidents. Record review of Resident #1's Historical Incidents Report, undated and accessed on 04/17/2025 by RN Assessment Coordinator B, revealed Resident #1 had a fall incident on 01/12/2025 at 08:05 p.m. The incident was noted as closed on 03/11/2025 at 02:50 p.m. RN Assessment Coordinator B stated she assumed Resident #1's fall on 01/12/2025 was not closed until 03/11/2025 because they were unable to determine his injury. <BR/>During an interview on 04/17/2025 at 07:13 p.m., the DON stated she had just started working at the facility on 04/09/2025. She stated it would be the MDS Coordinator's responsibility to ensure the MDS assessments were accurate. She stated an RN was required to review a completed MDS assessment and sign it to indicate the assessment was accurate and complete. She stated if an MDS assessment was not accurate for fall history, but the care plan was updated with the appropriate interventions following the fall, then the inaccuracy in the assessment would not impact the resident's care. <BR/>During an interview on 04/17/2025 at 07:18 p.m., the ADMIN revealed every weekday morning she would go over the incidents and accidents that occurred during the night with the care team, and then the care team would also have a stand down meeting at the end of the day to discuss anything that happened during that day. She stated she also believed incidents and accidents would appear on the staff's dashboard when they logged into the EMR. She stated during the care team discussions, they discussed what happened, interventions, and the necessity to update the care plan. She stated the MDS Coordinators were supposed to attend both daily meetings. She stated she believed it was the MDS Consultant's responsibility to initially catch MDS errors, but the facility also had a compliance nurse. She stated the MDS Coordinator would sign the MDS Assessments, but then the MDS Consultant would check them. She stated she was unsure if the MDS Consultant checked every MDS Assessment. The ADMIN stated the DON would normally be the person responsible for completing the facility incident documentation in the EMR, but in the absence of the DON, the compliance nurse was working on them. She stated the compliance nurse would have been able to see if any incidents were still open and she was usually at the facility weekly or able to do them offsite. The ADMIN stated the compliance nurse was able to communicate with the ADONs if there were any sections of an incident report that needed completion. The ADMIN revealed that if the care plan was updated appropriately after a resident fall, then an inaccurate MDS Assessment would not impact the residents care but may impact the facility's reimbursement for that care. <BR/>Record review of facility policy, Resident Assessment, noted as a section of the Nursing Policy & Procedure Manual 2003, revealed 7. Each assessment will be conducted or coordinate with the appropriate participation of health professionals. Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 12 residents (Resident #12) reviewed for care plans. <BR/>The facility failed to ensure Resident #12's care plan was revised to reflect prescribed diet and weight loss. <BR/>These failures could place residents at risk of current needs not being met. <BR/>Findings included:<BR/>Record review of Resident #12's admission Record, dated 4/22/24, reflected the resident was admitted to the facility on [DATE]. Resident #12 had diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning) , Malnutrition, Dysphagia (difficulty swallowing) , Cognitive Communication Deficit, Depression and GERD (digestive disease in which stomach acid or bile irritates the food pipe lining) . <BR/>Record review of Resident #12's quarterly MDS assessment, dated 1/3/24, reflected the resident had a BIMS score of 99, which indicated the resident was unable to complete the interview. Resident #12 weighed 147 pounds, a weight loss of 5% or more, was not on physician-prescribed weight-loss regimen and was on a mechanically altered and therapeutic diet. <BR/>Record review of Resident #12's Care Plan, dated 12/20/17, reflected the following focus area last revised on 6/3/23: Potential for weight loss due to impaired cognition with Dementia, Depression, edentulous status without the use of his dentures currently. DX: GERD and Malnutrition .Goal: Resident will maintain stable weight and adequate nutrition by consuming 75-100% of meals X 3 per day with diet and liquids at most lenient texture and with compliance to diet as ordered x90 days .Target date:4/9/24 <BR/>Record review of Resident #12's Order Summary, dated 4/20/24, reflected: Regular diet Mechanical Soft texture, Nectar consistency, Red Glass Program, Pur&eacute;ed meats with gravy, no straw. Magic cup with lunch for Per MBS study 2/13/23 related to Unspecified Protein-Calorie Malnutrition, start date 7/6/23; Readycare 2.0 four times a day for Weight Loss give 90CC, start date 2/27/24; Super Cereal in the morning for with breakfast, start date 10/25/23. <BR/>Record review of the facility's Weight and Vitals Summary, dated, 4/20/24, reflected Resident #12 weighed 145.6 lbs on 1/5/24 a 14.8% weight loss compared to 7/10/23 (170.8 lbs), 148.4 lbs on 1/12/24 a 13.1% weight loss compared to 7/10/23 (170.8 lbs), 143.4 lbs on 1/19/24 a 11.8% weight loss compared to 8/1/23 (162.2 lbs), 144.4 lbs on 2/2/24 a 10.3% weight loss compared to 8/11/23 (161 lbs), 144.4 lbs on 2/6/24 a 10.3% weight loss compared to 8/11/23 (161 lbs), and 144.4 lbs on 2/9/24 a 10.3% weight loss compared to 8/11/23 (161 lbs).<BR/>Record review of Resident #12's Progress Notes reflected:<BR/>Effective Date: 01/10/2024 09:31 [9:31 am] Type: Dietary Note .Note Text: Wt's 147.2 lbs, 145.6 lbs - loss of 11.6 lbs/90 days (7.38%), 25.2 lbs/180 days (14.75%). On a Mech Soft Diet, Nectar Thick Liquids, Pureed Meats with gravy, no straw, Super Cereal in a.m. with breakfast, Magic Cup with lunch . Red Glass Program. Provided a House Shake after meals and at bedtime d/t weight loss .Current diet, nutritional supplements and p. o. intake areadequate [sic] as evidenced by fairly stable weekly weights past 4 weeks. Recommend continuing with same plan of care - goal is no significant weight changes next 30 days. Author .Dietitian<BR/>Effective Date: 01/22/2024 18:28 [6:28 pm] Type: Nursing . Note Text: Contacted [NP] due to resident [sic] 5LBS wight [sic] loss in a week, did inform weight loss may have been due to resdient [sic] having a resp infection, will continue to monitor and weigh resdient [sic] weekly Author: [ADON A] Assistant Director of Nursing<BR/>Effective Date: 02/26/2024 10:16 [10:16 am] Type: Dietary Note .Note Text: Wt's 145.6 lbs, 144.4 lbs - loss of 17.8 lbs/180 days (10.97%). On a Mech Soft Diet, Nectar Thick Liquids, Super Cereal in a.m., pureed meats with gravy, no straw . Magic Cup with lunch. Red glass Program. Provided a House Shake after meals and at bedtime .Review of chart indicates p. o. intake is good for most meals, however, continued weight loss trend noted. Recommend the following: .House Shake after meals and at bedtime. Provide 90ml ReadyCare 2.0 or Med Pass 2.0 QID with med pass. Goal is no further weight loss. Author .Dietitian<BR/>Effective Date: 03/30/2024 07:18 [7:18 am] Type: Dietary Note . Note Text: Wt's 144.4 lbs, 142 lbs - loss of 17.4 lbs/180 days (10.92%). On a Mech Soft Diet, Nectar Thick Liquids, Pureed Meats with gravy, no straw, Magic Cup with lunch .Red Glass Program. Provided 90ml ReadyCare 2.0 QID . Review of chart indicates 2.24 RD recommendations are in place and weight has stabilized as evidenced by most recent weekly weight of 142 lbs. Recommend continuing with same plan of care . Author .Dietitian <BR/>Effective Date: 04/18/2024 11 :08 [11:08 am] Type: Dietary Note . Note Text: Wt's 142 lbs, 141 lbs - loss of 16.2 lbs/180 days (10.31 %). On a Mech Soft Diet, Nectar Thick Liquids, Super Cereal with breakfast, Pureed Meats with gravy, no straw, Magic Cup with lunch . Red Glass Program. Provided 90ml ReadyCare 2.0 QID .Current diet, nutritional supplements and p. o. intake are adequate as evidenced by fairly stable weight past 90 days. Recommend continuing with same plan of care . Author .Dietitian <BR/>During an interview on 4/27/24 at 12:47 PM, LVN A stated care plans were completed and updated by herself and RN A (MDS Coordinators). LVN A further stated care plans were completed quarterly when the MDS assessment was completed and PRN if there were changes in condition, services and/or needs. LVN A stated care plans were updated as soon as possible. LVN A further stated the facility had morning meetings and if changes were reported, she tried to update the appropriate care plans during the meeting. LVN A stated the facility also had daily nursing meetings with the DON, ADONs, Administrator and an the MDS nurse and standard of care meetings. LVN A stated care plans were supposed to reflect diet as ordered and stated Resident #12's diet was not included in the resident's care plan. <BR/>During interview on 4/27/24 at 2:17 PM, RN A stated the nurses on working on the floor were responsible for updating care plans with acute changes to the resident's conditions. RN A further stated the facility had a morning meeting every day and changes to the resident condition/orders were shared at this meeting. RN A stated she and LVN A were mainly responsible for admissions assessments, quarterly assessments and care plans. RN A further stated the MDS Coordinators (LVN A and RN A) updated care plans, but care plans were updated for acute changes in condition by the floor nurses. RN A stated updates were done when changes happened, and added there was not a timeframe, but the goal was to update the care plans immediately. RN A stated she not aware Resident #12's care plan had not been updated to reflect his weight loss and diet orders. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated diet orders were to be care planned. The DON further stated she expected care plans to be updated the day the change occurred. The DON stated the MDS, and charge nurses were responsible for updating care plans quarterly and when there were changes to orders. <BR/>Record review of the facility's, undated, policy, titled Comprehensive Care Planning, read: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life .The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented .revised based on changing goals, preferences and needs of the resident and in response to current interventions <BR/>Record review of the facility's policy, titled Red Glass and Fortified Food Program, dated 2012, revealed: .The red glass program uses the presence of a red glass on the resident's meal tray to alert facility staff to which residents may have had a weight loss and/or need additional monitoring and encouragement to complete meals and fluids. Dietary will provide the red glass .

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 3 of 3 medication carts (Medication cart #1, Medication cart #2, and Medication cart#3) reviewed for medication storage.<BR/>1. <BR/>The facility failed to ensure the Medication cart by the nurses' station did not have a medication cup with pills sitting on top of the cart. <BR/>2. <BR/>LVN F failed to ensure the Medication cart on 100 hall was not left unlocked with a resident standing next to it, while the LVN went into resident room to administer medications . <BR/>3. <BR/>The facility failed to ensure the Medication cart on 300 hall was not left unlocked. <BR/>4. <BR/>The facility failed to ensure the Medication cart was not left unlocked. <BR/>These deficient practices could place residents at risk of medication misuse and drug diversion.<BR/>Findings include:<BR/>1. Observation on 4/23/24 at 9:28 PM revealed LVN F was sitting at the nurses' station with her back to the medication cart #1. The medication cart was unlocked, unattended and had a medication cup with pills in it on top of the medication cart. There were no staff members or residents in the area.<BR/>During an interview on 4/23/24 at 9:34 PM, LVN F stated she usually went to each resident room with the medication cart and then pulled each resident's medications. LVN F further stated she was not told she could not prepare medications in advance, and she had done this in the past but usually locked the medication cups in the cart. LVN F stated medication carts were not supposed to be left unlocked when unattended. LVN F further stated medications should not have been left unattended on top of the cart because a resident could have taken medications. <BR/>2. During observation and interview on 4/23/24 at 10:05 PM, LVN F left the medication cart #1 unlocked with a resident standing next to the cart while she entered the resident's room to administer medications to another resident. LVN F stated the medication cart was left unlocked and medication carts were not to be left unlocked when unattended. LVN F further stated the resident standing in the hallway could have accessed the medication in the cart. <BR/>3. During observation and interview on 4/23/24 at 9:30 PM, the medication cart #2 on the 300 hall was unlocked and there were no staff in the hallway. MA A stated the medication cart should not have been unlocked.<BR/>4. During observation and interview on 4/24/24 at 7:04 AM, a medication cart #3 was unlocked and unattended. There were no staff at the nurses' station or in the hallway and a resident was sitting in his wheelchair next to the medication cart. MA B stated her medication cart #3 should not have been unlocked. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated medication carts should never be unlocked and medications should not be left on top of medication carts unattended. The DON further stated these expectations were relayed to the nursing staff several times. <BR/>Record review of the facility's policy titled, Medication Administration Procedures revised 10/25/17, reflected the following: 3. Open the unit dose package only when you are administering medication directly to the resident. Removing the medication from its unit dose packaging in advance lessens the ability to positively identify the medication and increases the chance of drug administration errors and contamination. During the medication administration process, the unlocked side of the cart must always be in full view of the nurse .8. the medication cart must be completely locked, or otherwise secured

Based on observation, interview, and record review the facility failed to prepare and serve food in accordance to professional standards for food service safety in that:<BR/>1-A piece of equipment (toaster) was used that was not cleaned before use to prevent contamination.<BR/>2-A dietary staff member did not wear a hair restraint to prevent hair from contacting food.<BR/>This deficient practice could place residents at risk of consuming contaminated food.<BR/>The findings include:<BR/>1.Observation on 08/23/22 at 10:40AM revealed Floor Tech-F not wearing a hair net. He stated he was working at multiple stations in the kitchen.<BR/>2-Observation on 08/24/22 at 1:15PM of a bread toaster which was dirty in appearance with brown stains on each of the bread toaster tracks that hold and rotate the bread slices. <BR/>3-Interview with DA-1 on 08/24/22 at 1:16PM who stated she felt the toaster did not have rust on it's working parts, and staff try and clean it at least once a day. The Food Service Director was observed placing signage on the toaster on 08/24/22 at 1:17PM which stated-do not use.<BR/>During an interview with the corporate maintenance director, on 08/24/22 at 2:05PM he stated he observed the toaster was dirty and needed to be cleaned.<BR/>During an interview with the Administrator on 08/26/22 at 1235PM, she stated that the toaster was discussed during a previous QAPI process. She did not feel the toast itself touched the surface tracks of the toaster when in use.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. <BR/>(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. <BR/>(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. <BR/>(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. <BR/>Record review of the Twin Pines 2012 Dietary Services Policy and Procedure Manual-IC-00.1.0 for Infection Control noted that kitchen staff are required to cover the hair with a restraint and section IC-00-6.0 for equipment sanitation which noted that all kitchenware should be cleaned and sanitized before use.

The facility failed to provide a therapeutic diet which was prescribed by the attending physician for two residents (#23, and #92) out of 25 residents observed during dining in that:<BR/> 1. Resident #23 did not have double portions of meat on her lunch plate as was ordered by the physician.<BR/> 2. Resident #92 did not have large portions of food on her plate as was ordered by the physician.<BR/>This deficient practice affects residents who are ordered therapeutic diets and could result in weight or nutritional loss.<BR/>The findings included:<BR/>1. Record review of Resident #23's Active Orders as of 10/10/2023 reflected she was on a regular diet, regular consistency with large portions and a fortified meal plan.<BR/>Observation and review on 10/10/2023 at 12:23 p.m. revealed Resident #23 was served only one portion of barbecue ribs and her meal ticket reflected DOUBLE PORTIONS MEAT.<BR/>Interview on 10/10/2023 at 12:25 p.m. with LVN D who passed out resident trays to staff as they trays came out of the kitchen, she stated the resident should have had two portions of barbecue ribs served and she went to get another one for the resident. She stated it was important to follow the meal ticket and physician orders because the resident may be on a weight gain program or need the nutrition for other reasons.<BR/>Interview on 10/10/2023 at 12:30 p.m. with Resident #23 she stated she was happy to get another portion of barbecued ribs.<BR/>Observation on 10/10/2023 at 12:45 p.m. of Resident #23, she appeared to finish eating both portions of barbecued ribs.<BR/>2. Record review of Resident #92's Active Orders as of 10/10/2023 reflected Regular diet, Mechanical Soft texture, Regular consistency, LARGE PORTIONS.<BR/>Observation and review on 10/10/2023 at 12:40 p.m. of Resident #92 sitting in the dining room eating. She had regular portions of food on her plate and her meal ticket reflected LARGE PORTIONS. <BR/>Interview on 10/10/2023 at 12:46 p.m. with LVN D, she stated the kitchen should have checked the trays and she confirmed Resident #92 did not have large portions and went to the kitchen to get her another portion of barbecue ribs.<BR/>Interview on 10/10/2023 with Resident #92 at 12:50 p.m., she stated she did not receive large portions.<BR/>Interview on Interview on 10/13/2023 at 10:53 a.m. with LVN A, she stated it was important for nurses to check the trays to ensure residents receive therapeutic diets as ordered, She stated that a resident is on a therapeutic diet to either get more nutrients, gain weight or help a wound to heal. She stated the nurses would be educated to check the trays.<BR/>Record review of the facility policy and procedure titled Large Portions reflected We will add extra calories and protein to the regular diet as appropriate. Large portions may be used to promote weight gain if the resident has a good appetite or to satisfy the resident with a large appetite. Extra food items are added to the regular diet throughout the day .Lunch and Dinner .2X indicated entr&eacute;e portions.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 3 of 3 medication carts (Medication cart #1, Medication cart #2, and Medication cart#3) reviewed for medication storage.<BR/>1. <BR/>The facility failed to ensure the Medication cart by the nurses' station did not have a medication cup with pills sitting on top of the cart. <BR/>2. <BR/>LVN F failed to ensure the Medication cart on 100 hall was not left unlocked with a resident standing next to it, while the LVN went into resident room to administer medications . <BR/>3. <BR/>The facility failed to ensure the Medication cart on 300 hall was not left unlocked. <BR/>4. <BR/>The facility failed to ensure the Medication cart was not left unlocked. <BR/>These deficient practices could place residents at risk of medication misuse and drug diversion.<BR/>Findings include:<BR/>1. Observation on 4/23/24 at 9:28 PM revealed LVN F was sitting at the nurses' station with her back to the medication cart #1. The medication cart was unlocked, unattended and had a medication cup with pills in it on top of the medication cart. There were no staff members or residents in the area.<BR/>During an interview on 4/23/24 at 9:34 PM, LVN F stated she usually went to each resident room with the medication cart and then pulled each resident's medications. LVN F further stated she was not told she could not prepare medications in advance, and she had done this in the past but usually locked the medication cups in the cart. LVN F stated medication carts were not supposed to be left unlocked when unattended. LVN F further stated medications should not have been left unattended on top of the cart because a resident could have taken medications. <BR/>2. During observation and interview on 4/23/24 at 10:05 PM, LVN F left the medication cart #1 unlocked with a resident standing next to the cart while she entered the resident's room to administer medications to another resident. LVN F stated the medication cart was left unlocked and medication carts were not to be left unlocked when unattended. LVN F further stated the resident standing in the hallway could have accessed the medication in the cart. <BR/>3. During observation and interview on 4/23/24 at 9:30 PM, the medication cart #2 on the 300 hall was unlocked and there were no staff in the hallway. MA A stated the medication cart should not have been unlocked.<BR/>4. During observation and interview on 4/24/24 at 7:04 AM, a medication cart #3 was unlocked and unattended. There were no staff at the nurses' station or in the hallway and a resident was sitting in his wheelchair next to the medication cart. MA B stated her medication cart #3 should not have been unlocked. <BR/>During an interview on 4/27/24 at 6:32 PM, the DON stated medication carts should never be unlocked and medications should not be left on top of medication carts unattended. The DON further stated these expectations were relayed to the nursing staff several times. <BR/>Record review of the facility's policy titled, Medication Administration Procedures revised 10/25/17, reflected the following: 3. Open the unit dose package only when you are administering medication directly to the resident. Removing the medication from its unit dose packaging in advance lessens the ability to positively identify the medication and increases the chance of drug administration errors and contamination. During the medication administration process, the unlocked side of the cart must always be in full view of the nurse .8. the medication cart must be completely locked, or otherwise secured

**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 and the facility provided food that accommodated resident allergies, intolerances, and preferences for 1 of 15 residents (Resident #16) reviewed for dietary services.<BR/>The facility failed to ensure Resident #16's was not served he was allergic to and was served onions with the meal. <BR/>This deficient practice could place residents at-risk by contributing to poor intake, weight loss and/or allergic reaction.<BR/>Findings include:<BR/>Record review of Resident #16's admission Record, dated 4/24/24, reflected the resident was re-admitted to the <BR/>facility on 8/21/20. Resident #16 had diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), Muscle Wasting and Hypertension (high blood pressure).<BR/>Record review of Resident #16's quarterly MDS assessment, dated 2/15/24, reflected the resident had a BIMS score of 12, which indicated moderately impaired cognition. <BR/>Record review of Resident #16's Order Summary, dated 4/24/24, reflected the resident had an allergy to onions. <BR/>Record review of Resident #16's Care Plan, revised 12/1/21, reflected: Resident is allergic to .onion .Resident will not receive known allergens .Do NOT administer food/medications/materials known to be allergens <BR/>Observation of Resident #16's dinner plate on 4/24/24 at 5:30 PM revealed the residents plate contained chicken salad on a lettuce leaf, a deviled egg, vegetables and peaches. <BR/>During an interview on 4/25/24 at 1:55 PM, Resident #16 said she was served chicken salad for dinner but could not eat it because she saw onions in it. Resident #16 further stated she asked for an alternate meal but was not brought anything else, so she ate [NAME] and crackers. Resident #16 said when she ingested onions she broke out in hives. <BR/>During an interview on 4/27/24 at 5:31 PM, [NAME] A said he believed he did use onions in the chicken salad. [NAME] A further stated he was not told there was a resident with an onion allergy and was not aware Resident #16 had an allergy to onions. <BR/>Record review of the facility's Recipes to Scale, dated 4/25/24, reflected: .Chicken salad on Lettuce Leaf .Onion Yellow Jumbo <BR/>Record review of the facility's policy, titled Preparation of Foods, dated 2012, reflected: .2. All food . will be attractively served .in a form to meet the individual needs of the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 1 of 15 residents (Resident #16) reviewed for dietary services.<BR/>The facility failed to ensure Resident #16's was not served he was allergic to and was served onions with the meal. <BR/>This deficient practice could place residents at-risk by contributing to poor intake, weight loss and/or allergic reaction.<BR/>Findings include:<BR/>Record review of Resident #16's admission Record, dated 4/24/24, reflected the resident was re-admitted to the <BR/>facility on 8/21/20. Resident #16 had diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), Muscle Wasting and Hypertension (high blood pressure).<BR/>Record review of Resident #16's quarterly MDS assessment, dated 2/15/24, reflected the resident had a BIMS score of 12, which indicated moderately impaired cognition. <BR/>Record review of Resident #16's Order Summary, dated 4/24/24, reflected the resident had an allergy to onions. <BR/>Record review of Resident #16's Care Plan, revised 12/1/21, reflected: Resident is allergic to .onion .Resident will not receive known allergens .Do NOT administer food/medications/materials known to be allergens <BR/>Observation of Resident #16's dinner plate on 4/24/24 at 5:30 PM revealed the residents plate contained chicken salad on a lettuce leaf, a deviled egg, vegetables and peaches. <BR/>During an interview on 4/25/24 at 1:55 PM, Resident #16 said she was served chicken salad for dinner but could not eat it because she saw onions in it. Resident #16 further stated she asked for an alternate meal but was not brought anything else, so she ate [NAME] and crackers. Resident #16 said when she ingested onions she broke out in hives. <BR/>During an interview on 4/27/24 at 5:31 PM, [NAME] A said he believed he did use onions in the chicken salad. [NAME] A further stated he was not told there was a resident with an onion allergy and was not aware Resident #16 had an allergy to onions. <BR/>Record review of the facility's Recipes to Scale, dated 4/25/24, reflected: .Chicken salad on Lettuce Leaf .Onion Yellow Jumbo <BR/>Record review of the facility's policy, titled Preparation of Foods, dated 2012, reflected: .2. All food . will be attractively served .in a form to meet the individual needs of the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess each resident after a significant change for 1 of 21 residents (Resident #90) whose MDS assessments were reviewed, in that:<BR/>Resident #90 s quarterly MDS assessment was not updated to reflect a significant change.<BR/>This failure could place residents at risk of not having their assessments updated in a timely manner and not receiving necessary treatments and services.<BR/>The findings were: <BR/>Record review of Resident #90's face sheet, dated 08/24/2022, revealed the female resident, aged 88, was admitted to the facility on [DATE] with diagnoses that included: congestive heart failure ( a condition in which the heart does not pump blood properly), a fracture of the left femur ( a breakage of the left thigh bone), and hypertensive heart disease ( high blood pressure)<BR/>Record review of the Resident # 90 physician's order summary report dated 8/24/22 revealed a<BR/>physician order dated 8/8/22 to admit to hospice with a start date of 8/8/22.<BR/>Record review of Resident #90's electronic record revealed the resident's last completed MDS was dated 08.08/22 as a quarterly assessment; it was not a significant change MDS assessment that reflected the hospice admission.<BR/>During an interview with LVN-A on 08/24/22 at 1045am she stated that as the MDS nurse she had forgotten to update the quarterly MDS on 8/9/22 to reflect a hospice admission for Resident# 90. She stated that this update should have been completed.<BR/>Record review of the facility's nursing policy and procedure manual for comprehensive care planning, section number: 03-18.0., noted that a significant change MDS assessment should be used to reflect the changing needs of the resident.

Based on observation, interview, and record review the facility failed to prepare and serve food in accordance to professional standards for food service safety in that:<BR/>1-A piece of equipment (toaster) was used that was not cleaned before use to prevent contamination.<BR/>2-A dietary staff member did not wear a hair restraint to prevent hair from contacting food.<BR/>This deficient practice could place residents at risk of consuming contaminated food.<BR/>The findings include:<BR/>1.Observation on 08/23/22 at 10:40AM revealed Floor Tech-F not wearing a hair net. He stated he was working at multiple stations in the kitchen.<BR/>2-Observation on 08/24/22 at 1:15PM of a bread toaster which was dirty in appearance with brown stains on each of the bread toaster tracks that hold and rotate the bread slices. <BR/>3-Interview with DA-1 on 08/24/22 at 1:16PM who stated she felt the toaster did not have rust on it's working parts, and staff try and clean it at least once a day. The Food Service Director was observed placing signage on the toaster on 08/24/22 at 1:17PM which stated-do not use.<BR/>During an interview with the corporate maintenance director, on 08/24/22 at 2:05PM he stated he observed the toaster was dirty and needed to be cleaned.<BR/>During an interview with the Administrator on 08/26/22 at 1235PM, she stated that the toaster was discussed during a previous QAPI process. She did not feel the toast itself touched the surface tracks of the toaster when in use.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. <BR/>(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. <BR/>(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. <BR/>(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. <BR/>Record review of the Twin Pines 2012 Dietary Services Policy and Procedure Manual-IC-00.1.0 for Infection Control noted that kitchen staff are required to cover the hair with a restraint and section IC-00-6.0 for equipment sanitation which noted that all kitchenware should be cleaned and sanitized before use.

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 of 1 meal observed in that:<BR/>1. The facility failed to ensure all residents received potato salad with their lunch meal on 09/28/2023.<BR/>2. The facility failed to ensure Baked Potato Salad was prepared by the recipe.<BR/>These failures could place residents at risk for dissatisfaction, poor intake, and diminished quality of life.<BR/>The findings included:<BR/>Record review of the facility's, Spring/Summer 2023, Week 1, menu revealed [NAME] Sugar BBQ Chicken QTR, Baked Potato Salad, Pinto Beans, Texas Toast and Strawberry Cobbler were to be served with the lunch meal on 09/28/2023.<BR/>An observation on 09/28/2023 at12:15 p.m. revealed a daily menu board in the dining room that listed [NAME] Sugar BBQ Chicken QTR, Baked Potato Salad, Pinto Beans, Texas Toast and Strawberry Cobbler for the lunch meal. The menu revealed no indication for a substitute.<BR/>During an observation and interview with Resident #4 on 09/28/2023 at 12:21 p.m., revealed Resident #4's lunch tray did not include potato salad. Resident #4 stated, many times the kitchen doesn't serve what was on the menu.<BR/>During an observation and interview with Resident #5 and Resident #6 on 09/28/2023 at 12:28 p.m., revealed Resident #5 and #6's lunch trays did not include potato salad. Resident #5 stated, it's just the kitchen messing up like always.<BR/>During an interview with LVN D on 09/28/2023 at 12:30 p.m., confirmed Residents #4, #5 and #6 did not receive potato salad on their lunch trays and she would return to the kitchen to get them a bowl. LVN D stated she had set the residents trays down and removed the lids however did not notice the potato salad was missing because she thought it was under the bread.<BR/>During an interview with FSD on 09/28/2023 at 12:36 p.m., the FSD revealed the DA had missed the three trays that did not receive potato salad. FSD stated the trays simply got overlooked.<BR/>In an observation on 09/28/2023 at 12:41 p.m., multiple staff members were observed walking the halls, delivering plates of potato salad to residents.<BR/>During an observation and interview with Resident #7 on 09/28/2023 at 12:44 p.m. revealed Resident #7's lunch tray did not include potato salad and the resident had made the note, none beside potato salad on the meal ticket indicating the item had not been included.<BR/>During an interview with ADON A on 09/28/2023 at 12:48 p.m., ADON A confirmed Resident #7 did not receive potato salad for lunch. Resident #7 was offered potato salad but declined stating, not now.<BR/>In an interview with the FSD on 09/28/2023 at 1:50 pm, the FSS revealed she was unsure what had happened that so many residents did not receive potato salad. The FSD also revealed she had made a cold potato salad instead of the Baked Potato Salad that was on the menu because she did not think most of the residents would like the Baked Potato Salad option.<BR/>In an interview with the Administrator on 09/28/2023 at 2:53 pm, the Administrator revealed she had been notified of the lunch menu problem and they had a plan to address the issue.<BR/>Record review of the facility's policy titled, Resident Menus, dated 2012, 4. If any meal served varies from the planned menu, the change and reason for the change shall be noted on the substitution log. 5. The menus will be prepared as written using standardized recipes.

Based on observation, interview, and record review the facility failed to prepare and serve food in accordance to professional standards for food service safety in that:<BR/>1-A piece of equipment (toaster) was used that was not cleaned before use to prevent contamination.<BR/>2-A dietary staff member did not wear a hair restraint to prevent hair from contacting food.<BR/>This deficient practice could place residents at risk of consuming contaminated food.<BR/>The findings include:<BR/>1.Observation on 08/23/22 at 10:40AM revealed Floor Tech-F not wearing a hair net. He stated he was working at multiple stations in the kitchen.<BR/>2-Observation on 08/24/22 at 1:15PM of a bread toaster which was dirty in appearance with brown stains on each of the bread toaster tracks that hold and rotate the bread slices. <BR/>3-Interview with DA-1 on 08/24/22 at 1:16PM who stated she felt the toaster did not have rust on it's working parts, and staff try and clean it at least once a day. The Food Service Director was observed placing signage on the toaster on 08/24/22 at 1:17PM which stated-do not use.<BR/>During an interview with the corporate maintenance director, on 08/24/22 at 2:05PM he stated he observed the toaster was dirty and needed to be cleaned.<BR/>During an interview with the Administrator on 08/26/22 at 1235PM, she stated that the toaster was discussed during a previous QAPI process. She did not feel the toast itself touched the surface tracks of the toaster when in use.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. <BR/>(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. <BR/>(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. <BR/>(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. <BR/>Record review of the Twin Pines 2012 Dietary Services Policy and Procedure Manual-IC-00.1.0 for Infection Control noted that kitchen staff are required to cover the hair with a restraint and section IC-00-6.0 for equipment sanitation which noted that all kitchenware should be cleaned and sanitized before use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 2 (Hallway A and Hallway E) of 7 resident hallways reviewed for environmental concerns.<BR/>1. On resident hallway-A the facility failed to repair: in room [ROOM NUMBER] both sides of the interior bathroom door had 4 inch wood cracks on the bottom of the door, in room [ROOM NUMBER] the phone jack was dislodged from the wall between beds A & B and there was a 2 foot black scrape mark behind the head board of bed A, in room [ROOM NUMBER] there was a black scrape mark on the wall besides the B-bed which measured 2 x2 feet, in room [ROOM NUMBER] there were 2 penetrations on the wall besides the B-bed which measured 7x5 and 1 x 1.5' and at the end of hallway-A there were water marks on 4 of the 2x2' ceiling tiles and 2 other ceiling tiles were removed from the ceiling.<BR/>2. On resident hallway-E the facility failed to repair: in room [ROOM NUMBER] both sides of the entry to the bathroom interior door had paint scraped off over a 5 area and the 2x2 ' bathroom ceiling tile was dislodged from the ceiling, in room [ROOM NUMBER] the toilet water was continually running and both sides of the entry to the interior bathroom door had paint scraped off of a 5 area, and across from the TV viewing area a section of the floor molding which measured 4 by 5' was dislodged from the wall.<BR/>These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.<BR/>The findings included:<BR/>1. During an observation on 12/5/24 from 1:50 p.m. to 2:05 p.m. with the Assistant Maintenance Director and the Administrator revealed the following:<BR/>a-in room [ROOM NUMBER] on Hallway-A both sides of the interior bathroom door had 4- inch wood cracks on the bottom of both sides of the door<BR/>b-in room [ROOM NUMBER] on Hallway-A the phone jack was dislodged from the wall between beds A & B and there was a 2' black scape mark behind the head board on bed A, <BR/>c-in room [ROOM NUMBER] on Hallway-A there was a black scrape mark on the wall besides the B-bed which measured <BR/> 2 x2'<BR/>d-in room [ROOM NUMBER] on Hallway-A there were 2 penetrations on the wall besides the B-bed which measured 7x5 and 1 x 1.5.' <BR/>e-at the end of hallway-A there were water marks on 4 of the 2x2' ceiling tiles and 2 other ceiling tiles were removed from the ceiling.<BR/>f.-in room [ROOM NUMBER] on Hallway E both sides of the entry to the bathroom interior door had paint scraped off over a 5 area and the 2x2 ' bathroom ceiling tile was dislodged from the ceiling.<BR/>g.in room [ROOM NUMBER] on Hallway-E the toilet water was continually running and both sides of the entry to the interior bathroom door had paint scraped off of a 5 area<BR/>h-across from the TV viewing area on Hallway-E a section of the floor moulding which measured 4 by 5' was dislodged from the wall.<BR/>During an interview with the Assistant Maintenance Director and the Administrator on 12/5/24 at 2:10 p.m. the Assistant Maintenace Director stated that she was made aware by nursing staff of some of the repairs needed on resident Hallways A & E. She stated the facility would be completing all repairs in the upcoming weeks. The Administrator and Assistant Maintenance Director stated that fixing the areas noted for repiar would provide a more homelike environment for the residents.<BR/> Record review of the facility's policy on Preventative Maintenance, undated, revealed the policy read that the facility's building, grounds, and equipment would be kept in good repair.