Cross Timbers Rehabilitation and Healthcare Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, based on a resident's comprehensive assessment, residents maintained acceptable parameters of nutritional status for 1 of 19 residents (Resident #68) reviewed for nutrition.<BR/>The facility failed to obtain Resident #68's weight upon her admission to the facility on [DATE] and failed to obtain weekly weights for the resident for four weeks, which resulted in the resident's weight loss not being identified. <BR/>This failure placed residents at-risk for loss of weight and inadequate nutrition.<BR/>Findings included:<BR/>Record review of Resident #68's admission MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included depression, bipolar disorder, dorsalgia (physical discomfort occurring anywhere on the spine or back, ranging from mild to disabling), disorder of kidney and ureter, cognitive impairment, and malnutrition. Resident #82 has a BIMS of 5 indicating she had severe cognitive impairment. The MDS further reflected Resident #68's weight was 127 pounds.<BR/>Record review of Resident #68's care plan revised on 01/07/25 did not reflect there were any weight concerns. <BR/>Record review of Resident #68's hospital records dated 12/30/24 reflected the resident weighed 127 pounds. <BR/>Record review of Resident #68's facility weights reflected the following:<BR/>01/15/25 - 128.6 pounds<BR/>01/21/25 - 119.4 pounds<BR/>01/23/25 - 119 pounds - surveyor witnessed weight being taken<BR/>Record review of Resident #68's meal intake from 01/01/25-01/21/25 reflected there were 4 meals where the resident ate 26%-50%, 23 meals where she ate 51%-75%, and 3 days where she ate 75%-100%. <BR/>Record review of Resident #68's admit evaluation initiated by LVN D dated 12/31/24 reflected there was not a weight entered for the resident. <BR/>Observation and interview on 01/23/25 at 1:44 PM revealed Resident #68 was in her room, in her wheelchair, eating lunch. The resident said she was full, and it appeared she had eaten about 50% of her meal. Resident #68 was asked if she had been having decreased appetite, and the resident was not able to answer yes or no to the question and just said she was full. <BR/>Interview on 01/23/25 at 12:35 PM with CNA B revealed she worked at the facility Monday through Friday and worked with Resident #68. CNA B said the resident was able to eat on her own with no issues and described her a good eater for breakfast and lunch. CNA B also said Resident #68 had never not eaten or said she was not hungry. <BR/>Interview on 01/24/25 at 2:26 PM with LVN D revealed she had just started working at the facility when Resident #68 was admitted and there was another nurse assisting her as it was her first new admit. LVN D said that nurse no longer worked at the facility. LVN D stated she did not get a weight on Resident #68 and was unsure if the other nurse had gotten an initial weight on the resident. <BR/>Interview on 01/23/25 at 12:20 PM with Resident #68's family revealed she visited the resident frequently, and she had not noticed any weight loss. The family said Resident #68's weight usually fluctuated anywhere from 120 pounds to 135 pounds. The family said Resident #68 normally ate well, and the resident had not said anything to her about not being hungry or that she was not eating well. <BR/>Interview on 01/23/25 at 12:16 PM with the ADON revealed she was not aware that new admits needed to be weighed weekly per their policy and did not know Resident #68's weight had not been taken when she first admitted . The ADON said some of the resident weights also might have been missed because of the recent ice storm that hit the area and staff calling in. The ADON further stated the DON had been on medical leave since the holiday break, and she (ADON) was trying to keep her head above water. She stated this is why the weight had been missed possibly. The ADON said if she would have noted the variance in weights, she should have called the doctor for further orders. <BR/>Interview on 01/23/25 at 1:53 PM with the Registered Dietitian revealed she saw Resident #68 on 01/07/25 and noted there was not a weight in the system for Resident #68 and she had sent an email to the DON and ADON along with other department heads to obtain a weight for the resident. The Registered Dietitian said she had planned on following up with the resident the week of the survey to see if the staff had obtained the weights. The Registered Dietitian stated if she would have been made aware of the resident's weight loss, she would have put some measures in place such as adding fortified foods to her meal or a supplement if the resident was not eating at least 75% during her meals. She said that based on the resident's current weight and height, the resident was slightly below her BMI, but she was not concerned about it. <BR/>Interview on 01/24/25 at 11:21 AM with the Physician revealed he had seen Resident #68, and she did not appear to be grossly underweight. The Physician said the staff were normally pretty good about letting him know when residents were experiencing weight loss and he or someone from his office was at the facility at least 5 times a week. The Physician further stated if he would have been told about Resident #68's weight loss he would have put some measures in place as well as trying to find out what was causing the weight loss. <BR/>Record review of the facility's Weight Management policy dated January 2021 reflected the following:<BR/> Procedure<BR/>1. Residents will be weighed on admission and readmission. <BR/>2. New admits will be weighed weekly for the first 4 weeks to establish baseline weights, after which they will be weighted monthly<BR/> .5. Any weight change (loss or gain) of 5lbs or more since the last weight assessment will be retaken <BR/>Additionally, the Interdisciplinary Team will assure the below tasks are accomplished:<BR/>Physician notification of weight loss and documentation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Residents #26 and #245) reviewed for dialysis. <BR/>The facility failed to ensure dialysis communication forms for Residents #26 and Resident #245 were received back after returning from dialysis treatment. <BR/>This failure could place residents at risk of inadequate communication between the facility and dialysis center. <BR/>Findings included: <BR/>1. Record review of Resident #26's admission MDS assessment, dated 01/12/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #26 had a diagnosis of end stage renal disease (a chronic condition that occurs when the kidneys can no longer filter waste from the blood and requires long-term dialysis). She had a BIMS score of 13, which indicated her cognition was intact. The MDS reflected Resident #26 received dialysis. <BR/>Record review of Resident #26's care plan, dated 01/07/25, reflected Resident #26 needed hemodialysis (medical procedure that filters blood to remove waste and extra fluid when the kidneys are no longer functioning properly) rule out renal failure. The care plan reflected the following goals: [Resident #26] would have no signs of complication from dialysis through next review date. The resident will have immediate intervention should any s/sx of complications from dialysis occurs through the review date. The care plan interventions reflected: Encourage resident to go for the scheduled dialysis appointments Tuesday's, Thursday's, and Saturday's. Resident receives dialysis. Monitor/document/report PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. <BR/>Record review of Resident #26's January 2025 physician's order reflected to monitor permcath (flexible tube that's inserted into a blood vessel to provide long-term access to the bloodstream) pressure dressing to rule out chest for excessive bleeding every shift. <BR/>Record review of Resident #26's EHR reflected nursing documentation regarding Resident #26's pre- and post-dialysis vital signs but missed any communication from dialysis center. <BR/>Record review of Resident #26's dialysis communication forms for 01/07/25 to 01/24/25 reflected dialysis communication form dated 01/18/25 and 01/23/25, all the other dialysis dates of the month of January 2025 were missing communication forms totaling to 6 days in January 2025 on the following days: 01/09/25, 01/11/25, 01/14/25, 01/16/25, 01/18/25, and 01/21/25. <BR/>2. Record review of Resident #245's admission MDS assessment, dated 01/11/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #245 had a diagnosis of end stage renal disease (a chronic condition that occurs when the kidneys can no longer filter waste from the blood and requires long-term dialysis). She had a BIMS score of 14, which indicated her cognition was intact. The MDS reflected Resident #245 received dialysis. <BR/>Record review of Resident #245's care plan, dated 01/07/25, reflected Resident #245 needed hemodialysis (medical procedure that filters blood to remove waste and extra fluid when the kidneys are no longer functioning properly) rule out renal failure. The goals reflected Resident #245 would have no signs of complication from dialysis through next review date. The care plan interventions included: Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis. Check and change dressing daily at access site. <BR/>Record review of Resident #245's January 2025 physician's order reflected Check Bruit &Thrill every Shift, notify provider if not palpable every shift for dialysis site Tuesday, Thursday, and Saturday every shift. <BR/>Record review of Resident #245's EHR reflected nursing documentation regarding Resident #245's pre- and post-dialysis vital signs but missed any communication from dialysis center. <BR/>Record review of Resident #245's dialysis communication forms for 01/07/25 to 01/24/25 reflected dialysis communication form dated 01/07/25, 01/11/25, 1/16/25 and 01/18/25 all the other dialysis dates of the month of January 2025 were missing communication forms totaling to 4 days in January 2025 on the following days: 01/09/25, 01/14/25, 01/21/25, and 01/23/25. <BR/>Interview on 01/21/25 at 12:35 PM with Resident #26 revealed she went for dialysis Tuesday, Thursday, and Saturday. She stated she got a form that she took to dialysis and brought back to the facility, but she stated she was not sure whether she brought the form back to the facility after dialysis. She stated she got checked for her vital signs when she left for dialysis and when she came back from dialysis. <BR/>Interview on 01/22/25 at 8:29 AM with Resident #245 revealed she went for dialysis Tuesday, Thursday, and Saturday. She stated she got a form that she took to dialysis and brought back to the facility in her bag, but she stated she was not sure whether the staff took the communication form from her bag. She stated her vital signs were checked when she left for dialysis and when she came back from dialysis.<BR/>Interview on 01/22/25 at 3:03 PM with RN E revealed she was aware she was supposed to send Resident #26 and Resident #245 with the dialysis communication form when they left for dialysis and then collect the form when the resident's returned from dialysis. RN E stated she knew she was supposed to monitor the dialysis access site for the bruit thrill (a vibration caused by blood flowing through the fistula and can be felt by placing fingers just above incision line), dressing for bleeding and vital signs when Residents #26 and Resident #245 were back from dialysis which she does and document in the progress notes. She stated it was all nurse's responsibility to collect the dialysis communication forms when Resident #26 and Resident #245 came back and filed them. RN E stated they were supposed to call the dialysis clinic and follow up if communication forms were not sent back with residents. She stated failure to follow up on the communication form after dialysis was completed could cause them to miss the orders and recommendations from dialysis center. She stated she had done trainings on dialysis communication form, but she could not recall when. <BR/>Interview on 01/23/25 at 12:40 PM with the ADON revealed the nurses were supposed to fill out the forms with the residents' pre-dialysis vitals, and the form would be taken to dialysis by Resident #26 and Resident #245. She stated she expected the nurses to collect the form after dialysis, perform vital signs, and document on electronic health records and put the communication forms on the binders. She stated the importance of the communication form was communication between the facility and dialysis center on new orders, treatment given, and any change of condition. She stated she had checked on the binders and had noticed the communication forms were missing after the surveyor brought it to her attention. She stated she talked to Resident #26 and Resident #245, and they told her they turned the communication forms into the dialysis center, and they do not bring them back. She stated she was responsible on ensuring nurses were completing the forms, monitoring vitals pre and post dialysis. She stated she could not recall the last time she checked the binders, but she checked on 01/23/25 after she was notified the communication forms were missing. She stated she checked on health records and the nurses were documenting the vitals pre and post dialysis. She stated admitting nurses were responsible of putting orders for monitoring pre and post-dialysis, and it was her responsibility and the DON to go through the orders and ensure none were missing. She stated the risk of not having the communication form brought back from dialysis was omission of orders. <BR/>Interview on 01/24/25 at 11:23 AM with the Corporate Nurse revealed her expectation was for the nurses to send Resident #26 and Resident #245 with a communication form and get it when back from dialysis. She stated post-dialysis assessments should be documented in electronic health records. She stated she also expected the facility to have orders for pre and post dialysis. She stated the failure to collect the forms back from dialysis were they could miss important orders from dialysis. She stated the DON was responsible of following up to ensure all orders were in place and the staff were getting the communication forms back from dialysis. She stated she would check whether the facility had done training with staff and provided a record dated 01/23/25 on dialysis protocol that addressed dialysis communication forms and monitoring before and after dialysis. <BR/>Record review of the facility's Dialysis Protocol policy, dated 05/17/24, reflected the following: <BR/> .2. Implement dialysis communication regarding plan of care. <BR/>3. Auscultate shunt site for presence or absence of thrill and bruit-if absent notify doctor immediately. <BR/>4. Monitor site for s/s of infection

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of three medication carts (200) and 2 of 19 residents (Residents #1, #3, and #190) reviewed for pharmacy services.<BR/>1. The facility failed to ensure the 200 Hall nurses' medication cart contained accurate narcotic logs for Resident #1 and #3. <BR/>2. The facility failed to ensure Resident #190's physician order for Lomotil was followed when Hospice Nurse G faxed the order on 01/20/25 to the facility, and it was not put in the system until 01/22/25.<BR/>These failures could place residents at risk for medication errors, drug diversion, and delay in medication administration. <BR/>Findings included: <BR/>1. Record review of Resident# 1's Quarterly MDS Assessment, dated 01/08/25, reflected the resident was [AGE] year-old female readmitted to the facility on [DATE] with original admission on [DATE], with diagnoses that included anxiety disorder (excessive and uncontrollable feelings of fear and anxiety). The resident had intact cognition with a BIMS score of 15. <BR/>Record review of Resident #1's physician's orders undated reflected an order for the resident to receive Xanax Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth every 8 hours related to anxiety disorder, (administer only at 2am, 10am, and 6pm as per resident request). <BR/>Record review of Resident# 3's Quarterly MDS assessment, dated 10/21/24, reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included pain. The resident had intact cognition with a BIMS score of 14. <BR/>Record review of Resident #3's physician orders dated 06/04/24 reflected an order for the resident to receive Tylenol with Codeine #3 Oral Tablet 300-30 mg (Acetaminophen w/Codeine) Give 1 tablet by mouth every 4 hours, as needed for pain. <BR/>Observation and record review on 01/22/25 at 01:57 PM of 200 Hall nurses' medication cart and the Narcotic Administration Record, with LVN A, revealed Resident #1's Narcotic Administration Record for Xanax 0.25 mg reflected a total of 18 pills remaining, while the blister pack count was 19 pills. It was last administered on 01/22/25 at 10:00 AM. It also revealed Resident#3's Narcotic Administration record Tylenol with Codeine #3 Oral Tablet 300-30 mg reflected a total of 15 pills remaining, while the blister pack count was 17 pills. Last administered on 01/22/25 at 1:28 PM. <BR/>Interview with LVN A on 01/22/25 at 2:17 PM revealed she administered Xanax 0.25 mg 1 tablet to Resident #1 at 10:00 AM, Tylenol with codeine 300-30 mg2 tablets to Resident #3 as needed every 4 hours, and she had not signed off on the narcotic administration record log. She stated she gave the residents the medication, but she forgot to sign off on the narcotic administration log. She stated she knew she was supposed to sign-out on the narcotic count sheet after administration and on the Medication Administration Record, but she did not. LVN A stated the failure to log off could lead to overdose since the person that came after her would not be able to tell when the narcotic was administered. She stated she had done an in-service on Medication administration. <BR/>In an interview on 01/22/25 at 3:48 PM, the ADON stated her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log. The ADON stated failure to document could lead to drug diversion and overdose. She stated it was her responsibility to audit the medication carts daily. <BR/>Interview on 01/24/25 at 11:38 AM, the Corporate RN revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log. The Corporate RN stated failure to document could lead to overdose and effect on resident management. She stated it was the responsibility of the DON and the ADONs to audit the medication carts. She stated she will check on facility training records and none was provided. <BR/>Record review of facility policy entitled Medication Administration , dated 07/08/24, reflected the following: did not address the narcotic administration record. <BR/>2. Record review of Resident #190's admission Record, dated 01/24/25, reflected she was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE].<BR/>Record review of Resident #190's Annual MDS Assessment, dated 12/28/24, reflected she had a BIMS score of 5 indicating severe cognitive impairment. Her diagnoses included heart failure (where the heart cannot keep up with its workload), hypertension (high blood pressure), and Alzheimer's disease (a neurological disorder that causes irreversible changes in memory, thinking, and behavior).<BR/>Record review of Resident #190's January Order Summary Report reflected an order of Lomotil Tablet 2.5-0.025 MG (Diphenoxylate-Atropine), Give 2 tablet by mouth every 6 hours for diarrhea give 2 tablet until diarrhea resolve [sic] with an order date of 01/22/25. There was no evidence of a PRN order for the Lomotil as of 01/20/25.<BR/>Record review of Resident #190's Medication Administration Record for January 2025 reflected Resident #190 received the Lomotil medication starting in the afternoon on 01/22/25. There was no additional orders or administrations for Lomotil.<BR/>Record review of a faxed order, dated 01/20/25, for Resident #190 from Hospice Agency H reflected: Lomotil; 2 Tablet ORAL 4 times a day As Needed for Diarrhea (2.5-0.025 MG Tablet); 2 tablets orally every 6 hours as needed for diarrhea. The order was signed by Hospice Nurse G.<BR/>Observation and interview on 01/22/25 at 11:00 AM with Resident #190 revealed she was in her bed in her room, dressed and groomed. Resident #190 said she had not been having any diarrhea and was doing great. Resident #190 said she was getting all her medications as far as she knew.<BR/>Interview on 01/22/25 at 3:43 PM with Hospice Nurse G revealed she was told on Monday that Resident #190 had been having diarrhea for four days. Hospice Nurse G said the facility was not giving Resident #190 her anti-diarrhea medicine as it was ordered so she changed the order. Hospice Nurse G said she had faxed an order on Monday to the facility that was PRN, but it was changed today (01/22/25) to be given on a routine basis instead. <BR/>Interview on 01/23/25 at 10:28 AM with RN H revealed Resident #190 did have some diarrhea but it was getting better. RN H said she thought the order for the anti-diarrhea medicine came on Monday, but she was not sure. RN H said the anti-diarrhea medicine was supposed to be PRN but was changed to be routine . <BR/>Interview on 01/24/25 at 10:17 AM with the ADON revealed she was told Resident #190's Hospice Nurse had faxed orders over for Lomotil instead of giving the order directly to the nurse to treat Resident #190's diarrhea. The ADON said she would have to check to see if anyone ever saw the order or not and would follow-up once she found out what happened.<BR/>Interview and record review on 01/24/25 at 11:40 AM with the ADON revealed she saw the order for Resident #190 still sitting on top of the fax machine. The ADON brought the faxed order for the Lomotil which showed an order date of 01/20/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure when the pharmacist reported any irregularities to the attending physician and the facility's medical director and director of nursing, these reports were acted upon for 3 of 5 residents (Residents #35, #44, and #39) reviewed for medication regimen review. <BR/>1. The facility's failed to ensure the Pharmacist Consultant recommendation for Residents #35's antipsychotic medication, Quetiapine Fumarate (Seroquel), were was reviewed by the physician for the identified irregularities. <BR/>2. The facility's failed to ensure the Pharmacist Consultant recommendation for Residents #44's antipsychotic medication, Quetiapine Fumarate (Seroquel), were was reviewed by the physician for the identified irregularities. <BR/>3. The facility failed to ensure the pharmacy consultant recommendation was sent to the physician for review for Resident #39's psychotropic medication, duloxetine (Cymbalta).<BR/>These failures could place residents at risk for medication errors, unnecessary medications, and incorrect administration.<BR/>Findings included: <BR/>1. Record review of Resident #35's Quarterly MDS Assessment, dated 01/03/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (mental health condition that can develop after someone experiences or witnesses a traumatic event). The resident had moderate cognitive impairment with a BIMS score of 09. <BR/>Record review of Resident #35's care plan, dated 10/22/24, reflected Resident #35 had a mood problem had diagnosis of post-traumatic stress disorder. The goals: - Resident #35 will have improved mood state through the review date. Interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness. <BR/>Record review of Resident #35's physician's orders dated 09/24/24 reflected an order for the resident to receive Quetiapine Fumarate Oral Tablet 25 MG Quetiapine Fumarate). Give 1 tablet by mouth every 24 hours as needed for agitation. Give medication at bedtime. <BR/>Record review of Resident #35's Medication Regimen Record review, dated October 2024, reflected Please ensure there is an informed consent 3713 form provided by health and human services. Resident [has] an order for quetiapine, prn orders for antipsychotic drugs are limited to 14 days. [if]he briefs it need to be extended, [he] beyond 14 days patient must be seen and evaluated by provider and a new order written every 14 days. Recommendation of the Quetiapine for 14 days prn to be extended beyond 14 days. Resident to be reviewed and order written every 14 days.'' <BR/>Record review of Resident #35's Medication Regimen Record review, dated November 2024, reflected Please ensure there [is] an informed consent 3713 form provided by health and human services. Resident [has] an order for quetiapine, prn orders for antipsychotic drugs are limited to 14 days. [if] [he] briefs it need to be extended, [he] beyond 14 days patient must be seen and evaluated by provider and a new order written every 14 days. Recommendation of the Quetiapine for 14 days prn to be extended beyond 14 days. Resident to be reviewed and order written every 14 days.<BR/>Record review of Resident#35 Medication Regimen record review for October 2024 and November 2024 revealed that the Medication Regimen Records were not reviewed by the physician. There was no documentation reflecting the physician indicated he agreed with or declined with the recommendation.<BR/>2. Record review of Resident# 44's Quarterly MDS Assessment, dated 12/12/24, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included unspecified dementia, severe, with other behavioral. The resident had severe cognitive impairment with a BIMS score of 00. <BR/>Record review of Resident #44's care plan, dated 11/30/24, reflected Resident #44 had a behavior problem rule out dementia (agitation including verbal and physical aggression, wandering, and hoarding), is verbally and physically aggressive at times. The goals: - Resident #44 will have fewer episodes of verbal and physical behaviors by review date. Interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness. <BR/>Record review of Resident #44's physician's orders dated 11/19/24 reflected an order for the resident to receive Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate). Give 1 tablet by mouth at bedtime for sleep. <BR/>Record review of Resident #44's Medication Regimen Record review, dated November 2024, reflected Please ensure there is an informed consent 3713 form provided by health and human services. <BR/>Record review of Resident#44 Medication Regimen record review for November 2024 revealed that the Medication Regimen Records were not reviewed by the physician. There was no documentation reflecting the physician indicated he agreed with or declined with the recommendation.<BR/>During an interview on 01/23/25 at 11:19AM with RN E she stated she was aware Resident#35 and #44 were receiving antipsychotic medication. She stated the doctor gives the orders, and the nurses were responsible of getting the consent form signed by either the patient or family member and the consent form is kept on residents' folders or scanned to electronic health records. <BR/>During an interview on 01/24/25 at 10:12 AM the ADON acknowledged that there were orders for Resident #35's Quetiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) and Resident #44 Quetiapine Fumarate Oral Tablet 25 MG. The ADON stated Resident#35 and Resident#44 were supposed to have signed a form for antipsychotic medications. She stated the form was supposed to be filled by the DON and put in the file. She could not tell what form it was. She brought the company consent form and the 3713 form and stated the 3713 was the one recommended but both residents did not have one. She stated Resident #35 PRN Quetiapine orders was supposed to be addressed as per the pharmacist's recommendation. She stated it was the DON's responsibility to review the Pharmacist recommendation and ensure the doctor reviewed them and recommendations were taken care of. <BR/>During an interview on 01/24/25 at 10:49AM with the Corporate RN, she stated pharmacist's recommendations were supposed to be reviewed by the DON and the attending physician. She stated she had contacted the DON who was admitted at the hospital, and she stated she could not find the physician review and recommendation forms. She stated she could find the consents, but they were the wrong forms that were used. She stated they were supposed to fill form 3713 as per the recommendation of the pharmacist and the physician was supposed to review the PRN orders for Resident#35 and either discontinue or write another order. She was asked of the risk and she stated it was not their facility policy to put residents on PRN antipsychotic.<BR/>3. Record review of Resident #39's MDS dated [DATE] reflected the resident was an an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included stroke, depression, bipolar disorder, and obstructive sleep apnea (a sleep disorder characterized by repeated episodes of complete or partial blockage of the upper airway during sleep). Resident #39 had a BIMS score of 14, indicating her cognition was intact. The MDS further indicated she was taking an antidepressant. <BR/>Record review of Resident #39's care plan initiated on 06/20/24 reflected Resident #39 used anti-depression medication related to depression. Interventions included to administer the medication as ordered by the physician. <BR/>Record review of Resident #39's pharmacy recommendation dated 11/25/24 reflected the following:<BR/> .Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for trial dose reduction. <BR/>Duloxetine 60mg QDay --&gt; Duloxetine 30mg QDay <BR/>If dose reduction is contraindicated or resident failed previous reduction attempt please document below <BR/>Record review of Resident #39's clinical record reflected the recommendation had not been acted on or reviewed by the physician.<BR/>Interview on 01/24/25 at 1:52 PM with the ADON revealed the DON was responsible for the pharmacy recommendations and she was not sure why the recommendation has not been acted on and sent to the physician for review. The ADON said the DON was on medical leave at the time of the survey. <BR/>Record review of the facility's Medication Regimen Record Review effective 10/01/18 reflected the following:<BR/>Policy<BR/>The consultant pharmacist performs a comprehensive of each resident's medication regimen (MRR) at least monthly. The MRR includes the evaluation of the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning while preventing or minimizing adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing, the attending practitioner, and the medical director.<BR/>Record review of facility Psychotropic Management policy dated 01/11/22 reflected the following: <BR/> .2.d. Consent should be obtained and documented on Texas Health and Human Services 3713, or most current form, as soon as possible. <BR/>3. PRN Antipsychotic and PRN Psychotropic medications- <BR/>a. Any as needed use of an antipsychotic can only be authorized for 14 days. These orders cannot be renewed unless the attending physician or prescribing practitioner evaluate the resident for the appropriateness of that medication. A new order for prn anti-psychotic will be required to be written every 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that PRN orders for antipsychotic drugs were limited to 14 days and could not be renewed, unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication and resident's drug regimen was free from unnecessary drugs, to include adequate indications for its use for 2 of 2 residents (Residents #35 and #44) reviewed for unnecessary medications. <BR/>1. The facility failed to ensure Resident #35's PRN order for Seroquel (Quetiapine Fumarate) , an antipsychotic medication, did not extend beyond 14 days without an identified end date.<BR/>2. The facility failed to ensure Resident #44 did not receive the antipsychotic medication Seroquel (Quetiapine Fumarate) for sleep. <BR/>This failure could place residents at risk for receiving unnecessary medications and adverse drug reactions. <BR/>Findings included: <BR/>1. Record review of Resident# 35's Quarterly MDS Assessment, dated 01/03/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included post-traumatic stress disorder (mental health condition that can develop after someone experiences or witnesses a traumatic event). The resident had moderate cognitive impairment with a BIMS score of 09. <BR/>Record review of Resident #35's care plan, dated 10/22/24, reflected Resident #35 had a mood problem and had a diagnosis of post-traumatic stress disorder. The care plan reflected the goals were [Resident #35] will have improved mood state through the review date. Interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness.<BR/>Record review of Resident #35's physician's orders dated 09/24/24 reflected an order for the resident to receive Quetiapine Fumarate Oral Tablet 25 mg (Seroquel). Give 1 tablet by mouth every 24 hours as needed for agitation. Give medication at bedtime. <BR/>Record review of Resident #35's September 2024 MAR revealed he received it on 09/25/24. <BR/>Record review of Resident #35's November 2024 MAR revealed he received it on 11/10/24. <BR/>In an interview on 01/24/25 at 10:12 AM the ADON acknowledged that the order for Resident #35's Quetiapine Fumarate Oral Tablet 25 mg PRN had been in the MAR since September 2024. The ADON stated Resident#35 was supposed to be on prn antipsychotic medication for 14 days and then discontinued or the doctor to review and decide whether to continue. She stated it seemed the resident admitted with the prn medication. She stated the admitting nurses put the orders in the electronic records and it was the DON and the ADON's responsibility to follow up the following day and she thought they missed the orders to make sure the residents who were on PRN antipsychotic medications were assessed every 14 days for the resident to continue with the medication. The ADON stated they have already called the resident's primary care provider to inform them of the need for the medication to be reviewed. She stated the doctor issued an order to reduce the order to 12.5mgs and then discontinue . She was not asked how the failure would affect the resident. <BR/>In an interview on 01/24/25 at 10:49 AM with the Corporate RN, she stated all PRN Psychotropic medications were supposed to be re-evaluated every 14 days by the resident's primary care provider and determine if the resident was to continue with the medication . She was asked but she could not answer. She stated it was not facility policy to put resident on antipsychotic medication.<BR/>In an interview on 01/24/25 at 12:18 PM with the NP, she stated Resident #35 was not supposed to be on PRN antipsychotic medication. She was not aware he was on PRN medication, and she did not prescribe the antipsychotic medications, but the doctor did. She could not say the effect unless she saw the file for the resident. <BR/>Interview on 01/24/25 at 12:19 PM with doctor was attempted by phone with no response and voice mail was left. <BR/>2. Record review of Resident# 44's Quarterly MDS Assessment, dated 12/12/24, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included unspecified dementia, severe, with other behaviors. The resident had severe cognitive impairment with a BIMS score of 00. <BR/>Record review of Resident #44's care plan, dated 11/30/24, reflected Resident #44 used the antipsychotic medication, Seroquel. The care plan reflected the goals were: [Resident #35] will reduce the use of psychotropic medication through the review date. Interventions: - Administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift. <BR/>Record review of Resident #44's physician's orders dated 11/19/24 reflected an order for the resident to receive Quetiapine Fumarate Oral Tablet 50 mg (Seroquel). Give 1 tablet by mouth at bedtime for sleep. <BR/>In an interview on 01/23/25 at 1:03 PM with the MDS Coordinator, she stated she prepared the care plan for Resident#44, and she was not supposed to be on an antipsychotic Quetiapine Fumarate for sleep. She stated Resident #44 had a diagnosis of Alzheimer disease and dementia , but the resident was not supposed to be on an antipsychotic. She stated she did not know of the risk associated with Resident #44 receiving these medications. <BR/>Interview on 01/24/25 at 10:12 AM with the ADON revealed she acknowledged the order for Resident #44's Quetiapine Fumarate Oral Tablet 50 mg for sleep. She stated the nurses put the orders in the electronic records and it was the DON and the ADON's responsibility to follow up the following day and she thought they missed the order to make sure the residents who were on antipsychotic medications were for the right diagnosis. The ADON stated they had already called the resident's primary care provider to inform them of the need for the medication to be reviewed. She stated the the resident would be sleeping alot. <BR/>Interview on 01/24/25 at 10:49 AM with the Corporate RN revealed her expectation was the facility could have used other alternative medication for sleep rather than Quetiapine Fumarate. She stated the ADON, and the DON could have caught it and notified the doctor for an alternative. She stated Quetiapine Fumarate was for resident with schizophrenia and not a choice for Resident #44 who had dementia and Alzheimer. She stated the risk of Resident#44 using Quetiapine Fumarate would be fatigue. She was not asked how the failure would affect the Resident #44<BR/>Interview on 01/24/25 at 12:14 PM with the NP revealed Resident #44 was not supposed to be on antipsychotic medication for sleep. She was aware she had diagnosis of dementia with behaviors, and she did not prescribe the antipsychotic medications, and if they admit with an antipsychotic, she did refer residents to be evaluated by a psychiatrist. She stated she did not belief it was meant for sleep since she had a diagnosis of dementia with behaviors. She was not asked on how the medication would affect the resident.<BR/>Interview on 01/24/25 at 12:43 PM with the Physician was attempted; however, the attempt was unsuccessful with no return call.<BR/>Record review of the facility's Psychotropic/Psychoactive Medication policy dated 12/09/24 reflected the following: <BR/> .1. Resident will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective . <BR/>Record review of the facility's Psychotropic Management policy dated 01/11/22 reflected the following: <BR/> .3. PRN Antipsychotic and PRN Psychotropic medications- <BR/>a. Any as needed use of an antipsychotic can only be authorized for 14 days. These orders cannot be renewed unless the attending physician or prescribing practitioner evaluate the resident for the appropriateness of that medication. A new order for prn anti-psychotic will be required to be written every 14 days .<BR/>Record review of the Seroquel: Package Insert/Prescribing Info last updated 01/30/24 reflected the following:<BR/>Highlights of Prescribing Information .<BR/>Warning: Increased Mortality in Elderly Patients with Dementia-Related Psychosis; and Suicidal Thoughts and Behaviors<BR/> .Indications and Usage for Seroquel<BR/>Seroquel is an atypical antipsychotic indicated for the treatment of:<BR/>- Schizophrenia<BR/>- Bipolar I disorder mania episodes<BR/>- Bipolar disorder, depressive episodes<BR/> .5. Warnings and Precautions<BR/>5.1 Increased Mortality in Elderly Patients with Dementia-Related Psychosis<BR/>Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death .Seroquel is not approved for the treatment of patients with dementia-related psychosis .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored securely for 1 of 25 residents (Resident #45) and had acceptable labeling for 2 of 4 medication carts (medication cart for Halls 200 and 300) reviewed for labeling and storage. <BR/>1. The facility failed to ensure Resident #45's 1 bottle of thymus 300 capsules, 1 bottle of thyroid 130 capsules, 1 bottle of Advil 200 mg, and 1 bottle of Tylenol 500 mg stored at the resident's bedside table were locked in a lock box or secured in the medication cart or medication room. <BR/>2. The facility failed to ensure insulin vials were dated after they were opened. <BR/>This failure could place residents at risk of not receiving the therapeutic dose of medication. <BR/>Findings included: <BR/>Record review of Resident# 45's Quarterly MDS Assessment, dated [DATE], reflected the resident was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included cancer (with or without metastasis) (when cancer spreads beyond the place where it started to other areas of your body). The resident had moderate cognitive impairment with a BIMS score of 10. <BR/>Record review of Resident #45's care plan, dated [DATE], reflected Resident #45 was on pain medication therapy to rule out cancer, pathological fracture in neoplastic disease (abnormal growths of cells or tissues that can invade and spread to other parts of the body), or wedge compression fracture of third lumbar vertebrae. The goals: - Resident #45 will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions: - Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift. <BR/>Record review of Resident #45's physician's orders dated [DATE] reflected an order for the resident tramadol HCl Oral tablet 50 mg (Tramadol HCl) Give 50 mg by mouth every 6 hours as needed for Pain. <BR/>Record review of Resident #45's physician's orders dated [DATE] reflected an order for the resident to Acetaminophen tablet 325 mg give 2 tablet by mouth every 4 hours as needed for general discomfort/pain. <BR/>Observation and interview on [DATE] at 12:23 PM revealed Resident #45 with 1 bottle of thymus 300 capsules, 1 bottle of thyroid 130 capsule, 1 bottle of Advil 200mgs, and 1 bottle of Tylenol 500 mg stored at the resident's bedside table. Resident #45 stated, he used the thymus and thyroid capsules before meals and Advil and Tylenol he took when in pain. <BR/>Observation and interview with RN E on [DATE] at 12:48 PM, who was the charge nurse for Hall 500, revealed she was aware the medications were in the room. She stated when the resident was admitted he was assessed for self-administration and was doing it but recently his cognitive status had changed. RN E stated she had checked on Resident#45's records and there was no assessment of self-administration and he had not been care planed for self-administration. RN E stated they did not have a resident who self-administered medications at the facility. RN E stated Resident #45 did not have an order for thymus 300 capsule, thyroid 130 capsule, Advil 200mgs, and Tylenol 500mgs and having the medication in his possession placed him at risk of overuse of the medication or adverse reactions and other residents could get them. RN E stated it was the responsibility of all nursing staff to remove any medications from the resident's bedside. She stated she had done training on medication in rooms, but she could not tell when. <BR/>Observation on [DATE] at 1:57 PM of the medication cart for Hall 200, with LVN A revealed 1 insulin pen,(basaglar is a long-acting insulin used to control high blood sugar) was opened, partially used, and not labeled with the open date. <BR/>Interview on [DATE] at 2:05 PM with LVN A, who was the charge nurse for Hall 200, revealed she knew insulin pens were supposed to be dated once they were opened or after they were removed from the refrigerator and placed on the cart. She stated she knew she was supposed to check her cart to ensure insulins were labeled and dated but she did not check that morning. She stated the risk of administering insulin when not dated was they might have expired and would not be effective. She stated she had done training on labeling and dating the insulins. <BR/>Observation on [DATE] at 2:23 PM of the medication cart for Hall 300 with LVN C revealed 2 insulin pens, glargine flex pen insulin injection and insulin Tresiba flex pen, were opened, partially used, and not labeled with the open date. <BR/>Interview on [DATE] at 2:28 PM with LVN C, who was the charge nurse for Hall 300, revealed she knew insulin pens were supposed to be dated once they were opened or after they were removed from the refrigerator and placed on the cart. She stated she knew she was supposed to check her cart to ensure insulins were labeled and dated but she had checked and missed the 2 vials. She stated the risk of administering insulin when not dated was they might have expired and would not be effective. She stated she had done training on labeling and dating the insulins. <BR/>Interview on [DATE] at 3:45 PM with the ADON revealed it was her expectation that staff date the insulin pens once they pulled them from the refrigerator. She stated it was also the responsibility of the staff to check daily on the expiration dates and labelling. She stated if the staff were not putting the opened dates on the insulin pens and vials that required an open date it placed residents at risk of not getting required therapy. The ADON stated it was her responsibility to audit the carts and the last time she audited was in December. She also stated she expected the nurse to sign off narcotics on the narcotic administration log once they were administered. She stated the risk would be overdose and drug diversion. She stated she was supposed to check the narcotic logs every day and the last time she had checked was [DATE]. <BR/>Interview on [DATE] at 3:51 PM with the ADON revealed it was all nursing staff's responsibility to ensure there were no medications in the residents' rooms. They were supposed to notify the ADON and the DON. She stated at one-point there was confusion on Resident#45 because at first, he was care planned for self-administration and when his cognition status changed, he was not able to self-administer. She stated that was one year ago when the previous DON was in the facility. She stated it was an oversight because when he started declining the medications were supposed to be removed from his room. She stated an assessment of self-administration was supposed to be done for him to have medications in the room but at this time they could not do the assessment, he could not pass. She stated the risk for Resident#45 having medications in the room was he could overdose, the roommate could take them and other wandering residents. She stated she was not sure whether facility had done training on medications in residents' rooms. <BR/>Interview on [DATE] at 11:38 AM with the Cooperate RN revealed residents were not supposed to have medication of any kind in their rooms unless they were assessed and were found to be safe with self-administration and there was a doctor's order to self-administer. She stated her expectation was staff were to remove medications from the rooms. The Corporate RN stated residents having medications in their rooms put them at risk of over medicating and other residents could get ahold of them. She stated she also expected staff to label insulin with an opening date once they opened and to check carts for dates and labeling every shift. She stated the risk was they could be expired and if administered they would not be effective. She stated she was not sure whether the facility had done training on labeling and putting an opening date. The Corporate RN stated her expectation was if nurse administered narcotics, they should sign off on the narcotic administration log. She stated the risk of not signing off was an overdose and effect on resident's management. She stated the ADON and the DON were responsible for auditing the carts for labeling and opening dates and on narcotic logging of after administration. <BR/>Record review of the facility's Administering Medication policy, dated [DATE], reflected: <BR/> .12 .when opening a multi-dose container, the date opened is recorded on the container .<BR/>Record review of the facility's policy Storage of Medication, dated [DATE], reflected: <BR/>Medications and biologicals used in the facility are stored in locked compartments under proper temperatures, lights, and humidity controls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report the results of all investigations to the State Survey Agency (HHSC), within 5 working days of the incident for 1 of 3 facility self-reported incidents (Incident Intake ID: 483847)reviewed for reporting to HHSC. <BR/>The facility failed to submit a Provider Investigation Report to HHSC within 5 working days of reporting an incident involving allegations of quality of care, administration/personnel, and resident rights regarding Resident #1 on 02/12/24.<BR/>This failure could place the residents at risk for not having investigations reported within the timeframe as required. <BR/>Findings included: <BR/>Record review of the face sheet printed on 02/28/24 indicated Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses including vascular dementia severe with agitation (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), cerebral atherosclerosis (build-up of plaque in the blood vessels of the brain), and high blood pressure.<BR/>Record review of the admission MDS dated [DATE] indicated Resident #1's cognition was severely impaired with a BIMS score of 00.<BR/>Record review of Resident#1 care plan, dated 02/05/24, indicated Resident #1 had impaired thought process due to dementia and had behaviors. Resident #1 was noted to have behavior problems due to being physically aggressive and resistive to care as evidenced by refusal for staff to provide incontinence care and activities of daily living rule out dementia. The care plan reflected: Intervention: Allow Resident #1 to make decisions about treatment regime, to provide sense of control.<BR/>Review of TULIP reflected the DON reported an incident (Incident Intake ID: 483847) on 02/12/24 at 5:00 PM. The incident involved Resident #1 and CNA A with allegations of administration/personnel, quality of care, and resident rights. Further review of the TULIP record reflected no evidence a Provider Investigation Report had been submitted for this incident as of 02/28/24.<BR/>Interview on 02/28/24 at 2:27 PM with the DON revealed she was notified by a family member on 02/12/24 that they heard CNA A walking down the hall with other staff stating she could not wait to get out of the facility because the residents were mean. CNA A was then observed pointing towards Resident #1's room. The DON stated after learning of the incident she notified the Administrator, called the intake in to the State Survey Agency, and CNA A was suspended. She stated she was aware the Provider Investigation Report was supposed to be completed within 5 days. <BR/>Interview on 02/28/24 at 3:35 PM with the Administrator revealed the family member reported the incident happened on the hallway on 02/10/24, and they notified the DON on 02/12/24. The DON notified him, since he was out of the office, and he told the DON to report to the State Survey Agency and suspend the CNA. The Administrator stated he was aware of the regulations he was supposed to submit the investigation report within 5 days, but he did not because he could not get ahold of CNA A for an interview. He stated there was no abuse, and he felt it was not reportable because this was unprofessional behavior on the hallway. CNA A was suspended, although she had already given her resignation letter to the facility, and that week was her last working at the facility. The Administrator stated he had not seen CNA A since that day. He stated failure to submit the investigation report could have caused the problem to continue or reoccur. He stated he did in-service training on abuse and neglect on 02/17/24, and he did safe surveys with interviewable residents, which resulted in no issues or concerns being reported.<BR/>Review of the in-service record, dated 02/17/24, on the topic of Abuse and Neglect revealed the staff were trained on the types of abuse, reporting of allegations of abuse to the Administrator, who was the facility's Abuse Coordinator, immediately. The training also reflected if an allegation was reported to a supervisor, it should also be reported to the Administrator. <BR/>Record review of the facility's current Abuse policy, dated 11/07/23, reflected: <BR/> .3. The facility will report the results of the investigations to the enforcement agency in accordance with state law, including the stated survey and certification agency.<BR/> .5. Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to review and revise care plan after each assessment for one (Residents #12) of six residents reviewed for care plans. <BR/>The facility failed to complete/revise Residents #12's care plan as being a smoker. <BR/>This failure could place residents at risk of not receiving individualized care, which could result in a decline and function and mental well- being. <BR/>Findings included:<BR/>Record review of Resident #12's Quarterly MDS assessment dated [DATE] revealed a 53- year- old female who admitted [DATE] with a BIMS score of 15 (no cognitive impairment), used a wheelchair with no impaired upper and lower extremities, independent with most ADL care, and occasionally incontinent to bowel and bladder, with 2 or more falls with no injury. <BR/>Record review of Resident #12's Order Summary Report dated 11/29/23 revealed she took medications for migraines, anxiety, pain, nausea vomiting, depression, schizoaffective (Mood Disorder) disorder, active bladder. <BR/>Record review of Resident #12's Care plan dated 11/29/23 by MDS C revealed, At risk for injury due to smoking preference .dated initiated and created (Today) 11/29/23 .will not suffer injury related to unsafe smoking practices through the next review period .Educate on risk of smoking and hazards .follow smoking times designated .smoking safety ability and provide appropriate interventions .may or may not use smoking apron during facility smoke times .noted as a safe smoker. <BR/>Record review of Resident #12's Smoking Safety Evaluation dated 10/27/23 revealed she was a safe smoker . <BR/>Interviews on 11/29/23 at 1:44 pm, CNA E stated Resident #12 was a smoker that was independent and was able to smoke unsupervised. She stated care plans were used to look at the residents progress to see if any changes had to be made about how they were cared for . <BR/>Interview on 11/29/23 at 2:09 pm, Medication Aide F stated the resident's Care Plans were used for each resident to know what they were allowed to do or not and what was needed to reach their goals. <BR/>Interview on 11/29/23 at 3:29 pm, CNA H stated the resident's care plan showed them how to care for the resident, for example, if they can walk or not . <BR/>Interview on 11/29/23 at 3:44 pm, MDS Coordinator C stated this facility had a comprehensive approach to assessing the residents who smoked. She stated SW I completed the smokers' care plans. She stated that she believed Resident #12 was a smoker and had a smoke assessment on 10/27/23. She stated she was considered a safe smoker and had a care plan for falls but not for being a smoker. She stated she did not see Resident #12's care plan for being a smoker and would do it right now. because she did not know she was a smoker. She stated in Resident #12's care plan there was no mention of her being a smoker and added if care plans were not accurate, the resident may not get the right type of care. She stated they had a binder in place with all of the smokers in it and said she needed to go to the Administrator to review the binder to ensure it was updated so that the resident's care plans were accurate. <BR/>Interview on 11/29/23 at 4:17 pm, SW I stated care plans were used to guide them on how to best care for the resident. She stated the MDS Coordinator was responsible for completing the care plans and after reviewing Resident #12 EMR she stated Resident #12 had a new smoking care plan added today (11/29/23). She stated from this day forward she would start reviewing the smoker's list and to update the smoker's assessment. She stated they had a care plan meeting with herself, with the ADON, and Rehabilitation Director, but the MDS Coordinator was not in the meeting and should be. <BR/>Interview on 11/29/23 at 6:22 pm, Former DON A stated Resident #12 was a smoker and she should have had a care plan that said she was. The former DON A said he was not aware she did not have a smoking care plan . <BR/>Interview on 11/29/23 at 6:48 pm, the Administrator stated they had clinical meetings regularly and that was also when MDS Coordinators updated about the smokers evaluations and care plans. He stated he was surprised about the lack of communication between the department heads and was not sure why MDS Coordinator C did not attend the care plan meetings. He stated Resident #12 was a smoker and she should have a care plan. The administrator added that the care plans were to provide the correct treatment and precautions in the least restrictive environment and instructed the staff on how to care for the resident. He stated if the residents care plan or smoke assessments were wrong it could cause the resident harm, resident could fall, or cigarette butts could fall on the resident. He stated SW I was responsible for giving the info to MDS Coordinator C so that she could input the data and create a care plan. He stated his expectations for care plans were for them to be completed and done in a timely and accurate manner. He stated for a change in condition, the nurse notified SW I for a care plan meeting, and a new smoke evaluation needed to be completed. He stated his plan to prevent this from happening again was to ensure all documentation from admission to discharge were in all of their records and accurate. <BR/>Record review of the facility's Smoking Policy revised 10/2022 revealed, Safe smoking environment: It is the responsibility of the facility to provide a safe and hazard free working environment for those residents having been assessed as being safe, for facility smoking privileges. The facility is responsible for informing residents, staff, visitors and other affected parties of facility's smoking policies through verbal mean, distribution and posting. This policy is intended to minimize the risks to: residents who smoke, including possible adverse effects on treatment, passive smoke and fire .<BR/>Record review of the Facility's Care plans policy reviewed on [DATE] revealed, Policy Statement: A comprehensive, person-center care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition changes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety in 1 of 1 kitchen reviewed.<BR/>1. The facility failed to ensure the ice and water dispenser, located in the facility dining room, was cleaned and free of white chalky substance with brown spots discoloring, white chalky spots and failed to ensure the overflow tray was not soiled with brown rust spots and spilled coffee. <BR/>2. The facility failed to ensure the ice machine, in the facility only kitchen, was cleaned and free of discoloring of white chalky and brown stains on the inside and outside of the ice machine and failed to ensure there was no dust particles with dirt and covering the filter used for the freezer.<BR/>3. The facility failed to ensure the hydration stations were cleaned, free of dirt, didn't have soiled surfaces on the cart ice scoop, and inside ice chest.<BR/>These failures could place residents at risk to bacteria, and other infectious illness. <BR/>Findings include:<BR/>1. Record review of Resident #83's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis which included stiff man syndrome (Stiff-person syndrome (SPS) is a rare neurological disorder with fluctuating muscle rigidity in the trunk and limbs and a heightened sensitivity to stimuli such as noise, touch, and emotional distress, which can set off muscle spasms.)<BR/>Observation on 09/20/2022 at 9:30 a.m., during the initial tour of the kitchen, the dining room ice and water machine dispenser was observed with spilled coffee, pink paper from used sugar packets, dirt, and further debris on the floor between the ice maker, table, and cabinets as well as behind the ice machine. The ice dispenser was soiled with splattered discoloring of white chalky and brown stains and rust on the overflow tray of the machine. The Large ice machine in the kitchen was observed with (chalky white spots) on the inside and outside of the ice machine and dust had visibly thick grey particles with dirt and covered the filter used for the freezer.<BR/>Interview with the Dietary Manager (DM) on 09/20/22 at 9:45 a.m. revealed it was the responsibility of maintenance to clean and service the ice machine in the kitchen, and both Housekeeping and maintenance to clean and service the machine in the dining room areas. She stated he serviced the machine approximately 1 time a month, and she did not want to get anyone in trouble. The DM stated she reported the filter in the machine to the maintenance department a few weeks ago. She stated she did not follow back up with MD. Documentation of the maintenance request was requested by the State Surveyor and was not received. She stated that she had documentation of the request for the freezer, however the documentation was not received. She stated it was the responsibility of the nursing staff to maintain the hydration stations and return to the kitchen for cleaning when soiled or to refill. She stated most of the time the staff would refill the ice from the machine in the dining room. She stated she did not use the ice/water machine in the dining room, as she preferred bottled water. <BR/>Interview with the Housekeeping Manager (HK) on 09/20/22 at 10:45 a.m. revealed it was his staff's responsibility to clean the dining hall ice machine, counters, and floors daily. He stated though the ice/water machine looked unclean, the machine was clean, and he drank from the machine daily. He stated that though the machine's appearance looked unclean, the housekeeping department cleaned it routinely according to standards. The ice dispenser was observed to be heavily soiled with splattered white chalky stains and rust on the overflow tray of the machine. The Large ice machine in the kitchen was observed with chalky white spots) He tried to remove the discoloration (white chalky stains with some rust) from the machine, and it wouldn't come off. He stated the staff cleaned the floors and the table around the machine daily. <BR/>The Housekeeping Manager stated the spills and debris were from breakfast this morning, and housekeeping had not cleaned. Housekeeping normally cleans at 10:00 a.m. He stated he reported to maintenance that the machine had white chalky discoloring with brown spots, and the maintenance director told him he was going to order parts to be replaced on the machine that would prevent this from occurring. The Housekeeping Manager stated the machine was broken and was always broken. He stated it had been over two weeks since the part was ordered, and he did not know why it had not arrived to install. He stated housekeeping and maintenance both were responsible for cleaning the ice machine in the dining areas.<BR/>Interview with the Maintenance Director (MD) on 09/20/22 at 9:45 a.m. revealed it was his responsibility to clean and service the ice machine in the kitchen, and dining room. Housekeeping was responsible sanitation of the dining hall ice machine. He stated the manufacture guidelines required him to install new filters every 6 months at a minimum. He stated he ordered parts for the machine in the dining room that would keep the stains of white chalky substance away. He stated he would clean and work his magic to remove the discoloring and stains. The Maintenance Director stated that he thought that he ordered the parts, but they were still in the internet basket for purchase, and he purchased them today.<BR/>Observation on 09/21/2022 at 9:30 a.m. revealed the hydration station located on the 300 hall of the facility had splattered liquids on the bottom of the cart, the top of ice chest inside had smudges of black/brown dirt on white surface, and the scoop holder was visibly soiled. <BR/>Observation on 09/21/2022 at 11:00 a.m. of Resident #83's room revealed his personal refrigerator was not the correct temperature, and there was food wrapped in paper from his tray, food was unsealed, dated, and uncovered in his fridge. The thermometer registered 40 degrees; however, the food was room temperature. The contents of the fridge had yogurt, ensure drinks, loose food spilled liquids and disposable dining trays.<BR/>An Interview on 09/21/22 at 11:00 a.m. with Resident #83 revealed he took food from his dinner tray that he did not eat and placed in his personal refrigerator in his room. He stated he told the kitchen not to send Ensure, yogurt, or fish, however they continued to, store it in here. He stated no one had come to clean his refrigerator. He stated he had not asked anyone to come and clean out his refrigerator or check the temperature.<BR/>Interview with the Dietary Manager (DM) on 09/21/2022 at 1:00 p.m. revealed she was not informed to check the resident's refrigerators in their rooms for dated and undated food, sealed properly, sanitation, and disinfecting. She stated that she was not aware that Resident #83 kept food in his room from the kitchen. <BR/>Interview with the Administrator on 09/21/2022 at 3:30 p.m. revealed he would have the refrigerator cleaned and operations of right temperatures checked, and routinely cleaned to meet kitchen guidelines. He did not have any further explanation regarding the condition and upkeep. He stated the hydration stations were to be kept up by the aides on the hall, by maintaining sanitation of the station and refilling. He stated residents should not be served ice from the hydration station when it was unsanitary. Staff should be monitoring and assuring hydration was clean, and the purpose of the sanitation station was to have ice and water available for residents to drink and prevent illnesses. <BR/>A record review of the facility's, undated, policy titled Guidelines for Resident Refrigerators, revealed, Each resident refrigerator will have a thermometer; All perishable items in the refrigerator must be dated and labeled; Designated personnel will monitor refrigerator temperature weekly; Refrigerator will be cleaned and defrosted periodically; Any unlabeled perishable items will be discarded; Labeled perishable items will be discarded within 48 hours of the date on the items <BR/>A record review of the facility's Hydration Management Policy, dated 10/08/2007 revealed all residents will be provided with sufficient fluid intake to maintain proper hydration and nutritional status. The policy did not address maintaining sanitation of the carts.<BR/>A record Review of the facility policy for cleaning and servicing ice machines revealed that Record review of the records for the logbook documentation, dated 7/29/2022, revealed service of the ice machine Check water filter (if present)<BR/>1. If incoming water pressure deteriorates, it's time to install new filter (at a minimum every six months); Check air-filter (if present)<BR/>2. Check that air filter is correctly installed<BR/>3. Replace filter if needed<BR/>4. Clean Coils<BR/>Sanitize Interior:<BR/>1. Sanitize interior of ice machine per manufacturer's instructions<BR/>2. Clean out and sanitize the ice bin<BR/>Clean Exterior:<BR/>1. Clean and wipe down exterior<BR/>2. Check electrical plug for burns Check water filter; Check Air Filter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had a clean, comfortable, and home like environment, which included but not limited to receiving treatment and supports for daily living safely for 1 of 3 residents (Resident #68) reviewed for a clean and homelike environment.<BR/>1. The facility failed to ensure Resident # 68's call light was clean and free from feces and food.<BR/>This deficient practice could place residents at risk of illness, infection due to contact with unclean surfaces in the facility. <BR/>Findings include: <BR/>Record review of Resident #68s face sheet, dated 09/22/2022, revealed an 88- year-old female with an admission date of 08/30/2022. Resident #68 had diagnoses which included Alzheimer's Disease with late onset (memory loss.), chronic kidney disease (kidneys is damaged in function), Major Depression (mood), Hypertension, (high blood pressure) Hypothyroidism (underactive thyroid, Pain unspecified joint., Diabetes Mellitus (increased sugar levels) with Diabetic Poly neuropathy (nerve damage), and generalized anxiety (excessive worrying). <BR/>Record review of Resident #68's admission Minimum Data Set (MDS) assessment, dated 09/06/2022, reflected a score of 4 on her Brief Interview for Mental Status (BIMS), signifying that she was severely impaired cognitively. The assessment of her behavior reflected Resident #68 wandered throughout the facility, and she was an elopement risk and often delusional. Her functional status assessment reflected she needed extensive assistance with bed mobility, transfer and locomotion, transfers, locomotion off unit, dressing and eating with supervision. The assessment reflected she required extensive two- person assistance with toilet use and personal hygiene. Resident #65's urinary status was not rated, and she was always continent of bowel. Her diagnoses included: peripheral vascular disease, obstructive and reflux uropathy (when urine cannot drain through the urinary tract), diabetes mellitus (increased blood sugar), low back pain, and muscle weakness. <BR/>Record review of Resident #68's [NAME], dated 09/22/2022, reflected the following ADL task entered: orders entered included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed and avoid isolation.<BR/>An interview was attempted with Resident #68 on 09/20/22 @ 11:00 a.m. and she was not responsive, only smiled and continued to ambulate to the nursing station.<BR/>An observation on 09/22/2022 at 9:52 a.m. revealed Resident #68 was sitting in her wheelchair in her room asleep. Her call light was on the bedside table next to her and was observed with a brown gritty substance with the consistency of feces. <BR/>Interview on 09/22/2022 at 9:50 a.m., CNA B stated when she entered the room for calls, she did not observe the call light with a brown substance. She stated usually when she responded to a resident call light, she would first disable the light and ask the resident for their request. She then entered Resident #68's room and observed the call light with a brown substance and stated EWW .<BR/>Interview on 09/22/2022 at 9:58 a.m. with the Housekeeping Aide (HK-E) revealed she cleaned the resident's rooms daily and before leaving her shift. She stated she had not cleaned the resident's room for the day. She observed the resident's call light with the soiled brown substance. She stated she would clean it immediately. She denied observing the call light soiled with the substance prior to this being brought to her attention today. She stated she had been cleaning the same resident rooms daily and sanitized the call lights. <BR/> In an interview with the Housekeeping Supervisor on 09/20/2022 revealed his staff cleaned, sanitized, and disinfected resident bed tables and call lights daily. He stated he conducted walk throughs for inspections daily throughout the facility. He stated if a resident's room needed further attention, the health care staff would notify him or his staff to come and clean. <BR/>Interview on 09/22/2022 at 10:05 a.m. with the DON revealed she expected housekeeping to keep resident #68's call light clean and free of unsanitary conditions at all times, and her staff should observe for clean sanitary call lights during rounds to the resident's room and when answering the call lights. Once observing the call light, she called for housekeeping to come immediately and sanitize, she then notified the Administrator. DON stated that it was important to ensure the call light and other surfaces were disinfected and sanitized to prevent unsanitary conditions that could lead to illnesses and infections.<BR/>During an interview with the Administrator on 09/22/2022 at 12:56 p.m., the Administrator stated the call light had been cleaned, and he was notified by the DON. He expected resident's call lights to be disinfected and sanitized and all staff should be inspecting and assuring the task was complete to maintain a clean environment. <BR/>Record review of the facility's, undated, policy titled Resident Room Cleaning Procedures did not specifically address call light sanitation. The policy stated that resident rooms are to be cleaned daily by housekeeping staff, starting at the back, and working forward cleaning window seals, base boards, bed rails, bedside tables, nightstands, stationary chairs, bathroom, and mop floors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the interdisciplinary team determined if a resident was able to self-administer medications d for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility's interdisciplinary team failed to ensure Resident #1 was clinically appropriate to self-administer Systane ophthalmic eyedrops that were at the resident's bedside. The failure had the potential to place residents at risk for unsafe drug administration. Findings included:Record review of Resident #1's admission MDS, dated [DATE], reflected Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's BIMS score of 14, which indicated his cognition was intact. Resident #1's MDS was pending completion. Record review of Resident #1's Baseline Care Plan, admission date 10/04/25, reflected Section D. Medications revealed Resident #1 was not able to self-administer any medications. Record review of Resident #1's clinical records reflected no assessment was completed to indicate if Resident #1 was able to self-administer medication. Record review of Resident #1's order summary report reflected the following: Systane Ophthalmic Solution 0.4-0.3 % (Polyethylene Glycol-Propylene Glycol (Ophth)) Instill 2 drop in both eyes at bedtime for dry eyes Start date 10/04/25. Record review of Resident #1's order summary reflected Resident #1 had a new order for Systane Ophthalmic Solution 0.4-0.3 % (Polyethylene Glycol-Propylene Glycol [Ophth]) Instill 2 drop in both eyes at bedtime for dry eyes able to keep at bed side for self-administer and Artificial Tears Ophthalmic Solution (Artificial Tear Solution) Instill 2 drop in both eyes every 6 hours as needed for dry eyes able to keep at bed side and self administer Start Date: 10/08/25. Observation and interview on 10/08/25 at 10:21 AM, revealed Resident #1 had a bottle of Systane Ophthalmic Solution (eye drops) at his bedside table and an unopen bag with a box inside which contained Artificial Tears Ophthalmic Solution (eyedrops). Resident #1 stated she had the bottles since being admitted on [DATE], she stated staff had not mentioned anything about her eyedrops. Resident #1 stated she administered the eye drops at bedtime. She stated staff did not come by to ensure if she put them in. She stated she was not sure if staff knew she had them, but they never took them away from her bedside table, she stated I think they trust me. Interview on 10/08/25 at 10:40 AM, RN A revealed he was the nurse assigned to Resident #1. He stated he was not sure if he had residents who could self-administer eyedrops. RN A observed eyes drops at Resident #1's bedside table, he stated he did not observe the eye drops when he completed his rounds. RN A reviewed Resident #1's orders and stated the resident only had one order for eye drops to be administered at bedtime. He stated he was not aware Resident #1 had another bottle of artificial tear ophthalmic solution. RN A stated someone from the night shift might have left the eyedrop solution in the resident's room. Interview on 10/08/25 at 2:24 PM, ADON B revealed residents were able to self-administer eye-drop medications only if they were assessed and obtained a physician's order to self-administer and to keep medications at the bedside. She stated she was not aware of any residents who could self-administer eye drop medication. She stated expectations were for nurses to assess the residents to ensure residents were able to self-administer and obtain an order. ADON B stated there was no potential risk for the resident to self-administer and to keep eye drops at the bedside; however, the eye drops would need to be removed until the assessment was completed on the resident. Interview on 10/08/25 at 2:39 PM, LVN C revealed she was the 2:00 PM-10:00 PM nurse assigned to Resident #1 on 10/07/25. She stated she was not sure if she had any residents who could self-administer eye drops and keep them at the bedside. She stated the Medication Aides administered eye drops to residents, but she could not recall which Medication Aide was assigned to Resident #1. LVN C stated they had to first determine if a resident could self-administer eye drops. She stated she did not observe any eye drops at the resident's bedside during her shift for Resident #1. Interview on 10/08/25 at 2:45 PM, MA D revealed she was the 2:00 PM-10:00PM Medication Aide assigned to Resident #1 on 10/07/25. She stated Resident #1 kept her eye drops at her bedside and kept them at her bedside since admission. MA D stated Resident #1 had an order for the eyedrops, and the resident self-administered her own eye drops. She stated by the time she followed-up with Resident #1 at bedtime to ensure she administered the eyedrops the resident confirmed she had administered them. MA D stated no one had mentioned anything to her regarding whether Resident #1 could keep the eyedrops at her bedside or if she could self-administer them. She stated she assumed Resident #1 had an order to self-administer the eyedrops and to keep the eyedrops at her bedside. MA D stated she should had checked to ensure resident had orders to self-administer. She stated there was no potential risk to the resident because she was alert and knew when to administer. Interview on 10/08/25 at 3:13 PM, the DON revealed she had residents who could self-administer medications; however, she could not recall if Resident #1 was one who could self-administer. The DON stated the expectation was for the residents to be assessed first to ensure they were capable of self-administering, and then they would obtain a physician order. She stated the assessment was for them to know if the resident knew how to correctly administer medications and be aware of the times. The DON stated if the resident wanted to keep medications at her bedside a physician order had to be obtained. She stated the potential risk of keeping medications at the bedside would be someone else could get the medications or the residents not being able to self-administer. Record review of the facility Medication Administration policy, revised June 2025 reflected the following: .27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Residents # 1 and #2) reviewed for accidents.<BR/>1. The facility failed to ensure Residents #1 and #2 were provided adequate staff supervision during a smoking session. <BR/>2. The facility failed to increase supervision of the residents even though they had negative altercations prior to the altercation in the courtyard. <BR/>This failure could place residents at risk for further altercations, which could result in injury, pain, and hospitalization. <BR/>3. Facility prematurely prepared Resident #3, who required a two-person assisted transfer, using a mechanical lift, for transfer. By the resident having to wait for a second staff to assist with the transfer, she became impatient and attempted to transfer herself, which resulted in a fall.<BR/>This failure could place residents at risk for accidents or serious injury. <BR/>Findings Include:<BR/>A record review of Resident #1's Face Sheet dated 08/07/23, revealed a [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), difficulty in walking, lack of coordination, Anxiety Disorder (persistent and excessive worry that interferes with daily activities), Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania {increased talkativeness, rapid speech, a decreased need for sleep, racing thoughts, distractibility, increase in goal-directed activity, and psychomotor agitation} or hypomania {periods of over-active and high energy behavior that can have a significant impact on your day-to-day life}] and lows [depression]).<BR/>A record review of Resident #1's Care Plan, dated 05/30/23 at 10:07 AM, reflected she had limited mobility related to muscle weakness and Dementia. She had a mood problem related to bipolar disorder and anxiety disorder. Interventions: She required a wheelchair to self-propel. She required monitoring and observation for impaired judgment or safety awareness. Also, monitoring for increased anger or agitation. Resident #1 is/has potential to be verbally aggressive related to Dementia, Ineffective coping skills, Mental / Emotional illness, Poor impulse control <BR/>yelling/screaming, abusive language, threatening behavior at staff and residents. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Assess resident's coping skills and support system. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Give the resident as many choices as possible about care and activities. Monitor behaviors Qshift. Document observed behavior and attempted interventions. Psychiatric/Psychogeriatric consult as indicated. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>No updates to the residents care plan in reference to the altercations between Resident #1 and Resident #2 were noted.<BR/>A record review of Resident #1's MDS dated [DATE] at 10:12 AM, revealed a BIMS assessment score of 15, which indicated the resident was cognitively intact. She had verbally aggressive behaviors toward staff and other residents. <BR/>A record review of the Progress Note created by RA A, dated 07/30/23 at 10:41 PM, for Resident #1 reflected the following, Resident got in physical altercation with another resident. This physical altercation was not witnessed by me, however, I cleaned up resident's hands. Resident had two scratches on left hand and one on right. Cleaned residents wounds and put triple antibiotic on top and covered with bandaid. Wound on right hand was not covered with bandaid. Resident denied being pain. <BR/>A record review of the Progress Note created by RN F, dated 08/02/23 at 1:29 PM, for Resident #1 reflected the following, At about 12 noon, another nurse called me to the resident's room. As I entered the room, the resident stated that she was out on the patio and another resident came and grabbed her from behind, so she grabbed her hands too. The resident fell backwards onto the ground. Staff intervened. Head to toe assessment done. Scratches on the right side of her cheek, chin and left arm are noted. Dressings done. Vital signs taken and recorded. Administrator, DON, MD and family were all informed.<BR/>A record review of the Progress Note created by the Social Worker, dated 08/02/23 at 2:12 PM, for Resident #1 reflected the following, Late entry. Resident had physical altercation with another resident. She has a history of bipolar disorder and her mood swings have been unmanageable. She becomes angry and a few minutes later she is crying. She is agreeable to go to a psychiatric hospital for medication management and mood stabilization.<BR/>A record review of Resident #2's Face Sheet dated 08/07/23, revealed a [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Cognitive Communication Deficit (difficulty with thinking and how someone uses language), Anxiety Disorder, Major Depressive Disorder Personal history of Transient Ischemic Attack (a stroke that lasts only a few minutes) and Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Hypertension, and Chronic Obstructive Pulmonary Disease.<BR/>A record review of Resident #2's MDS dated [DATE] at 10:20 AM, revealed a BIMS score of 13, which indicated she was cognitively intact. No behaviors were noted. She required a wheelchair for ambulation. <BR/>A record review of Resident #2's Care Plan, dated 05/30/23 at 10:25 AM, reflected she had potential to be physically aggressive (with other residents) r/t Depression, Poor impulse control. 8/2/23- Resident is on one-to-one supervision and family has also agreed to help provide supervision. Interventions: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Monitor each shift. Document observed behavior and attempted interventions in behavior log. Monitor/document/report as needed any signs/symptoms of resident posing danger to self and others. <BR/>A record review of the Progress Note created by Nurse G, dated 08/01/23 at 6:11 PM, for Resident #2 reflected the following, This resident remains with no injury and denies pain after incident with other resident. Doctor and family notified. No further concern at this time.<BR/>A record review of the Progress Note created by the ADON, dated 08/02/23 at 3:39 PM, for Resident #2 reflected the following, spoke with [family member] regarding episode of aggression in detail-Stated that resident becomes very mean and sees things when she has a UTI and resident 'needs IV antibiotics when she gets them'-Spoke with Np regarding the above and new order written for ceftriaxone 1gm IM x 3days<BR/>A record review of the Progress Note created by the Social Worker, dated 08/02/23 at 4:53 PM, for Resident #2 reflected the following, SW spoke with resident's[family member], regarding recent aggressive behaviors. She is agreeable to Psych referral. SW sent referral this date and sent text message to the Psychatrist to request face time visit asap. Resident is on one-to-one supervision and family has also agreed to help provide supervision.<BR/>A record review of the Progress Note created by RN H, dated 08/05/23 at 6:22 PM, for Resident #2 reflected the following, Lidocaine HCl Injection Solution 1 %<BR/>Inject 2.1 ml intramuscularly in the evening for mix with Ceftriaxone, until 08/05/2023 23:59 mix 2.1 ml with Ceftriaxone ABX was ordered for 3 days initial dose was given on the 8/2/23. Thus, all doses were given.<BR/>Record Review of Physician's Orders for Resident #2 on 08/15/23 at 10:49 AM, revealed cefTRIAXone Sodium Injection Solution Reconstituted<BR/>1 GM Inject 1 gram intramuscularly one time a day for<BR/>UTI for 3 Days<BR/>Completed 08/02/2023 08/02/2023 08/05/2023 _________ _________ Lidocaine HCl Injection Solution 1 % Inject 2.1 ml<BR/>intramuscularly in the evening for mix with<BR/>Ceftriaxone. until 08/05/2023 23:59 mix 2.1 ml with<BR/>Ceftriaxone<BR/>Completed 08/02/2023 08/03/2023 08/05/2023 _________ _________ Macrobid Oral Capsule 100 MG Give 1 capsule by<BR/>mouth two times a day for UTI for 5 Days<BR/>An interview with the Administrator on 08/15/23 at 9:35 AM, revealed he stated on 08/01/23, during lunch time, the two residents got into a physical altercation. He stated no actual hits made contact; however, Resident #1 was scratched. He stated the residents were separated, assessed, then placed on 1:1. He stated physicians and families were notified. He stated on 08/02/23, Resident #2 saw Resident #1 exiting the building, so she followed her out. He stated Resident #2 attempted to punch Resident #1, however, Resident #1 grabbed her arm; however, in doing so, she lost balance and fell over in her wheelchair. He stated the staff ran to stop them but didn't get to them in time to prevent it. He stated Resident #1 sustained abrasions on the right side of her head and on her right arm. He stated Resident #2 was placed on 1:1. The physicians and families were notified, and she was sent out for psychiatric evaluation. He stated Resident #1 said that on 07/30/23, she and Resident #2 got into an argument, but no punches were thrown . He stated Resident #1 said she told RA A about it. When he asked RA A about it, she confirmed Resident #1 told her, but she did not think it was serious enough to report it to him. He stated he placed her on a final level disciplinary action and re-educated her. He stated they conducted an in-service and Quality Assurance Assessment afterward. He stated Resident #2 was discharged from the facility on 08/14/23. <BR/>On 08/15/23 at 10:12 AM, a record review of a written statement by the Activities Director, reflected, I was up by the nurse's station and when the door tot he courtyard was opened, I heard Resident #1 yelling. I [NAME] to the courtyard, the Central Supply Clerk was at the door as well. Resident #2 was trying to get in the door, the Central Supply Clerk helped her inside and Resident #1 was laying, wiht her wheelchair flipped on it back. She was still in a sitting position with her head and back on the sidewalk. We called a nurse. RN H came out and assessed her. We moved her wheelchair and helped her stand up and get back into her wheelchair. She was upset and said that Resident #2 came behind her and hit her and flipped her over backwards. When we got to her room, we got her some ice water and talked to her for a little bit to get her to cool off.<BR/>On 08/15/23 at 10:17 AM, a record review of a written statement of an interview by the Administrator with Resident #2, revealed Resident #2 stated she did try to hit Resident #1 because she called her a bitch the day before and she does not like that lady. She stated she did follow Resident #1 into the courtyard and it was intentional. The Administrator added that there were not injuries to Resident #2.<BR/>On 08/15/23 at 10:24 AM, a record reivew of a written statement from the ADON, reflected I was notified that there was an incident regarding Resident #1 and Resident #2 in the enclosed patio area by the Activities Director. Resident #1 was observed in her wheelchair and was escorted to her room with htis author and another staff member. Resident #1 stated she was outside in the patio area when the other resident reached for her from behind and she grabbed Resident #2's arms and fell backward from her wheelchair. Resident #2 was also escorted to her room. Upon interview, stated that she followed Resident #1 outside. She came up behind her and reached forward to hit her. Resident #1 grabbed her arms and subsequently Resident #1 fell while in a wheelchair. Resident #2 stated, 'I was trying to hit her .cause she called me a bitch yesterday.' Resident #2 remained in her room with a staff member.<BR/>An interview with Resident #1 on 05/18/23 at 2:19 PM, revealed she and Resident #2 had exchanged words at lunch one day because she was talking to someone else and then Resident #2 told her to be quiet. She stated she already did not like Resident #2, but could not give a reason why she did not like her. She stated they began to argue because she was not going to let Resident #2 tell her what to do. She stated staff pulled them apart because they were trying to hit each other. She stated the next evening, she had gone to the courtyard to smoke and Resident #2 came out there. She stated Resident #2 did not say anything to her, she just came toward her and tried to hit her. She stated she grabbed her arm to keep her from hitting her and because of how she had to lean while holding onto her arm, it caused her to fall back. She stated she got a few scrapes, but at least Resident #2 did not get to hit her. She stated staff came out to help her and the nurse checked her out. She stated she thought the whole thing was done with, but Resident #2 would not let it go. She stated she had not seen Resident #2 for a while and she was glad she had not seen her.<BR/>An interview with the C.N.A B on 08/15/23 at 4:58 PM, revealed Resident #1 was never happy. She liked to smoke and when she didn't have cigarettes, she would torture everyone. She stated Resident #1 picked fights with residents. She stated she fusses and fights with residents and staff. She stated Resident #1 did not like Resident #2 and would always talk badly about her to her face and to others and say it loudly. She stated she was never told to keep the two residents separated or to keep an eye on them. She stated she felt it was just good to always watch Resident #1 because she messed with everyone. She stated she believed if they had been told to keep an eye on the two of them, specifically, because if that was the case, someone would have seen when Resident #2 followed Resident #1 outside and prevented the incident in which Resident #2 attempted to hit Resident #1 and Resident #1 grabbed her arm and ended up falling backward in her wheelchair. <BR/>An additional interview with the Administrator on 08/15/23 at 4:50 PM, revealed C.N.A. C had gotten the mechanical lift and had asked Nurse E to come assist her with the resident's transfer. He stated she was at the door of the room, looking for assistance, when the resident became impatient and started trying to maneuver out of bed on her own, and was reaching for the lift. Then C.N.A. C ran to catch her because she was slipping. He stated the sit-to-stand board had already been placed under the resident and that is how she was able to scoot and reach for the mechanical lift. He stated if C.N.A. C had not started the process without assistance present, the fall most likely would not have happened.<BR/>On 08/15/23 at 6:15 PM, record review of the Psychiatric Evaluation for Resident #2, dated 08/03/23 revealed an evaluation was compted by the Psychiatrist and a recommendationf or the discontinuation of the 1:1 monitoring was issued. <BR/>On 08/15/23 at 6:21 PM, record review of documents entitled 1:1 Monitoring for Resident #2, dated 08/02/23 - 08/03/23, revealed staff began monitoring the resident at 2:00 PM and continued with hourly documentation through 5:00 PM on 08/03/23.<BR/>Review of Resident #3's Face Sheet, dated 08/15/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left non-dominant side, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Major Depressive Disorder, Anxiety Disorder, Hypertension, and Osteoarthritis.<BR/>Review of Resident #3's Minimum Data Set (MDS) Assessment, dated 05/19/23, reflected the resident's Brief Interview of Mental Status score of 15, which means she was cognitively intact. She required extensive two-person for bed mobility, transfer, locomotion off unit, dressing, and toilet use.<BR/>Review of Resident #3's Care Plan dated revised on 05/30/23 reflected, the resident was at high risk for falls related to gait/balance problems, incontinence, unaware of safety needs with interventions included: Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs and follow facility fall protocol. The Care Plan did not address the resident's transfer requirements.<BR/>A record review of the Progress Note dated 08/09/23 at 6:50 AM, for Resident #3 reflected the following, 5:00 AM one of the CNA calls this nurse announcing the patient is on the floor. Resident is seated on the floor and next to her back is a commode. resident who is alert and oriented x 4 says she slid off the commode on transfer. She denied being hurt although the sling rubbed hard on my left shoulder as i went to the floor. she also denies banging self in the process. Spouse informed through a telephone message. Medical Director (MD) and Director of Nursing (DON) notified. x ray order of the sacral in the witnessed fall is made.<BR/>An interview with the Administrator on 08/15/23 at 2:40 PM, revealed Resident #3 cursed staff out every chance she got. He stated on the morning of the fall, C.N.A. C was assisting Resident #3 to the toilet, and the resident slipped and fell to the floor. The resident's legs were pinned underneath her. He stated C.N.A. C called for help and Nurse E entered and assisted C.N.A. C with lifting the resident from the floor. Nurse E then conducted a head-to-toe assessment on the resident and found no injuries. He stated the incident was reported to him by the resident. <BR/>On 08/15/23 at 3:19 PM, record review of a written account of a phone conversation between the Administrator and Resident #3, reflected I received a call from Resident #3, stating she had a complaint from the morning (08/09/23) at 5:00 AM. She stated C.N.A. C was helping her to the toilet when she slipped and fell. She stated the weight of her body was on her shoulder. C.N.A. C called for help and Nurse E then helped C.N.A. finish. He added, Nurse E performed a body check where no injuries were noted.<BR/>An additional interview with the Administrator on 08/15/23 at 4:50 PM, revealed C.N.A. C had gotten the mechanical lift and had asked Nurse E to come assist her with the resident's transfer. He stated she was at the door of the room, looking for assistance, when the resident became impatient and started trying to maneuver out of bed on her own, and was reaching for the lift. Then C.N.A. C ran to catch her because she was slipping. He stated the sit-to-stand board had already been placed under the resident and that is how she was able to scoot and reach for the mechanical lift. He stated if C.N.A. C had not started the process without assistance present, the fall most likely would not have happened.<BR/>An interview with C.N.A. D on 08/15/23 at 5:13 PM, revealed she stated Resident #3 is a very particular lady. She stated the resident hates to have a bowel movement in her brief. She stated the resident can scoot and grab the lift, when they put her on the sit-to-stand board. She stated the resident will try to do things for herself, as much as she can. She stated whenever she responds to the resident's call light, she will go in and see what the resident needs. She stated when the resident tells her she needs to go to the toilet, she will tell her ok and that she will be back with someone to help her with getting her to the bathroom. She stated the resident says ok and waits, with no problem. She stated if the resident were to ever get impatient and try to get out of bed on her own, she would try to talk to her to calm her and explain to her that she needs to wait for assistance, so she won't fall and hurt herself.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Residents # 1 and #2) reviewed for accidents.<BR/>1. The facility failed to ensure Residents #1 and #2 were provided adequate staff supervision during a smoking session. <BR/>2. The facility failed to increase supervision of the residents even though they had negative altercations prior to the altercation in the courtyard. <BR/>This failure could place residents at risk for further altercations, which could result in injury, pain, and hospitalization. <BR/>3. Facility prematurely prepared Resident #3, who required a two-person assisted transfer, using a mechanical lift, for transfer. By the resident having to wait for a second staff to assist with the transfer, she became impatient and attempted to transfer herself, which resulted in a fall.<BR/>This failure could place residents at risk for accidents or serious injury. <BR/>Findings Include:<BR/>A record review of Resident #1's Face Sheet dated 08/07/23, revealed a [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), difficulty in walking, lack of coordination, Anxiety Disorder (persistent and excessive worry that interferes with daily activities), Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania {increased talkativeness, rapid speech, a decreased need for sleep, racing thoughts, distractibility, increase in goal-directed activity, and psychomotor agitation} or hypomania {periods of over-active and high energy behavior that can have a significant impact on your day-to-day life}] and lows [depression]).<BR/>A record review of Resident #1's Care Plan, dated 05/30/23 at 10:07 AM, reflected she had limited mobility related to muscle weakness and Dementia. She had a mood problem related to bipolar disorder and anxiety disorder. Interventions: She required a wheelchair to self-propel. She required monitoring and observation for impaired judgment or safety awareness. Also, monitoring for increased anger or agitation. Resident #1 is/has potential to be verbally aggressive related to Dementia, Ineffective coping skills, Mental / Emotional illness, Poor impulse control <BR/>yelling/screaming, abusive language, threatening behavior at staff and residents. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Assess resident's coping skills and support system. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Give the resident as many choices as possible about care and activities. Monitor behaviors Qshift. Document observed behavior and attempted interventions. Psychiatric/Psychogeriatric consult as indicated. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>No updates to the residents care plan in reference to the altercations between Resident #1 and Resident #2 were noted.<BR/>A record review of Resident #1's MDS dated [DATE] at 10:12 AM, revealed a BIMS assessment score of 15, which indicated the resident was cognitively intact. She had verbally aggressive behaviors toward staff and other residents. <BR/>A record review of the Progress Note created by RA A, dated 07/30/23 at 10:41 PM, for Resident #1 reflected the following, Resident got in physical altercation with another resident. This physical altercation was not witnessed by me, however, I cleaned up resident's hands. Resident had two scratches on left hand and one on right. Cleaned residents wounds and put triple antibiotic on top and covered with bandaid. Wound on right hand was not covered with bandaid. Resident denied being pain. <BR/>A record review of the Progress Note created by RN F, dated 08/02/23 at 1:29 PM, for Resident #1 reflected the following, At about 12 noon, another nurse called me to the resident's room. As I entered the room, the resident stated that she was out on the patio and another resident came and grabbed her from behind, so she grabbed her hands too. The resident fell backwards onto the ground. Staff intervened. Head to toe assessment done. Scratches on the right side of her cheek, chin and left arm are noted. Dressings done. Vital signs taken and recorded. Administrator, DON, MD and family were all informed.<BR/>A record review of the Progress Note created by the Social Worker, dated 08/02/23 at 2:12 PM, for Resident #1 reflected the following, Late entry. Resident had physical altercation with another resident. She has a history of bipolar disorder and her mood swings have been unmanageable. She becomes angry and a few minutes later she is crying. She is agreeable to go to a psychiatric hospital for medication management and mood stabilization.<BR/>A record review of Resident #2's Face Sheet dated 08/07/23, revealed a [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Cognitive Communication Deficit (difficulty with thinking and how someone uses language), Anxiety Disorder, Major Depressive Disorder Personal history of Transient Ischemic Attack (a stroke that lasts only a few minutes) and Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Hypertension, and Chronic Obstructive Pulmonary Disease.<BR/>A record review of Resident #2's MDS dated [DATE] at 10:20 AM, revealed a BIMS score of 13, which indicated she was cognitively intact. No behaviors were noted. She required a wheelchair for ambulation. <BR/>A record review of Resident #2's Care Plan, dated 05/30/23 at 10:25 AM, reflected she had potential to be physically aggressive (with other residents) r/t Depression, Poor impulse control. 8/2/23- Resident is on one-to-one supervision and family has also agreed to help provide supervision. Interventions: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Monitor each shift. Document observed behavior and attempted interventions in behavior log. Monitor/document/report as needed any signs/symptoms of resident posing danger to self and others. <BR/>A record review of the Progress Note created by Nurse G, dated 08/01/23 at 6:11 PM, for Resident #2 reflected the following, This resident remains with no injury and denies pain after incident with other resident. Doctor and family notified. No further concern at this time.<BR/>A record review of the Progress Note created by the ADON, dated 08/02/23 at 3:39 PM, for Resident #2 reflected the following, spoke with [family member] regarding episode of aggression in detail-Stated that resident becomes very mean and sees things when she has a UTI and resident 'needs IV antibiotics when she gets them'-Spoke with Np regarding the above and new order written for ceftriaxone 1gm IM x 3days<BR/>A record review of the Progress Note created by the Social Worker, dated 08/02/23 at 4:53 PM, for Resident #2 reflected the following, SW spoke with resident's[family member], regarding recent aggressive behaviors. She is agreeable to Psych referral. SW sent referral this date and sent text message to the Psychatrist to request face time visit asap. Resident is on one-to-one supervision and family has also agreed to help provide supervision.<BR/>A record review of the Progress Note created by RN H, dated 08/05/23 at 6:22 PM, for Resident #2 reflected the following, Lidocaine HCl Injection Solution 1 %<BR/>Inject 2.1 ml intramuscularly in the evening for mix with Ceftriaxone, until 08/05/2023 23:59 mix 2.1 ml with Ceftriaxone ABX was ordered for 3 days initial dose was given on the 8/2/23. Thus, all doses were given.<BR/>Record Review of Physician's Orders for Resident #2 on 08/15/23 at 10:49 AM, revealed cefTRIAXone Sodium Injection Solution Reconstituted<BR/>1 GM Inject 1 gram intramuscularly one time a day for<BR/>UTI for 3 Days<BR/>Completed 08/02/2023 08/02/2023 08/05/2023 _________ _________ Lidocaine HCl Injection Solution 1 % Inject 2.1 ml<BR/>intramuscularly in the evening for mix with<BR/>Ceftriaxone. until 08/05/2023 23:59 mix 2.1 ml with<BR/>Ceftriaxone<BR/>Completed 08/02/2023 08/03/2023 08/05/2023 _________ _________ Macrobid Oral Capsule 100 MG Give 1 capsule by<BR/>mouth two times a day for UTI for 5 Days<BR/>An interview with the Administrator on 08/15/23 at 9:35 AM, revealed he stated on 08/01/23, during lunch time, the two residents got into a physical altercation. He stated no actual hits made contact; however, Resident #1 was scratched. He stated the residents were separated, assessed, then placed on 1:1. He stated physicians and families were notified. He stated on 08/02/23, Resident #2 saw Resident #1 exiting the building, so she followed her out. He stated Resident #2 attempted to punch Resident #1, however, Resident #1 grabbed her arm; however, in doing so, she lost balance and fell over in her wheelchair. He stated the staff ran to stop them but didn't get to them in time to prevent it. He stated Resident #1 sustained abrasions on the right side of her head and on her right arm. He stated Resident #2 was placed on 1:1. The physicians and families were notified, and she was sent out for psychiatric evaluation. He stated Resident #1 said that on 07/30/23, she and Resident #2 got into an argument, but no punches were thrown . He stated Resident #1 said she told RA A about it. When he asked RA A about it, she confirmed Resident #1 told her, but she did not think it was serious enough to report it to him. He stated he placed her on a final level disciplinary action and re-educated her. He stated they conducted an in-service and Quality Assurance Assessment afterward. He stated Resident #2 was discharged from the facility on 08/14/23. <BR/>On 08/15/23 at 10:12 AM, a record review of a written statement by the Activities Director, reflected, I was up by the nurse's station and when the door tot he courtyard was opened, I heard Resident #1 yelling. I [NAME] to the courtyard, the Central Supply Clerk was at the door as well. Resident #2 was trying to get in the door, the Central Supply Clerk helped her inside and Resident #1 was laying, wiht her wheelchair flipped on it back. She was still in a sitting position with her head and back on the sidewalk. We called a nurse. RN H came out and assessed her. We moved her wheelchair and helped her stand up and get back into her wheelchair. She was upset and said that Resident #2 came behind her and hit her and flipped her over backwards. When we got to her room, we got her some ice water and talked to her for a little bit to get her to cool off.<BR/>On 08/15/23 at 10:17 AM, a record review of a written statement of an interview by the Administrator with Resident #2, revealed Resident #2 stated she did try to hit Resident #1 because she called her a bitch the day before and she does not like that lady. She stated she did follow Resident #1 into the courtyard and it was intentional. The Administrator added that there were not injuries to Resident #2.<BR/>On 08/15/23 at 10:24 AM, a record reivew of a written statement from the ADON, reflected I was notified that there was an incident regarding Resident #1 and Resident #2 in the enclosed patio area by the Activities Director. Resident #1 was observed in her wheelchair and was escorted to her room with htis author and another staff member. Resident #1 stated she was outside in the patio area when the other resident reached for her from behind and she grabbed Resident #2's arms and fell backward from her wheelchair. Resident #2 was also escorted to her room. Upon interview, stated that she followed Resident #1 outside. She came up behind her and reached forward to hit her. Resident #1 grabbed her arms and subsequently Resident #1 fell while in a wheelchair. Resident #2 stated, 'I was trying to hit her .cause she called me a bitch yesterday.' Resident #2 remained in her room with a staff member.<BR/>An interview with Resident #1 on 05/18/23 at 2:19 PM, revealed she and Resident #2 had exchanged words at lunch one day because she was talking to someone else and then Resident #2 told her to be quiet. She stated she already did not like Resident #2, but could not give a reason why she did not like her. She stated they began to argue because she was not going to let Resident #2 tell her what to do. She stated staff pulled them apart because they were trying to hit each other. She stated the next evening, she had gone to the courtyard to smoke and Resident #2 came out there. She stated Resident #2 did not say anything to her, she just came toward her and tried to hit her. She stated she grabbed her arm to keep her from hitting her and because of how she had to lean while holding onto her arm, it caused her to fall back. She stated she got a few scrapes, but at least Resident #2 did not get to hit her. She stated staff came out to help her and the nurse checked her out. She stated she thought the whole thing was done with, but Resident #2 would not let it go. She stated she had not seen Resident #2 for a while and she was glad she had not seen her.<BR/>An interview with the C.N.A B on 08/15/23 at 4:58 PM, revealed Resident #1 was never happy. She liked to smoke and when she didn't have cigarettes, she would torture everyone. She stated Resident #1 picked fights with residents. She stated she fusses and fights with residents and staff. She stated Resident #1 did not like Resident #2 and would always talk badly about her to her face and to others and say it loudly. She stated she was never told to keep the two residents separated or to keep an eye on them. She stated she felt it was just good to always watch Resident #1 because she messed with everyone. She stated she believed if they had been told to keep an eye on the two of them, specifically, because if that was the case, someone would have seen when Resident #2 followed Resident #1 outside and prevented the incident in which Resident #2 attempted to hit Resident #1 and Resident #1 grabbed her arm and ended up falling backward in her wheelchair. <BR/>An additional interview with the Administrator on 08/15/23 at 4:50 PM, revealed C.N.A. C had gotten the mechanical lift and had asked Nurse E to come assist her with the resident's transfer. He stated she was at the door of the room, looking for assistance, when the resident became impatient and started trying to maneuver out of bed on her own, and was reaching for the lift. Then C.N.A. C ran to catch her because she was slipping. He stated the sit-to-stand board had already been placed under the resident and that is how she was able to scoot and reach for the mechanical lift. He stated if C.N.A. C had not started the process without assistance present, the fall most likely would not have happened.<BR/>On 08/15/23 at 6:15 PM, record review of the Psychiatric Evaluation for Resident #2, dated 08/03/23 revealed an evaluation was compted by the Psychiatrist and a recommendationf or the discontinuation of the 1:1 monitoring was issued. <BR/>On 08/15/23 at 6:21 PM, record review of documents entitled 1:1 Monitoring for Resident #2, dated 08/02/23 - 08/03/23, revealed staff began monitoring the resident at 2:00 PM and continued with hourly documentation through 5:00 PM on 08/03/23.<BR/>Review of Resident #3's Face Sheet, dated 08/15/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left non-dominant side, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Major Depressive Disorder, Anxiety Disorder, Hypertension, and Osteoarthritis.<BR/>Review of Resident #3's Minimum Data Set (MDS) Assessment, dated 05/19/23, reflected the resident's Brief Interview of Mental Status score of 15, which means she was cognitively intact. She required extensive two-person for bed mobility, transfer, locomotion off unit, dressing, and toilet use.<BR/>Review of Resident #3's Care Plan dated revised on 05/30/23 reflected, the resident was at high risk for falls related to gait/balance problems, incontinence, unaware of safety needs with interventions included: Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs and follow facility fall protocol. The Care Plan did not address the resident's transfer requirements.<BR/>A record review of the Progress Note dated 08/09/23 at 6:50 AM, for Resident #3 reflected the following, 5:00 AM one of the CNA calls this nurse announcing the patient is on the floor. Resident is seated on the floor and next to her back is a commode. resident who is alert and oriented x 4 says she slid off the commode on transfer. She denied being hurt although the sling rubbed hard on my left shoulder as i went to the floor. she also denies banging self in the process. Spouse informed through a telephone message. Medical Director (MD) and Director of Nursing (DON) notified. x ray order of the sacral in the witnessed fall is made.<BR/>An interview with the Administrator on 08/15/23 at 2:40 PM, revealed Resident #3 cursed staff out every chance she got. He stated on the morning of the fall, C.N.A. C was assisting Resident #3 to the toilet, and the resident slipped and fell to the floor. The resident's legs were pinned underneath her. He stated C.N.A. C called for help and Nurse E entered and assisted C.N.A. C with lifting the resident from the floor. Nurse E then conducted a head-to-toe assessment on the resident and found no injuries. He stated the incident was reported to him by the resident. <BR/>On 08/15/23 at 3:19 PM, record review of a written account of a phone conversation between the Administrator and Resident #3, reflected I received a call from Resident #3, stating she had a complaint from the morning (08/09/23) at 5:00 AM. She stated C.N.A. C was helping her to the toilet when she slipped and fell. She stated the weight of her body was on her shoulder. C.N.A. C called for help and Nurse E then helped C.N.A. finish. He added, Nurse E performed a body check where no injuries were noted.<BR/>An additional interview with the Administrator on 08/15/23 at 4:50 PM, revealed C.N.A. C had gotten the mechanical lift and had asked Nurse E to come assist her with the resident's transfer. He stated she was at the door of the room, looking for assistance, when the resident became impatient and started trying to maneuver out of bed on her own, and was reaching for the lift. Then C.N.A. C ran to catch her because she was slipping. He stated the sit-to-stand board had already been placed under the resident and that is how she was able to scoot and reach for the mechanical lift. He stated if C.N.A. C had not started the process without assistance present, the fall most likely would not have happened.<BR/>An interview with C.N.A. D on 08/15/23 at 5:13 PM, revealed she stated Resident #3 is a very particular lady. She stated the resident hates to have a bowel movement in her brief. She stated the resident can scoot and grab the lift, when they put her on the sit-to-stand board. She stated the resident will try to do things for herself, as much as she can. She stated whenever she responds to the resident's call light, she will go in and see what the resident needs. She stated when the resident tells her she needs to go to the toilet, she will tell her ok and that she will be back with someone to help her with getting her to the bathroom. She stated the resident says ok and waits, with no problem. She stated if the resident were to ever get impatient and try to get out of bed on her own, she would try to talk to her to calm her and explain to her that she needs to wait for assistance, so she won't fall and hurt herself.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored securely for 1 of 25 residents (Resident #45) and had acceptable labeling for 2 of 4 medication carts (medication cart for Halls 200 and 300) reviewed for labeling and storage. <BR/>1. The facility failed to ensure Resident #45's 1 bottle of thymus 300 capsules, 1 bottle of thyroid 130 capsules, 1 bottle of Advil 200 mg, and 1 bottle of Tylenol 500 mg stored at the resident's bedside table were locked in a lock box or secured in the medication cart or medication room. <BR/>2. The facility failed to ensure insulin vials were dated after they were opened. <BR/>This failure could place residents at risk of not receiving the therapeutic dose of medication. <BR/>Findings included: <BR/>Record review of Resident# 45's Quarterly MDS Assessment, dated [DATE], reflected the resident was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included cancer (with or without metastasis) (when cancer spreads beyond the place where it started to other areas of your body). The resident had moderate cognitive impairment with a BIMS score of 10. <BR/>Record review of Resident #45's care plan, dated [DATE], reflected Resident #45 was on pain medication therapy to rule out cancer, pathological fracture in neoplastic disease (abnormal growths of cells or tissues that can invade and spread to other parts of the body), or wedge compression fracture of third lumbar vertebrae. The goals: - Resident #45 will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions: - Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift. <BR/>Record review of Resident #45's physician's orders dated [DATE] reflected an order for the resident tramadol HCl Oral tablet 50 mg (Tramadol HCl) Give 50 mg by mouth every 6 hours as needed for Pain. <BR/>Record review of Resident #45's physician's orders dated [DATE] reflected an order for the resident to Acetaminophen tablet 325 mg give 2 tablet by mouth every 4 hours as needed for general discomfort/pain. <BR/>Observation and interview on [DATE] at 12:23 PM revealed Resident #45 with 1 bottle of thymus 300 capsules, 1 bottle of thyroid 130 capsule, 1 bottle of Advil 200mgs, and 1 bottle of Tylenol 500 mg stored at the resident's bedside table. Resident #45 stated, he used the thymus and thyroid capsules before meals and Advil and Tylenol he took when in pain. <BR/>Observation and interview with RN E on [DATE] at 12:48 PM, who was the charge nurse for Hall 500, revealed she was aware the medications were in the room. She stated when the resident was admitted he was assessed for self-administration and was doing it but recently his cognitive status had changed. RN E stated she had checked on Resident#45's records and there was no assessment of self-administration and he had not been care planed for self-administration. RN E stated they did not have a resident who self-administered medications at the facility. RN E stated Resident #45 did not have an order for thymus 300 capsule, thyroid 130 capsule, Advil 200mgs, and Tylenol 500mgs and having the medication in his possession placed him at risk of overuse of the medication or adverse reactions and other residents could get them. RN E stated it was the responsibility of all nursing staff to remove any medications from the resident's bedside. She stated she had done training on medication in rooms, but she could not tell when. <BR/>Observation on [DATE] at 1:57 PM of the medication cart for Hall 200, with LVN A revealed 1 insulin pen,(basaglar is a long-acting insulin used to control high blood sugar) was opened, partially used, and not labeled with the open date. <BR/>Interview on [DATE] at 2:05 PM with LVN A, who was the charge nurse for Hall 200, revealed she knew insulin pens were supposed to be dated once they were opened or after they were removed from the refrigerator and placed on the cart. She stated she knew she was supposed to check her cart to ensure insulins were labeled and dated but she did not check that morning. She stated the risk of administering insulin when not dated was they might have expired and would not be effective. She stated she had done training on labeling and dating the insulins. <BR/>Observation on [DATE] at 2:23 PM of the medication cart for Hall 300 with LVN C revealed 2 insulin pens, glargine flex pen insulin injection and insulin Tresiba flex pen, were opened, partially used, and not labeled with the open date. <BR/>Interview on [DATE] at 2:28 PM with LVN C, who was the charge nurse for Hall 300, revealed she knew insulin pens were supposed to be dated once they were opened or after they were removed from the refrigerator and placed on the cart. She stated she knew she was supposed to check her cart to ensure insulins were labeled and dated but she had checked and missed the 2 vials. She stated the risk of administering insulin when not dated was they might have expired and would not be effective. She stated she had done training on labeling and dating the insulins. <BR/>Interview on [DATE] at 3:45 PM with the ADON revealed it was her expectation that staff date the insulin pens once they pulled them from the refrigerator. She stated it was also the responsibility of the staff to check daily on the expiration dates and labelling. She stated if the staff were not putting the opened dates on the insulin pens and vials that required an open date it placed residents at risk of not getting required therapy. The ADON stated it was her responsibility to audit the carts and the last time she audited was in December. She also stated she expected the nurse to sign off narcotics on the narcotic administration log once they were administered. She stated the risk would be overdose and drug diversion. She stated she was supposed to check the narcotic logs every day and the last time she had checked was [DATE]. <BR/>Interview on [DATE] at 3:51 PM with the ADON revealed it was all nursing staff's responsibility to ensure there were no medications in the residents' rooms. They were supposed to notify the ADON and the DON. She stated at one-point there was confusion on Resident#45 because at first, he was care planned for self-administration and when his cognition status changed, he was not able to self-administer. She stated that was one year ago when the previous DON was in the facility. She stated it was an oversight because when he started declining the medications were supposed to be removed from his room. She stated an assessment of self-administration was supposed to be done for him to have medications in the room but at this time they could not do the assessment, he could not pass. She stated the risk for Resident#45 having medications in the room was he could overdose, the roommate could take them and other wandering residents. She stated she was not sure whether facility had done training on medications in residents' rooms. <BR/>Interview on [DATE] at 11:38 AM with the Cooperate RN revealed residents were not supposed to have medication of any kind in their rooms unless they were assessed and were found to be safe with self-administration and there was a doctor's order to self-administer. She stated her expectation was staff were to remove medications from the rooms. The Corporate RN stated residents having medications in their rooms put them at risk of over medicating and other residents could get ahold of them. She stated she also expected staff to label insulin with an opening date once they opened and to check carts for dates and labeling every shift. She stated the risk was they could be expired and if administered they would not be effective. She stated she was not sure whether the facility had done training on labeling and putting an opening date. The Corporate RN stated her expectation was if nurse administered narcotics, they should sign off on the narcotic administration log. She stated the risk of not signing off was an overdose and effect on resident's management. She stated the ADON and the DON were responsible for auditing the carts for labeling and opening dates and on narcotic logging of after administration. <BR/>Record review of the facility's Administering Medication policy, dated [DATE], reflected: <BR/> .12 .when opening a multi-dose container, the date opened is recorded on the container .<BR/>Record review of the facility's policy Storage of Medication, dated [DATE], reflected: <BR/>Medications and biologicals used in the facility are stored in locked compartments under proper temperatures, lights, and humidity controls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of four residents (Resident #1) observed for infection control in that: <BR/>CNA A failed to perform hand hygiene and change clean gloves from dirty to clean area during providing incontinence care to Resident #1.<BR/>This failure could place the residents at risk for infection.<BR/>Findings include:<BR/>Record review of Resident #1's admission Record dated 05/05/23 reflected Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses of other specified sepsis (infection), diabetes, major depressive disorder, high blood pressure, heart failure, respiratory failure, and lower leg infection. <BR/>Record review of Resident #1's Baseline Care Pla n dated 05/05/23 reflected Resident #1 required physical assistance with one person for her activity of daily livings. Resident #1 was occasionally incontinent for her bladder and occasionally incontinent for her bowel. <BR/>Observation of incontinent care on Resident #1 on 05/05/23 at 12:15 PM revealed Resident #1 was lying flat on her bed. CNA A was observed to gather supplies and entered Resident #1's room and explained the incontinent procedure to the resident. CNA A performed hand hygiene and put on clean gloves. Then, CNA A unfastened Resident #1's brief and wiped Resident #1's front and back peri area with wipe with a single stroke from front to back direction. After cleaning Resident #1's front and back peri cares, CNA A turned the resident to her left side and wiped with a single stroke from peri area toward her back area. CNA A removed Resident #1's soiled brief. which was observed to be soiled with urine. Then, CNA A grabbed a clean brief and placed underneath Resident #1's bottom and applied barrier cream on Resident #1's peri area without performing hand hygiene or changing her gloves. CNA A removed her soiled gloves and put on a clean pair of gloves. CNA A continued to complete incontinence care to Resident #1. CNA A removed her gloves and washed her hand at Resident #1's bathroom. <BR/>An interview on 05/05/23 at 12:36 PM, CNA A stated she worked at the facility for four years and she was trained for newly hired aide during orientation. CNA A stated she was assigned to take care of Resident #1 on 05/05/23. CNA A stated she normally performed hand hygiene and changed gloves from dirty to clean area during incontinent care. CNA A stated she totally forgot to perform hand hygiene and change into a clean pair of gloves while providing incontinent care to Resident #1 on 05/05/23. CNA A stated she realized that she did not do hand hygiene during providing incontinent care to Resident #1 on 05/05/23. She stated she forgot but she should not miss it to change her soiled gloves after wiping Resident #1's front and back peri areas. CNA A stated the resident would have infection including urinary tract infection and other infection from not following infection control procedure. which included hand washing and using a clean glove during incontinent care. <BR/>An interview on 05/05/23 at 4:02 PM, the interim DON stated he expected all aides to perform hand hygiene and use a clean pair of gloves from dirty to clean area during incontinence care. The interim DON stated the residents can get infection including urinary tract infection and sepsis (infection in the blood stream) from not performing hand hygiene and not using clean gloves from dirty to clean area. <BR/>Record review of the facility's policy on Perineal Care dated 10/09/20 reflected, Purpose: The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections, and skin irritation, and to observe the residents' skin condition. Steps in the procedure: 4. Wash hands and apply gloves . 9. Change gloves. Reposition patient for comfort. 10. Apply thin layer of skin barrier.<BR/>Record review of CNA A's Verification of Education Level Completion dated 08/26/22 reflected that CNA A had completed check off list for hand washing, pericare/incontinent care and infection control procedure on 08/26/22. <BR/>Record review of the facility's policy on Handwashing/Hand Hygiene dated 03/01/20 reflected, This facility considers hand hygiene the primary means to prevent the spread of infections . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitor. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap, . and water for the following situation; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; k. After handling used dressing, contaminated equipment, etc,; . m. After removing gloves; q. After personal use of the toilet or conducting your personal hygiene.10. Hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #56) reviewed for personal privacy. <BR/>RN B failed to provide privacy for Resident #56 when providing medications via the resident's g-tube and the resident was visible to people walking down the hallway. <BR/>This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to lack of privacy during a medical treatment. <BR/>Findings include:<BR/>Record review of Resident #56's face sheet, dated 09/21/22, reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cerebral infarction (stroke), aphasia (loss of ability to understand or express speech), hemiplegia (one-sided paralysis), and dysphagia (difficulty swallowing). <BR/>Record review of Resident #56's MDS, dated [DATE], reflected he had a BIMS score of 5, which indicated a severe cognitive impairment. The swallowing and nutritional assessment reflected Resident #56 had a feeding tube and received 51% of his total calories and 501 mL or more of fluid intake through tube feeding. <BR/>Record review of Resident #56's care plans, dated 08/24/22, reflected he required tube feeding due to swallowing problems. Interventions included he needed total assistance with tube feeding and water flushes. See MD orders for current feeding orders.<BR/>An observation on 09/20/22 at 12:04 PM revealed Resident #56 was lying in bed with the head of bed elevated. Resident #56 was not able to speak or answer questions. Resident #56 had a g-tube. The enteral feeding pump was disconnected from Resident #56 and was turned off. The formula hanging was Glucerna 1.5.<BR/>An observation on 09/21/22 at 7:54 AM revealed RN B entered Resident #56's room and disconnected the feeding pump. RN B did not close the resident's room door and did not draw the privacy curtain to cover the resident. The resident was visible to anyone who walked past the resident's room in the hallway. RN B listened over Resident #56's abdomen with a stethoscope, pulling the resident's gown up, and exposed his abdomen. RN B then administered Resident #56's medications via his g-tube. After medication administration, RN B reconnected Resident #56's g-tube to the enteral feeding pump and started the pump to deliver the feeding at 88 mL per hour. <BR/>In an interview on 09/21/21 at 11:41 AM, RN B said he should have provided privacy for Resident #56 during medication administration because the resident's abdomen was exposed. <BR/>In an interview on 09/21/22 at 12:25 PM, the DON stated she expected nurses to provide privacy during medication administration and privacy was due to them with all care. The DON said the nurses were to pull privacy curtains and said medication administration via g-tube was more extensive and the nurse needed to listen to the abdomen and would expect privacy would be provided on all sides of the resident because of the risk for exposure. The DON said full privacy should be provided as if doing peri-care.<BR/>Record review of the facility's policy titled Resident Rights, dated December 2016, reflected employees were to treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents in the facility. These rights include the resident's right to . privacy and confidentiality . <BR/>Record review of the facility's policy titled, Administering Medications through an Enteral Tube, dated November 2018, reflected, the purpose of this procedure is to provide guidelines for the safe administration of medication through an enteral tube . If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them they may now enter the room .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had a clean, comfortable, and home like environment, which included but not limited to receiving treatment and supports for daily living safely for 1 of 3 residents (Resident #68) reviewed for a clean and homelike environment.<BR/>1. The facility failed to ensure Resident # 68's call light was clean and free from feces and food.<BR/>This deficient practice could place residents at risk of illness, infection due to contact with unclean surfaces in the facility. <BR/>Findings include: <BR/>Record review of Resident #68s face sheet, dated 09/22/2022, revealed an 88- year-old female with an admission date of 08/30/2022. Resident #68 had diagnoses which included Alzheimer's Disease with late onset (memory loss.), chronic kidney disease (kidneys is damaged in function), Major Depression (mood), Hypertension, (high blood pressure) Hypothyroidism (underactive thyroid, Pain unspecified joint., Diabetes Mellitus (increased sugar levels) with Diabetic Poly neuropathy (nerve damage), and generalized anxiety (excessive worrying). <BR/>Record review of Resident #68's admission Minimum Data Set (MDS) assessment, dated 09/06/2022, reflected a score of 4 on her Brief Interview for Mental Status (BIMS), signifying that she was severely impaired cognitively. The assessment of her behavior reflected Resident #68 wandered throughout the facility, and she was an elopement risk and often delusional. Her functional status assessment reflected she needed extensive assistance with bed mobility, transfer and locomotion, transfers, locomotion off unit, dressing and eating with supervision. The assessment reflected she required extensive two- person assistance with toilet use and personal hygiene. Resident #65's urinary status was not rated, and she was always continent of bowel. Her diagnoses included: peripheral vascular disease, obstructive and reflux uropathy (when urine cannot drain through the urinary tract), diabetes mellitus (increased blood sugar), low back pain, and muscle weakness. <BR/>Record review of Resident #68's [NAME], dated 09/22/2022, reflected the following ADL task entered: orders entered included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed and avoid isolation.<BR/>An interview was attempted with Resident #68 on 09/20/22 @ 11:00 a.m. and she was not responsive, only smiled and continued to ambulate to the nursing station.<BR/>An observation on 09/22/2022 at 9:52 a.m. revealed Resident #68 was sitting in her wheelchair in her room asleep. Her call light was on the bedside table next to her and was observed with a brown gritty substance with the consistency of feces. <BR/>Interview on 09/22/2022 at 9:50 a.m., CNA B stated when she entered the room for calls, she did not observe the call light with a brown substance. She stated usually when she responded to a resident call light, she would first disable the light and ask the resident for their request. She then entered Resident #68's room and observed the call light with a brown substance and stated EWW .<BR/>Interview on 09/22/2022 at 9:58 a.m. with the Housekeeping Aide (HK-E) revealed she cleaned the resident's rooms daily and before leaving her shift. She stated she had not cleaned the resident's room for the day. She observed the resident's call light with the soiled brown substance. She stated she would clean it immediately. She denied observing the call light soiled with the substance prior to this being brought to her attention today. She stated she had been cleaning the same resident rooms daily and sanitized the call lights. <BR/> In an interview with the Housekeeping Supervisor on 09/20/2022 revealed his staff cleaned, sanitized, and disinfected resident bed tables and call lights daily. He stated he conducted walk throughs for inspections daily throughout the facility. He stated if a resident's room needed further attention, the health care staff would notify him or his staff to come and clean. <BR/>Interview on 09/22/2022 at 10:05 a.m. with the DON revealed she expected housekeeping to keep resident #68's call light clean and free of unsanitary conditions at all times, and her staff should observe for clean sanitary call lights during rounds to the resident's room and when answering the call lights. Once observing the call light, she called for housekeeping to come immediately and sanitize, she then notified the Administrator. DON stated that it was important to ensure the call light and other surfaces were disinfected and sanitized to prevent unsanitary conditions that could lead to illnesses and infections.<BR/>During an interview with the Administrator on 09/22/2022 at 12:56 p.m., the Administrator stated the call light had been cleaned, and he was notified by the DON. He expected resident's call lights to be disinfected and sanitized and all staff should be inspecting and assuring the task was complete to maintain a clean environment. <BR/>Record review of the facility's, undated, policy titled Resident Room Cleaning Procedures did not specifically address call light sanitation. The policy stated that resident rooms are to be cleaned daily by housekeeping staff, starting at the back, and working forward cleaning window seals, base boards, bed rails, bedside tables, nightstands, stationary chairs, bathroom, and mop floors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 4 of 24 residents (Residents #19, #5, #67 and #6) reviewed for Activities of Daily Living (ADL's.)<BR/>The facility failed to ensure Residents #19, #5, #67, and #6 received the necessary hygiene services: nail care <BR/>and face cleaning. <BR/>This failure could place residents at risk for loss of dignity, risk for infections and a decreased quality of life. <BR/>Findings include:<BR/>Resident #19<BR/>1. Record review of Resident #19's face sheet, dated 09/22/22, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included dementia (Difficulty with cognition and memory, lack of coordination, muscle weakness, cerebral infarction (stroke), end stage renal disease, and depression. <BR/>Record review of Resident #19's care plan, dated 08/25/22, reflected she had an ADL self-care performance deficit due to impaired balance, limited Mobility, limited Range of Motion (ROM,) musculoskeletal impairment, and pain. Interventions included: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse.<BR/>An observation and interview on 9/20/22 at 10:24 AM revealed Resident #19 were sitting in bed watching television. The nails on both her hands were approximately 0.5 (centimeters) cm to 1 cm in length which extended from the tip of her finger. The nails were discolored tan and the underside had dark brown colored residue. Resident #19 said she would like her nails trimmed and tried to get someone to trim them yesterday, but she could not find anyone. Resident #19 could not remember who she notified or when. <BR/>An observation on 09/21/22 at 7:51 AM revealed Resident #19 was sitting in bed, eating breakfast. The nails on both her hands were approximately 0.5 cm to 1cm in length which extended from the tip of her finger. The Resident's nails were discolored tan and the underside had dark brown colored residue.<BR/>In an interview on 09/21/22 at 1:51 PM, CNA A said she worked at the facility since November 2021, and she regularly worked with Resident #19. CNA A said she first noted Resident #19's nails were long and dirty about 2 weeks ago and stated she had reported it to one of the facility's nurses. CNA A said she did not think CNAs were allowed to cut the residents' nails because she was not aware who was diabetic. CNA A said she did not remember which nurse she notified about Resident #1's nails. <BR/>In an interview on 09/21/22 at 2:50 pm with CNA D, revealed that she was the aid that worked with residents #5,6, and 67, and she conducts ADL care for nails if the resident was not a diabetic. She stated that when she conducts nail care she does conduct handwashing with the residents to assure the nails were clean. She stated that when she provided care to Resident #5, #6, and #67, she did not observe that they were soiled underneath. <BR/>In an interview on 09/21/22 at 1:54 PM, RN B said only nurses cut residents' nails. RN B said no one had notified him Resident #19's nails were long and dirty, and he had not noticed the nails himself. <BR/>In an interview with LVN E on 09/21/22, she stated that she was responsible for supervising the CNA's and their assignments. She stated that she had not observed residents with unclean nails during her rounds, however the aides should be conducted ADL's for nails during daily showers and handwashing. if the resident needed their nails trimmed the aide will notify LVN E and she will complete if the resident was a diabetic. She does the assignment of CNAs on her unit. Resident #67's nails are long and need cleaning and she did not do her nails. She stated that the aide can clean and Resident #67's cut nails. She expects the CNAs to wash the residents face when they wake up and conduct any needs with ADLs.<BR/>Resident #5<BR/>2. Record review of Resident #5's face sheet, dated 09/22/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. <BR/>Record review of Resident #5's Quarterly Minimum Data Set (MDS) assessment, dated 07/06/22, reflected a score of 4 on her Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The assessment of her behavior reflected Resident #5 did not refuse care, and she required extensive assistance with bed mobility, transfer and locomotion, locomotion off unit, dressing and eating with supervision. The assessment reflected she was total assistance with toilet use and personal hygiene. <BR/>Resident #5's urinary and bowel were rated as always incontinent. Her diagnoses included: Muscle weakness and wasting, poor muscle control, lack of coordination, mild cognitive impairment, hearing loss, and macular degeneration.<BR/>Record review of Resident #5s care plan, dated 06/25/22, reflected she had an ADL self-care performance deficit and required total assistance from staff for bath and showering and for the staff to check nail length and trim and clean on bath days and as necessary. <BR/>Record review of Resident #5's order summary report, dated 09/22/22, reflected an order, dated 08/30/22, for Artificial Tears solution 0.5-0.6% Instill one drop in both eyes two times a day for dry eyes. Monitor/document/report PRN any sign or symptoms of acute eye problems: Change in ability to perform ADLs, decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, complaint of halos around lights, double vision, tunnel vision, blurred or hazy vision.<BR/>Record review of Resident #5's ADL [NAME] for personal hygiene revealed she required extensive assistance with 1-person staff with personal hygiene. <BR/>Observation of Resident #5's on 09/20/22 at 10:15 PM., 09/20/22 1:00 PM, and 09/21/22 at 2:00 PM. revealed dried mucus around the resident's eyes, between the eyebrows, along the temple of the face, and around her nose. <BR/>On 09/20/22 at 1:00 PM an interview was attempted with Resident #5; she was very confused and could not recall her name.<BR/>Resident #67<BR/>3. Record review of Resident #67's face sheet, dated 09/22/22, revealed 98- year-old female who was admitted to the facility on [DATE]. <BR/>Record review of Resident #67's Quarterly Minimum Data Set (MDS) assessment, dated 09/07/22, reflected a score of 12 for her Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. The assessment of her behavior reflected Resident #6 did not refuse care, she required limited assistance with bed mobility, transfer, and supervision with locomotion off the unit and eating. Resident # 67's assessment stated she required total assistance with toilet use and personal hygiene. Resident #67 required extensive assistance as she was rated as occasionally incontinent. Her diagnoses included: after-effect symptoms of a stroke, muscle wasting, lack of coordination, and mild cognitive impairment. <BR/>Record review of Resident #67s care plan, dated 7/14/22, reflected she had an ADL self-care performance deficit and staff should check residents nail length and trim and clean on bath days and as necessary. <BR/>Record review of Resident #67's ADL [NAME] for personal hygiene revealed she required extensive assistance from 1 staff with personal hygiene. <BR/>Observation and interview with Resident #67 on 09/21/22 at 11:30 AM. revealed she could not understand what the State Surveyor was saying despite trying 5 times, speaking loudly. Resident #67 had long uneven nails with brown stain/coloring. <BR/>Resident #6<BR/>4. Record review of Resident #6's face sheet, dated 09/22/22, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. <BR/>Record review of Resident #6's Quarterly Minimum Data Set (MDS) assessment, dated 09/07/22, reflected a score of 00 for her Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. <BR/>The assessment of her behavior reflected Resident #6 did not refuse care, she required limited assistance with bed mobility, transfer, and supervision with locomotion off the unit and eating. The assessment reflected she was total assistance with toilet use and personal hygiene. Resident #6 required extensive assistance as she was rated as occasionally incontinent. Her diagnoses included: Alzheimer's Disease with early onset, psychosis (condition affecting the brain), muscle weakness, arthritis of both knees, and cognitive communication deficit. <BR/>Record review of Resident #6's ADL [NAME] and Care Plan dated 09/09/2022 for personal hygiene revealed she required extensive assistance from 1 staff with personal hygiene and to keep her hands and body parts from excessive moisture and fingernails short.<BR/>Observation and interview on 09/20/22 at 11:30 a.m. of Resident #6's nails revealed they were long and uneven with a dark and light brown gritty substance under her nails. Resident #67 was limited in communication and was not interviewable. <BR/>In an interview on 09/22/22 at 10:27 AM, the DON said nail care should be done as needed and every time aides washed the residents' hands. The DON said nails should be observed daily. The DON said nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON said there was previously not a routine scheduled for nail care but put one in to place on 09/21/22 for nail care to be done every Sunday. The DON said she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON said if the resident refused, she expected the CNAs to notify the nurse and family. The DON said residents who had long, and dirty nails could be an infection control issue and it depended on what was underneath the nail especially if they ate finger foods. The DON said no one went to her to tell her they had issues cutting Resident #19's nails. The DON stated that she was notified of Resident #19 and #67's nails, so she personally trimmed their nails on 09/21/22 at 9:00 P.M. She stated that resident nails should be monitored by staff and reported for the to be kept trimmed. She stated that residents #19 and #67 will refuse care with nails at times, however she has implemented a routine for the restorative aides to specifically check on the residents. Currently the residents did not verbalize any difficulty. The DON stated that nail care was important and should be as needed based on the resident. If residents were Diabetes a nurse could perform the task of nail trimming, all others can be done by the aides. The aides are aware that this was a task because residents could have a building up of bacteria and germs that could lead to illness. Resident's # 6 was not a diabetic, therefore the aide was responsible for trimming the nails.<BR/>Record review of the facility's policy titled ADLs, Supporting, dated March 2018, reflected appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care . If the resident with cognitive impairment or dementia resisted care, staff would attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. <BR/>Record review of the facility's policy titled, Fingernails/Toenails, Care of, dated February 2018, reflected,The purposes of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections . Nail care includes daily cleaning and regular trimming. Proper nails care can aid in the prevention of skin problems around the nail bed. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. Trimmed and smooth nails prevent the resident from accidently scratching and injuring his or her skin . Notify the supervisor if the resident refuses the care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received 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 1 of 3 residents (Resident #56) reviewed for feeding tubes.<BR/>The facility failed to administer the correct formula rate and water flushes for Resident #56. <BR/>This could place residents at an increased and unnecessary risk of complications such as diarrhea or constipation, nausea, and vomiting, and nutritional or metabolic imbalances. <BR/>Findings include:<BR/>Record review of Resident #56's face sheet, dated 09/21/22, reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cerebral infarction (stroke), aphasia (loss of ability to understand or express speech), hemiplegia (one-sided paralysis), and dysphagia (difficulty swallowing). <BR/>Record review of Resident #56's MDS, dated [DATE], reflected he had a BIMS score of 5, which indicated a severe cognitive impairment. The swallowing and nutritional assessment reflected Resident #56 had a feeding tube and received 51% of his total calories and 501 mL or more of fluid intake through tube feeding. <BR/>Record review of Resident #56's care plan, dated 08/24/22, reflected he required a tube feeding due to swallowing problems. Interventions included he needed total assistance with tube feeding and water flushes. See MD orders for current feeding orders.<BR/>Record review of Resident #56's orders reflected an order, dated 08/24/22, for flushing the resident's g-tube with 10 mL of water between medications and 30 mL of water before and after medications. An order on 09/02/22 reflected continuous tube feeding of Glucerna 1.5 at 85 mL per hour. <BR/>An observation on 09/20/22 at 12:04 PM revealed Resident #56 was lying in bed with the head of bed elevated. Resident #56 was not able to speak or answer questions. Resident #56 had a g-tube. The enteral feeding pump was disconnected from Resident #56 and was turned off. The formula hanging was Glucerna 1.5.<BR/>An observation on 09/20/22 at 1:14 PM revealed Resident #56 was lying in bed and his g-tube was connected to the enteral feeding pump. The formula hanging was Glucerna 1.5, and the pump was set to deliver the formula at a rate of 88 mL per hour.<BR/>An observation on 09/21/22 at 7:54 AM revealed RN B entered Resident #56's room, turned off the feeding pump which was set to deliver the hanging Glucerna 1.5 at 88mL per hour. RN B disconnected the feeding pump and administered Resident #56's medications via his g-tube. RN B flushed before and after medication administration with 30 mL of water and between every medication with 30 mL per hour. After medication administration, RN B reconnected Resident #56's g-tube to the enteral feeding pump and started the pump to deliver the feeding at 88 mL per hour. <BR/>In an interview and observation on 09/21/21 at 11:41 AM, RN B said he reviewed Resident #56's orders prior to the medication administration and enteral feeding administration. RN B said he had not noted the enteral feeding pump was set to deliver 88 mL per hour instead of the ordered 85 mL per hour. RN B said Resident #56 did not have a recent order change and was not aware why the enteral feeding pump was not set correctly according to the physician's order. RN B said he gave Resident #56 30 mL of water in between every medication instead of the ordered 10 mL in between every medication because the crushed medication would stick to the cup. RN B said if the physician's order for enteral feeding and flushes were not followed, this could result in overfeeding or underfeeding the resident. RN B observed Resident #56's pump was set to deliver 88mL per hour and corrected the setting to deliver 85mL per hour. <BR/>In an interview on 09/21/22 at 12:25 PM, the DON stated she expected nurses to verify enteral pump settings against orders at the start of their shift or when giving medications. The DON said it was important for nurses to verify enteral feeding orders for the residents' nutrition status and to make sure they were getting the ordered amount and not too much nutrition. <BR/>Record review of the facility's policy titled Enteral Tube Feeding via Continuous Pump,, dated November 2018, reflected the purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings .Verify that there is a physician's order for the procedure .Check the enteral nutrition label against the order before administration. Check the following information .rate of administration . <BR/>Record review of the facility's policy titled, Administering Medications through an Enteral Tube, dated November 2018, reflected the purpose of this procedure is to provide guidelines for the safe administration of medication through an enteral tube .Verify there is a physician's medication order for this procedure . Administer each medication separately and flush between medications .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety in 1 of 1 kitchen reviewed.<BR/>1. The facility failed to ensure the ice and water dispenser, located in the facility dining room, was cleaned and free of white chalky substance with brown spots discoloring, white chalky spots and failed to ensure the overflow tray was not soiled with brown rust spots and spilled coffee. <BR/>2. The facility failed to ensure the ice machine, in the facility only kitchen, was cleaned and free of discoloring of white chalky and brown stains on the inside and outside of the ice machine and failed to ensure there was no dust particles with dirt and covering the filter used for the freezer.<BR/>3. The facility failed to ensure the hydration stations were cleaned, free of dirt, didn't have soiled surfaces on the cart ice scoop, and inside ice chest.<BR/>These failures could place residents at risk to bacteria, and other infectious illness. <BR/>Findings include:<BR/>1. Record review of Resident #83's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis which included stiff man syndrome (Stiff-person syndrome (SPS) is a rare neurological disorder with fluctuating muscle rigidity in the trunk and limbs and a heightened sensitivity to stimuli such as noise, touch, and emotional distress, which can set off muscle spasms.)<BR/>Observation on 09/20/2022 at 9:30 a.m., during the initial tour of the kitchen, the dining room ice and water machine dispenser was observed with spilled coffee, pink paper from used sugar packets, dirt, and further debris on the floor between the ice maker, table, and cabinets as well as behind the ice machine. The ice dispenser was soiled with splattered discoloring of white chalky and brown stains and rust on the overflow tray of the machine. The Large ice machine in the kitchen was observed with (chalky white spots) on the inside and outside of the ice machine and dust had visibly thick grey particles with dirt and covered the filter used for the freezer.<BR/>Interview with the Dietary Manager (DM) on 09/20/22 at 9:45 a.m. revealed it was the responsibility of maintenance to clean and service the ice machine in the kitchen, and both Housekeeping and maintenance to clean and service the machine in the dining room areas. She stated he serviced the machine approximately 1 time a month, and she did not want to get anyone in trouble. The DM stated she reported the filter in the machine to the maintenance department a few weeks ago. She stated she did not follow back up with MD. Documentation of the maintenance request was requested by the State Surveyor and was not received. She stated that she had documentation of the request for the freezer, however the documentation was not received. She stated it was the responsibility of the nursing staff to maintain the hydration stations and return to the kitchen for cleaning when soiled or to refill. She stated most of the time the staff would refill the ice from the machine in the dining room. She stated she did not use the ice/water machine in the dining room, as she preferred bottled water. <BR/>Interview with the Housekeeping Manager (HK) on 09/20/22 at 10:45 a.m. revealed it was his staff's responsibility to clean the dining hall ice machine, counters, and floors daily. He stated though the ice/water machine looked unclean, the machine was clean, and he drank from the machine daily. He stated that though the machine's appearance looked unclean, the housekeeping department cleaned it routinely according to standards. The ice dispenser was observed to be heavily soiled with splattered white chalky stains and rust on the overflow tray of the machine. The Large ice machine in the kitchen was observed with chalky white spots) He tried to remove the discoloration (white chalky stains with some rust) from the machine, and it wouldn't come off. He stated the staff cleaned the floors and the table around the machine daily. <BR/>The Housekeeping Manager stated the spills and debris were from breakfast this morning, and housekeeping had not cleaned. Housekeeping normally cleans at 10:00 a.m. He stated he reported to maintenance that the machine had white chalky discoloring with brown spots, and the maintenance director told him he was going to order parts to be replaced on the machine that would prevent this from occurring. The Housekeeping Manager stated the machine was broken and was always broken. He stated it had been over two weeks since the part was ordered, and he did not know why it had not arrived to install. He stated housekeeping and maintenance both were responsible for cleaning the ice machine in the dining areas.<BR/>Interview with the Maintenance Director (MD) on 09/20/22 at 9:45 a.m. revealed it was his responsibility to clean and service the ice machine in the kitchen, and dining room. Housekeeping was responsible sanitation of the dining hall ice machine. He stated the manufacture guidelines required him to install new filters every 6 months at a minimum. He stated he ordered parts for the machine in the dining room that would keep the stains of white chalky substance away. He stated he would clean and work his magic to remove the discoloring and stains. The Maintenance Director stated that he thought that he ordered the parts, but they were still in the internet basket for purchase, and he purchased them today.<BR/>Observation on 09/21/2022 at 9:30 a.m. revealed the hydration station located on the 300 hall of the facility had splattered liquids on the bottom of the cart, the top of ice chest inside had smudges of black/brown dirt on white surface, and the scoop holder was visibly soiled. <BR/>Observation on 09/21/2022 at 11:00 a.m. of Resident #83's room revealed his personal refrigerator was not the correct temperature, and there was food wrapped in paper from his tray, food was unsealed, dated, and uncovered in his fridge. The thermometer registered 40 degrees; however, the food was room temperature. The contents of the fridge had yogurt, ensure drinks, loose food spilled liquids and disposable dining trays.<BR/>An Interview on 09/21/22 at 11:00 a.m. with Resident #83 revealed he took food from his dinner tray that he did not eat and placed in his personal refrigerator in his room. He stated he told the kitchen not to send Ensure, yogurt, or fish, however they continued to, store it in here. He stated no one had come to clean his refrigerator. He stated he had not asked anyone to come and clean out his refrigerator or check the temperature.<BR/>Interview with the Dietary Manager (DM) on 09/21/2022 at 1:00 p.m. revealed she was not informed to check the resident's refrigerators in their rooms for dated and undated food, sealed properly, sanitation, and disinfecting. She stated that she was not aware that Resident #83 kept food in his room from the kitchen. <BR/>Interview with the Administrator on 09/21/2022 at 3:30 p.m. revealed he would have the refrigerator cleaned and operations of right temperatures checked, and routinely cleaned to meet kitchen guidelines. He did not have any further explanation regarding the condition and upkeep. He stated the hydration stations were to be kept up by the aides on the hall, by maintaining sanitation of the station and refilling. He stated residents should not be served ice from the hydration station when it was unsanitary. Staff should be monitoring and assuring hydration was clean, and the purpose of the sanitation station was to have ice and water available for residents to drink and prevent illnesses. <BR/>A record review of the facility's, undated, policy titled Guidelines for Resident Refrigerators, revealed, Each resident refrigerator will have a thermometer; All perishable items in the refrigerator must be dated and labeled; Designated personnel will monitor refrigerator temperature weekly; Refrigerator will be cleaned and defrosted periodically; Any unlabeled perishable items will be discarded; Labeled perishable items will be discarded within 48 hours of the date on the items <BR/>A record review of the facility's Hydration Management Policy, dated 10/08/2007 revealed all residents will be provided with sufficient fluid intake to maintain proper hydration and nutritional status. The policy did not address maintaining sanitation of the carts.<BR/>A record Review of the facility policy for cleaning and servicing ice machines revealed that Record review of the records for the logbook documentation, dated 7/29/2022, revealed service of the ice machine Check water filter (if present)<BR/>1. If incoming water pressure deteriorates, it's time to install new filter (at a minimum every six months); Check air-filter (if present)<BR/>2. Check that air filter is correctly installed<BR/>3. Replace filter if needed<BR/>4. Clean Coils<BR/>Sanitize Interior:<BR/>1. Sanitize interior of ice machine per manufacturer's instructions<BR/>2. Clean out and sanitize the ice bin<BR/>Clean Exterior:<BR/>1. Clean and wipe down exterior<BR/>2. Check electrical plug for burns Check water filter; Check Air Filter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of four residents (Resident #1) observed for infection control in that: <BR/>CNA A failed to perform hand hygiene and change clean gloves from dirty to clean area during providing incontinence care to Resident #1.<BR/>This failure could place the residents at risk for infection.<BR/>Findings include:<BR/>Record review of Resident #1's admission Record dated 05/05/23 reflected Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses of other specified sepsis (infection), diabetes, major depressive disorder, high blood pressure, heart failure, respiratory failure, and lower leg infection. <BR/>Record review of Resident #1's Baseline Care Pla n dated 05/05/23 reflected Resident #1 required physical assistance with one person for her activity of daily livings. Resident #1 was occasionally incontinent for her bladder and occasionally incontinent for her bowel. <BR/>Observation of incontinent care on Resident #1 on 05/05/23 at 12:15 PM revealed Resident #1 was lying flat on her bed. CNA A was observed to gather supplies and entered Resident #1's room and explained the incontinent procedure to the resident. CNA A performed hand hygiene and put on clean gloves. Then, CNA A unfastened Resident #1's brief and wiped Resident #1's front and back peri area with wipe with a single stroke from front to back direction. After cleaning Resident #1's front and back peri cares, CNA A turned the resident to her left side and wiped with a single stroke from peri area toward her back area. CNA A removed Resident #1's soiled brief. which was observed to be soiled with urine. Then, CNA A grabbed a clean brief and placed underneath Resident #1's bottom and applied barrier cream on Resident #1's peri area without performing hand hygiene or changing her gloves. CNA A removed her soiled gloves and put on a clean pair of gloves. CNA A continued to complete incontinence care to Resident #1. CNA A removed her gloves and washed her hand at Resident #1's bathroom. <BR/>An interview on 05/05/23 at 12:36 PM, CNA A stated she worked at the facility for four years and she was trained for newly hired aide during orientation. CNA A stated she was assigned to take care of Resident #1 on 05/05/23. CNA A stated she normally performed hand hygiene and changed gloves from dirty to clean area during incontinent care. CNA A stated she totally forgot to perform hand hygiene and change into a clean pair of gloves while providing incontinent care to Resident #1 on 05/05/23. CNA A stated she realized that she did not do hand hygiene during providing incontinent care to Resident #1 on 05/05/23. She stated she forgot but she should not miss it to change her soiled gloves after wiping Resident #1's front and back peri areas. CNA A stated the resident would have infection including urinary tract infection and other infection from not following infection control procedure. which included hand washing and using a clean glove during incontinent care. <BR/>An interview on 05/05/23 at 4:02 PM, the interim DON stated he expected all aides to perform hand hygiene and use a clean pair of gloves from dirty to clean area during incontinence care. The interim DON stated the residents can get infection including urinary tract infection and sepsis (infection in the blood stream) from not performing hand hygiene and not using clean gloves from dirty to clean area. <BR/>Record review of the facility's policy on Perineal Care dated 10/09/20 reflected, Purpose: The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections, and skin irritation, and to observe the residents' skin condition. Steps in the procedure: 4. Wash hands and apply gloves . 9. Change gloves. Reposition patient for comfort. 10. Apply thin layer of skin barrier.<BR/>Record review of CNA A's Verification of Education Level Completion dated 08/26/22 reflected that CNA A had completed check off list for hand washing, pericare/incontinent care and infection control procedure on 08/26/22. <BR/>Record review of the facility's policy on Handwashing/Hand Hygiene dated 03/01/20 reflected, This facility considers hand hygiene the primary means to prevent the spread of infections . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitor. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap, . and water for the following situation; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; k. After handling used dressing, contaminated equipment, etc,; . m. After removing gloves; q. After personal use of the toilet or conducting your personal hygiene.10. Hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 5 residents (Resident #1 ) reviewed for respiratory care in that:<BR/>1.The facility failed to ensure Resident #1's oxygen tube and humidifier bottle was dated.<BR/>2.The facility failed to ensure Resident #1's oxygen humidifier bottle was changed to prevent difficulties with moisture. <BR/>These deficient practices could affect residents who received oxygen therapy and could result in residents receiving incorrect or inadequate oxygen support, nasal irritation and dryness, and nosebleed.<BR/>The findings were:<BR/>Record review of Resident #1's face sheet dated 01/04/2022 reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: COVID 19 (contagious respiratory virus), Chronic Respiratory Failure with Hypoxia (decreased level of oxygen).<BR/>Record Review of Resident #1's Admissions MDS assessment dated [DATE] revealed a Brief Mental Assessment score of 15 indicating no cognitive impairment. Section O (Special treatments, procedures and programs) listed no documentation of oxygen therapy.<BR/>Record Review of Resident #1's Care Plan dated 12/23/2022 revealed that she had oxygen therapy related to acute and chronic respiratory failure with hypoxia, with an initiation date of 09/13/2022 to prevent signs and symptoms of poor oxygen absorption.<BR/>Record Review of Resident #1's physician orders dated 12/24/2022 reflected and order for oxygen every 4 hours. if O2 sat &lt; 90 on 2L O2 for covid. No other orders were noted. <BR/>An observation on 01/03/2023 at 12:59 PM revealed Resident #1 with oxygen cannula positioned correctly on her nostrils. The tubing was observed to be dry and cloudy. Oxygen concentrator was operating. Resident's oxygen tubing and humidifier bottle were not dated, and the humidifier bottle was empty. Resident did not appear to be in any respiratory distress.<BR/>In an interview with Resident #1 on 01/03/2022 at 1:00 PM revealed that she used oxygen as needed, and she was receiving oxygen from the nasal cannula. She denied respiratory distress. She stated that she could not recall the last time the nurse checked, changed, or assessed her tubing. <BR/>In an interview with RN M on 01/03/2023 at 1:10 PM revealed that she was not aware that the resident's oxygen tubing was not dated. RN M stated that she did not know that the resident's humidifier water bottle was undated and empty. She did not know when the resident's tubing was last changed or water bottle was refilled. She stated that she did not observe the oxygen machine when she conducted rounds. She stated that she conducted rounds every 2 hours. She stated that the overnight nursing were responsible for changing and dating tubing, and she was responsible for checking for accurate operations, dating, and tubing during her patient rounds. RN M stated that tubing should be changed weekly and dating the tubing at the time of change prevents oxygen overuse that could lead to infections. RN M stated that once the installation process was complete nurse should document in the resident Treatment Record. He stated that the water bottles should be filled when observed empty.<BR/>In an interview with the ADON on 01/03/2023 at 2:30 PM revealed that he was notified by the RN M that the tubing was undated, and the humidifier bottle was empty and undated after interview with surveyor. He stated that he did not know the resident's oxygen orders and would have to go review. He said that failing to change and date the oxygen tubing on a residents' cannula could lead to overuse and respiratory infection and complications. He stated that failing to refill or change out the water bottle could lead to the resident having complications of dryness, irritation and nose bleeds. He stated that the water helps with the moisturizing while the oxygen flows in the nose. He stated that shift nurses were responsible for checking oxygen during rounds to observed patients and provide care. He stated that the facilities policy was for overnight nurse to change tubing on residents and date. The stated that the DON and ADON are responsible for monitoring and auditing the overnight nurses changing of resident tubing to ensure compliance through review of the MAR, TAR, and rounds. ADON searched TAR for documentation of orders and treatment notes and could not find them. <BR/>In an interview with the DON on 01/03/2023 at 2:40 PM revealed that she expects the nurses to check MD orders and follow them for resident care. She said that overnight nursing staff are responsible for changing tubing and expected to date and document upon completion. DON stated that the night shift nurses are expected to check oxygen tubing and water bottlers as well as function of concentrators as needed and during rounds. The DON stated that the resident could incur complications with oxygen and breathing leading to infections or poor air consumption. She stated the resident had to have water in the humidifier bottle to prevent dryness, irritations, and nose bleeding. DON stated that she and the ADON are responsible for monitoring and reviewing the patient's MD orders, MAR and TARs of scheduled nursing staff completion of tubing change, dating, and documentation. <BR/>An interview attempt was made on 01/03/2023 at 2:50 PM with LVN night nurse scheduled to perform the treatment for Resident #1, and she did not return call.<BR/>In an interview with the Administrator on 01/03/2023 at 3:00 PM revealed that it was his expectation for staff to follow the physician orders and change the resident's respiratory devices as need when not operating properly. <BR/>A review of facility policy Titled Oxygen Administration dated October 2010 read:<BR/>The purpose of this procedure is to provide guidelines for safe oxygen administration<BR/>Preparation<BR/>1.Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration Review the resident's care plan to assess for any special needs of the resident. <BR/>2.Review the resident's care plan to assess for any special needs of the resident.<BR/>3.Assemble the equipment and supplies as needed.<BR/>General Guidelines:<BR/>1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head.<BR/>Assessment:<BR/>2. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order . Be sure there is water in the humidifying jar and that the water level is high enough that water bubbles as oxygen flows through .<BR/>3. Periodically re-check water level in humidifying jar <BR/>Documentation:<BR/>The date and time that the procedure was performed .The name and title of the individual who performed the procedure.<BR/>The rate of oxygen flow, route, and rationale.<BR/>The frequency and duration of the treatment.<BR/>The reason for the P.R.N. administration.<BR/>All assessment data obtained before, during, and after procedure.<BR/>How the resident tolerated the procedure.<BR/>If the resident refused the procedure, the reason(s) why and the intervention take.<BR/>The signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Residents # 1 and #2) reviewed for accidents.<BR/>1. The facility failed to ensure Residents #1 and #2 were provided adequate staff supervision during a smoking session. <BR/>2. The facility failed to increase supervision of the residents even though they had negative altercations prior to the altercation in the courtyard. <BR/>This failure could place residents at risk for further altercations, which could result in injury, pain, and hospitalization. <BR/>3. Facility prematurely prepared Resident #3, who required a two-person assisted transfer, using a mechanical lift, for transfer. By the resident having to wait for a second staff to assist with the transfer, she became impatient and attempted to transfer herself, which resulted in a fall.<BR/>This failure could place residents at risk for accidents or serious injury. <BR/>Findings Include:<BR/>A record review of Resident #1's Face Sheet dated 08/07/23, revealed a [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), difficulty in walking, lack of coordination, Anxiety Disorder (persistent and excessive worry that interferes with daily activities), Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania {increased talkativeness, rapid speech, a decreased need for sleep, racing thoughts, distractibility, increase in goal-directed activity, and psychomotor agitation} or hypomania {periods of over-active and high energy behavior that can have a significant impact on your day-to-day life}] and lows [depression]).<BR/>A record review of Resident #1's Care Plan, dated 05/30/23 at 10:07 AM, reflected she had limited mobility related to muscle weakness and Dementia. She had a mood problem related to bipolar disorder and anxiety disorder. Interventions: She required a wheelchair to self-propel. She required monitoring and observation for impaired judgment or safety awareness. Also, monitoring for increased anger or agitation. Resident #1 is/has potential to be verbally aggressive related to Dementia, Ineffective coping skills, Mental / Emotional illness, Poor impulse control <BR/>yelling/screaming, abusive language, threatening behavior at staff and residents. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Assess resident's coping skills and support system. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Give the resident as many choices as possible about care and activities. Monitor behaviors Qshift. Document observed behavior and attempted interventions. Psychiatric/Psychogeriatric consult as indicated. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>No updates to the residents care plan in reference to the altercations between Resident #1 and Resident #2 were noted.<BR/>A record review of Resident #1's MDS dated [DATE] at 10:12 AM, revealed a BIMS assessment score of 15, which indicated the resident was cognitively intact. She had verbally aggressive behaviors toward staff and other residents. <BR/>A record review of the Progress Note created by RA A, dated 07/30/23 at 10:41 PM, for Resident #1 reflected the following, Resident got in physical altercation with another resident. This physical altercation was not witnessed by me, however, I cleaned up resident's hands. Resident had two scratches on left hand and one on right. Cleaned residents wounds and put triple antibiotic on top and covered with bandaid. Wound on right hand was not covered with bandaid. Resident denied being pain. <BR/>A record review of the Progress Note created by RN F, dated 08/02/23 at 1:29 PM, for Resident #1 reflected the following, At about 12 noon, another nurse called me to the resident's room. As I entered the room, the resident stated that she was out on the patio and another resident came and grabbed her from behind, so she grabbed her hands too. The resident fell backwards onto the ground. Staff intervened. Head to toe assessment done. Scratches on the right side of her cheek, chin and left arm are noted. Dressings done. Vital signs taken and recorded. Administrator, DON, MD and family were all informed.<BR/>A record review of the Progress Note created by the Social Worker, dated 08/02/23 at 2:12 PM, for Resident #1 reflected the following, Late entry. Resident had physical altercation with another resident. She has a history of bipolar disorder and her mood swings have been unmanageable. She becomes angry and a few minutes later she is crying. She is agreeable to go to a psychiatric hospital for medication management and mood stabilization.<BR/>A record review of Resident #2's Face Sheet dated 08/07/23, revealed a [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Cognitive Communication Deficit (difficulty with thinking and how someone uses language), Anxiety Disorder, Major Depressive Disorder Personal history of Transient Ischemic Attack (a stroke that lasts only a few minutes) and Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Hypertension, and Chronic Obstructive Pulmonary Disease.<BR/>A record review of Resident #2's MDS dated [DATE] at 10:20 AM, revealed a BIMS score of 13, which indicated she was cognitively intact. No behaviors were noted. She required a wheelchair for ambulation. <BR/>A record review of Resident #2's Care Plan, dated 05/30/23 at 10:25 AM, reflected she had potential to be physically aggressive (with other residents) r/t Depression, Poor impulse control. 8/2/23- Resident is on one-to-one supervision and family has also agreed to help provide supervision. Interventions: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Monitor each shift. Document observed behavior and attempted interventions in behavior log. Monitor/document/report as needed any signs/symptoms of resident posing danger to self and others. <BR/>A record review of the Progress Note created by Nurse G, dated 08/01/23 at 6:11 PM, for Resident #2 reflected the following, This resident remains with no injury and denies pain after incident with other resident. Doctor and family notified. No further concern at this time.<BR/>A record review of the Progress Note created by the ADON, dated 08/02/23 at 3:39 PM, for Resident #2 reflected the following, spoke with [family member] regarding episode of aggression in detail-Stated that resident becomes very mean and sees things when she has a UTI and resident 'needs IV antibiotics when she gets them'-Spoke with Np regarding the above and new order written for ceftriaxone 1gm IM x 3days<BR/>A record review of the Progress Note created by the Social Worker, dated 08/02/23 at 4:53 PM, for Resident #2 reflected the following, SW spoke with resident's[family member], regarding recent aggressive behaviors. She is agreeable to Psych referral. SW sent referral this date and sent text message to the Psychatrist to request face time visit asap. Resident is on one-to-one supervision and family has also agreed to help provide supervision.<BR/>A record review of the Progress Note created by RN H, dated 08/05/23 at 6:22 PM, for Resident #2 reflected the following, Lidocaine HCl Injection Solution 1 %<BR/>Inject 2.1 ml intramuscularly in the evening for mix with Ceftriaxone, until 08/05/2023 23:59 mix 2.1 ml with Ceftriaxone ABX was ordered for 3 days initial dose was given on the 8/2/23. Thus, all doses were given.<BR/>Record Review of Physician's Orders for Resident #2 on 08/15/23 at 10:49 AM, revealed cefTRIAXone Sodium Injection Solution Reconstituted<BR/>1 GM Inject 1 gram intramuscularly one time a day for<BR/>UTI for 3 Days<BR/>Completed 08/02/2023 08/02/2023 08/05/2023 _________ _________ Lidocaine HCl Injection Solution 1 % Inject 2.1 ml<BR/>intramuscularly in the evening for mix with<BR/>Ceftriaxone. until 08/05/2023 23:59 mix 2.1 ml with<BR/>Ceftriaxone<BR/>Completed 08/02/2023 08/03/2023 08/05/2023 _________ _________ Macrobid Oral Capsule 100 MG Give 1 capsule by<BR/>mouth two times a day for UTI for 5 Days<BR/>An interview with the Administrator on 08/15/23 at 9:35 AM, revealed he stated on 08/01/23, during lunch time, the two residents got into a physical altercation. He stated no actual hits made contact; however, Resident #1 was scratched. He stated the residents were separated, assessed, then placed on 1:1. He stated physicians and families were notified. He stated on 08/02/23, Resident #2 saw Resident #1 exiting the building, so she followed her out. He stated Resident #2 attempted to punch Resident #1, however, Resident #1 grabbed her arm; however, in doing so, she lost balance and fell over in her wheelchair. He stated the staff ran to stop them but didn't get to them in time to prevent it. He stated Resident #1 sustained abrasions on the right side of her head and on her right arm. He stated Resident #2 was placed on 1:1. The physicians and families were notified, and she was sent out for psychiatric evaluation. He stated Resident #1 said that on 07/30/23, she and Resident #2 got into an argument, but no punches were thrown . He stated Resident #1 said she told RA A about it. When he asked RA A about it, she confirmed Resident #1 told her, but she did not think it was serious enough to report it to him. He stated he placed her on a final level disciplinary action and re-educated her. He stated they conducted an in-service and Quality Assurance Assessment afterward. He stated Resident #2 was discharged from the facility on 08/14/23. <BR/>On 08/15/23 at 10:12 AM, a record review of a written statement by the Activities Director, reflected, I was up by the nurse's station and when the door tot he courtyard was opened, I heard Resident #1 yelling. I [NAME] to the courtyard, the Central Supply Clerk was at the door as well. Resident #2 was trying to get in the door, the Central Supply Clerk helped her inside and Resident #1 was laying, wiht her wheelchair flipped on it back. She was still in a sitting position with her head and back on the sidewalk. We called a nurse. RN H came out and assessed her. We moved her wheelchair and helped her stand up and get back into her wheelchair. She was upset and said that Resident #2 came behind her and hit her and flipped her over backwards. When we got to her room, we got her some ice water and talked to her for a little bit to get her to cool off.<BR/>On 08/15/23 at 10:17 AM, a record review of a written statement of an interview by the Administrator with Resident #2, revealed Resident #2 stated she did try to hit Resident #1 because she called her a bitch the day before and she does not like that lady. She stated she did follow Resident #1 into the courtyard and it was intentional. The Administrator added that there were not injuries to Resident #2.<BR/>On 08/15/23 at 10:24 AM, a record reivew of a written statement from the ADON, reflected I was notified that there was an incident regarding Resident #1 and Resident #2 in the enclosed patio area by the Activities Director. Resident #1 was observed in her wheelchair and was escorted to her room with htis author and another staff member. Resident #1 stated she was outside in the patio area when the other resident reached for her from behind and she grabbed Resident #2's arms and fell backward from her wheelchair. Resident #2 was also escorted to her room. Upon interview, stated that she followed Resident #1 outside. She came up behind her and reached forward to hit her. Resident #1 grabbed her arms and subsequently Resident #1 fell while in a wheelchair. Resident #2 stated, 'I was trying to hit her .cause she called me a bitch yesterday.' Resident #2 remained in her room with a staff member.<BR/>An interview with Resident #1 on 05/18/23 at 2:19 PM, revealed she and Resident #2 had exchanged words at lunch one day because she was talking to someone else and then Resident #2 told her to be quiet. She stated she already did not like Resident #2, but could not give a reason why she did not like her. She stated they began to argue because she was not going to let Resident #2 tell her what to do. She stated staff pulled them apart because they were trying to hit each other. She stated the next evening, she had gone to the courtyard to smoke and Resident #2 came out there. She stated Resident #2 did not say anything to her, she just came toward her and tried to hit her. She stated she grabbed her arm to keep her from hitting her and because of how she had to lean while holding onto her arm, it caused her to fall back. She stated she got a few scrapes, but at least Resident #2 did not get to hit her. She stated staff came out to help her and the nurse checked her out. She stated she thought the whole thing was done with, but Resident #2 would not let it go. She stated she had not seen Resident #2 for a while and she was glad she had not seen her.<BR/>An interview with the C.N.A B on 08/15/23 at 4:58 PM, revealed Resident #1 was never happy. She liked to smoke and when she didn't have cigarettes, she would torture everyone. She stated Resident #1 picked fights with residents. She stated she fusses and fights with residents and staff. She stated Resident #1 did not like Resident #2 and would always talk badly about her to her face and to others and say it loudly. She stated she was never told to keep the two residents separated or to keep an eye on them. She stated she felt it was just good to always watch Resident #1 because she messed with everyone. She stated she believed if they had been told to keep an eye on the two of them, specifically, because if that was the case, someone would have seen when Resident #2 followed Resident #1 outside and prevented the incident in which Resident #2 attempted to hit Resident #1 and Resident #1 grabbed her arm and ended up falling backward in her wheelchair. <BR/>An additional interview with the Administrator on 08/15/23 at 4:50 PM, revealed C.N.A. C had gotten the mechanical lift and had asked Nurse E to come assist her with the resident's transfer. He stated she was at the door of the room, looking for assistance, when the resident became impatient and started trying to maneuver out of bed on her own, and was reaching for the lift. Then C.N.A. C ran to catch her because she was slipping. He stated the sit-to-stand board had already been placed under the resident and that is how she was able to scoot and reach for the mechanical lift. He stated if C.N.A. C had not started the process without assistance present, the fall most likely would not have happened.<BR/>On 08/15/23 at 6:15 PM, record review of the Psychiatric Evaluation for Resident #2, dated 08/03/23 revealed an evaluation was compted by the Psychiatrist and a recommendationf or the discontinuation of the 1:1 monitoring was issued. <BR/>On 08/15/23 at 6:21 PM, record review of documents entitled 1:1 Monitoring for Resident #2, dated 08/02/23 - 08/03/23, revealed staff began monitoring the resident at 2:00 PM and continued with hourly documentation through 5:00 PM on 08/03/23.<BR/>Review of Resident #3's Face Sheet, dated 08/15/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left non-dominant side, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Major Depressive Disorder, Anxiety Disorder, Hypertension, and Osteoarthritis.<BR/>Review of Resident #3's Minimum Data Set (MDS) Assessment, dated 05/19/23, reflected the resident's Brief Interview of Mental Status score of 15, which means she was cognitively intact. She required extensive two-person for bed mobility, transfer, locomotion off unit, dressing, and toilet use.<BR/>Review of Resident #3's Care Plan dated revised on 05/30/23 reflected, the resident was at high risk for falls related to gait/balance problems, incontinence, unaware of safety needs with interventions included: Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs and follow facility fall protocol. The Care Plan did not address the resident's transfer requirements.<BR/>A record review of the Progress Note dated 08/09/23 at 6:50 AM, for Resident #3 reflected the following, 5:00 AM one of the CNA calls this nurse announcing the patient is on the floor. Resident is seated on the floor and next to her back is a commode. resident who is alert and oriented x 4 says she slid off the commode on transfer. She denied being hurt although the sling rubbed hard on my left shoulder as i went to the floor. she also denies banging self in the process. Spouse informed through a telephone message. Medical Director (MD) and Director of Nursing (DON) notified. x ray order of the sacral in the witnessed fall is made.<BR/>An interview with the Administrator on 08/15/23 at 2:40 PM, revealed Resident #3 cursed staff out every chance she got. He stated on the morning of the fall, C.N.A. C was assisting Resident #3 to the toilet, and the resident slipped and fell to the floor. The resident's legs were pinned underneath her. He stated C.N.A. C called for help and Nurse E entered and assisted C.N.A. C with lifting the resident from the floor. Nurse E then conducted a head-to-toe assessment on the resident and found no injuries. He stated the incident was reported to him by the resident. <BR/>On 08/15/23 at 3:19 PM, record review of a written account of a phone conversation between the Administrator and Resident #3, reflected I received a call from Resident #3, stating she had a complaint from the morning (08/09/23) at 5:00 AM. She stated C.N.A. C was helping her to the toilet when she slipped and fell. She stated the weight of her body was on her shoulder. C.N.A. C called for help and Nurse E then helped C.N.A. finish. He added, Nurse E performed a body check where no injuries were noted.<BR/>An additional interview with the Administrator on 08/15/23 at 4:50 PM, revealed C.N.A. C had gotten the mechanical lift and had asked Nurse E to come assist her with the resident's transfer. He stated she was at the door of the room, looking for assistance, when the resident became impatient and started trying to maneuver out of bed on her own, and was reaching for the lift. Then C.N.A. C ran to catch her because she was slipping. He stated the sit-to-stand board had already been placed under the resident and that is how she was able to scoot and reach for the mechanical lift. He stated if C.N.A. C had not started the process without assistance present, the fall most likely would not have happened.<BR/>An interview with C.N.A. D on 08/15/23 at 5:13 PM, revealed she stated Resident #3 is a very particular lady. She stated the resident hates to have a bowel movement in her brief. She stated the resident can scoot and grab the lift, when they put her on the sit-to-stand board. She stated the resident will try to do things for herself, as much as she can. She stated whenever she responds to the resident's call light, she will go in and see what the resident needs. She stated when the resident tells her she needs to go to the toilet, she will tell her ok and that she will be back with someone to help her with getting her to the bathroom. She stated the resident says ok and waits, with no problem. She stated if the resident were to ever get impatient and try to get out of bed on her own, she would try to talk to her to calm her and explain to her that she needs to wait for assistance, so she won't fall and hurt herself.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services, based on the comprehensive assessment, to prevent urinary tract infections for 1 of 3 residents (Resident #68) reviewed for urinary catheters. <BR/>The facility failed to keep Resident #68's catheter tubing off the floor while the resident was in her wheelchair causing it to drag on the floor and be stepped on while she was being pushed down the hall. <BR/>This failure could affect residents with catheters by placing them at risk for the development and/or worsening of urinary tract infections and injury. <BR/>Findings included:<BR/>Record review of Resident #68's MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included depression, bipolar disorder, dorsalgia (physical discomfort occurring anywhere on the spine or back, ranging from mild to disabling), disorder of kidney and ureter. Resident #82 has a BIMS of 5 indicating she had severe cognitive impairment. <BR/>Record review of Resident #68's January 2025 monthly orders reflected she had a catheter 18 French 10 cc bulb. <BR/>Observation on 01/21/25 at 11:18 AM of Resident #68 revealed she was being pushed in her wheelchair from her room to the dining room by the Activity Director. The resident's catheter tubing was dragging on the floor and the Activity Director stepped on the tubing. When the Activity Director stepped on the tubing, she moved her foot and continued to push the resident. The resident did not appear to be in distress or noticed her tubing had been stepped on. <BR/>Interview on 01/24/25 at 11:53 AM with the Activity Director revealed she recalled stepping on Resident #68's catheter tubing when she was pushing the resident in her wheelchair. The Activity Director said she was not aware the catheter tubing was not supposed to be dragging on the floor and did not know she had to tell someone so they could lift it off the ground. <BR/>Interview on 01/24/25 at 1:27 PM with LVN A revealed Resident #68's catheter tubing should not drag on the floor because it could introduce bacteria and was an infection control issue and if the Activity Director stepped on the tubing it could pull the catheter or hurt the resident. LVN A said if non-nursing staff were to see a catheter tube dragging, they should let the nursing staff know so they could fix the issue. <BR/>Interview on 01/24/25 at 2:33 PM with the ADON revealed if non-nursing staff saw catheter tubing dragging on the floor, they could pick it up themselves or ask nursing staff for assistance. When the Activity Director stepped on the tubing, the ADON stated it could have pulled the catheter causing discomfort to the resident. She stated it was also an infection control issue. <BR/>Record review of the facility's Catheter Care, Urinary policy, revised January 2023, reflected the following:<BR/>Purpose<BR/>The purpose of this procedure is to prevent catheter-associated urinary tract infections.<BR/> .Infection Control .<BR/> .b. Be sure the catheter tubing and drainage bags are kept off the floor

Based on observation, interview, and record review, the facility failed to ensure the facility provided food that was palatable, for 1 of 3 observed meals (the lunch meal on 01/22/25) reviewed for dietary services.<BR/>The facility failed to serve food that had a smooth, puddling like texture during the lunch meal on 01/22/25.<BR/>This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life.<BR/>Findings included:<BR/>Observation on 01/22/25 at 10:00 AM of the kitchen revealed [NAME] F was boiling spaghetti pasta on the stove and after being fully cooked, she added them to the machine to puree the food. [NAME] F pureed the cooked pasta, but it still had bits of pasta in it and was not smooth or pudding like. <BR/>A sample tray was requested and tasted on 01/22/25 at 1:45 PM with three state surveyors and the DM. The tray that was tasted included pureed spaghetti meat sauce, pureed bread, pureed vegetables, and pureed pasta. The pureed pasta was chunky with pieces of cooked pasta chunks in it; it did not have a smooth or pudding like texture . <BR/>Interview on 01/22/25 at 1:47 PM with the DM revealed the noodles were very chunky and had pieces of pasta leaving it not smooth or puddling like. The DM said [NAME] F was responsible for making the pureed pasta today for the lunch meal and she should have used a different type of pasta. The DM said [NAME] F was nervous and used regular spaghetti pasta instead of egg noodle pasta that she would normally use for pureed pasta since they were easier to puree. The DM said she did not check the texture of the pureed pasta and normally did not check the texture of pureed food items. The DM said residents could choke if the pureed food item was not the right texture. The DM said each pureed food item should be smooth and puddling like.<BR/>Record review of a list of residents who were ordered a pureed diet revealed nine total residents.<BR/>Record review of a menu, dated 01/14/25, and titled Diet Extension: Wednesday, Week 4 [Facility Name] [City Initials] 2024 5Wk [sic] reflected for the Regular/Puree Lunch meal was: Meatballs w/Spaghetti Sc, Spaghetti Noodles, Italian Bld Veg, Herb Butter Roll, Cheesecake Bar.<BR/>Record review of the facility's Food and Nutrition Services policy, dated 06/12/24, reflected: .7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature .

Based on observation, and interview the facility failed to maintain essential patient care equipment in safe operating condition for the facility's only medication carts for 1 of 4 carts (medicataion cart #1) reviewed for essential equipment. <BR/>1.The facility failed to restore and repair the lock on medication cart #1 prior to storing medications and assigning on the hall. <BR/>These failures could place residents who were cognitively impaired or independently ambulating, as well as staff and visitors at risk of missed medications, overdose, or diversion of drugs. <BR/>Findings included:<BR/>An observation on 07/13/23 at 10:00 a.m. revealed a medication cart was observed on the west front side of the facility's nursing station. Further observation determined that the lock did not work and locking would prevent access to medication<BR/>In an interview on 07/13/23 10:13 a.m. RN-G stated that the cart was not locking and needed to be repaired. He said when he locked the cart it was difficult to open. He said that all equipment issues should be reported to the DON who would notify maintenance. RN-G said that the cart contained medications for daily administration and controlled medications in a locked box inside the cart. The controlled substance and biological box in the second drawer were observed locked. RN=G said he had notified the DON and the lock was jamming upon arrival to his shift this morning at 6a.m.<BR/>In an interview on 7/13/23 at 10:05 a.m. the DON stated the cart would be repaired today and maintenance had been notified. She said that she was aware that the cart was not working. she said she would remove the cart from the floor until repaired. <BR/>In an observation on 07/12/23 at 10:08 am the DON and RN-G moved the medication cart to the medication locked room.<BR/>In an interview on 7/13/23 at 10:07 a.m. the Administrator stated it was his expectations the DON or maintenance would be notified of equipment that was not working properly and be removed from the floor until repaired, replaced, or restored. <BR/>The policy for repairs were not requested or reviewed.<BR/>In an interview with the administrator on 07/12/23 the stated that the maintenance director was not available for interview. <BR/>In an interview with the administrator on 07/12/23 he stated the ADON that repaired the lock was not working and was asked to call for interview as he was preparing to leave the country.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so the facility was free of pests and rodents for 1 of 1 facility reviewed for pest control. <BR/>The facility failed to keep an effective pest control program to ensure the kitchen was free of gnats.<BR/>This failure could place residents at risk for a reduced quality of life.<BR/>Findings include:<BR/>Observations on 09/20/2022 at 9:38 a.m. and 11:30 a.m. and 09/21/22 at 9:00 a.m. and 12:00 p.m. in the beverage area of the kitchen, where the coffee was brewed, tea, and drink dispensers for ice and water machine were located,, multiple gnats were observed to land on plastic containers, coffee mugs, cups, the coffee and tea dispenser, and the table where the items were stored and served residents preferred beverage. <BR/>Interview on 09/20/2022 at 9:40 a.m. with the Dietary Manager DM revealed the kitchen tried to get rid of the gnats and it reported to maintenance. She stated the kitchen was sprayed for pests routinely (monthly), however they couldn't get rid of the gnats. Maintenance Director was notified of the gnats by Dietary manager previously about 2 weeks ago and today, 09/21/22.<BR/>Interview on 09/20/2022 at 9:48 a.m. with the Maintenance Director MD revealed he reported to the pest control, and they had been completing regular maintenance of pest spraying. The kitchen tried to get rid of the gnats and reported to maintenance. She stated the kitchen was sprayed for pests routinely, however they couldn't get rid of the gnats. <BR/>Interview with the Administrator on 09/21/2022 at 3:30 p.m. revealed he expected the facility to have routine pest control and be free of pest to prevent any illnesses. The administrator stated that Maintenance Director was responsible for scheduling pest control routinely and as needed for the facility.<BR/>Record review of facility's Pest Control Log requested from MD on 09/22/2022 was not provided to address the pest control of gnats.<BR/>Record review of facility's policy Pest Control, revised May 2008, reflected the facility shall maintain an effective pest control program .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. A reviewed updated pest control contract was completed. There was no documentation of reports of gnats listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe environment for residents, staff and the public for one (400 halls) of four hallways observed for oxygen storage safety. <BR/>The facility failed to securely store oxygen cylinders in room [ROOM NUMBER].<BR/>This failure could affect the residents by placing them at risk of injury due to oxygen cylinders becoming unsecured and becoming a hazard. <BR/>Findings included:<BR/>Observation on 07/11/23 at 9:50 AM revealed two free-standing oxygen cylinders without a rack, chain or strap in the corner of room [ROOM NUMBER] near the entry room door. <BR/>Observation on 07/11/23 at 10:06 AM revealed two free-standing oxygen cylinders without a rack, chain or strap in the corner of room [ROOM NUMBER] near the entry room door. <BR/>Observation on 07/11/23 at 11:05 AM revealed two free-standing oxygen cylinders without a rack, chain or strap in the corner of room [ROOM NUMBER] near the entry room door. <BR/>Observation and interview on 07/11/23 at 11:15 AM with the DON revealed she observed the two free standing unsecured oxygen cylinders in the corner of room [ROOM NUMBER] near the entry room door. She stated, It should be secured in a rack, bag or with a strap and the risk of the cylinders being unsecured is they are combustible. <BR/>Interview on 07/11/23 at 11:57 AM with the Administrator revealed oxygen cylinders should be secured with a rack, bag or strap to prevent them from falling over because they are combustible.<BR/>Review of the facility policy titled Oxygen Safety, dated 08/16/22, revealed 1. Oxygen cylinders must be stored in racks with chains, study portable carts or approved stands .9. Oxygen cylinders should never be left free-standing .<BR/>Review of National Fire Protective Association, (NFPA) 99,2012 Edition, Section 11.6.2.3, reflected: .(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 19 residents (Resident #39) reviewed for resident call system. <BR/>The facility failed to ensure Resident #39 had a working call light.<BR/>This failure could have placed residents at risk of being unable to obtain assistance when needed.<BR/>Findings included:<BR/>Record review of Resident #39's MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included stroke, depression, bipolar disorder, and obstructive sleep apnea (a sleep disorder characterized by repeated episodes of complete or partial blockage of the upper airway during sleep). Resident #39 had a BIMS score of 14, indicating her cognition was intact.<BR/>Record review of Resident #39's care plan initiated on 10/25/24 reflected the resident had an ADL self-care performance deficit related impaired balance. Interventions included to encourage the resident to use bell to call for assistance. <BR/>Observation and interview on 01/21/25 at 2:14 PM of Resident #39 revealed she was lying in bed and had just finished breakfast. The resident said she had recently been moved to that room the night prior and she said she did not think her call light was working because she had pushed it for someone to pick up her lunch tray and no one had been in yet. The resident was asked to push the call light again and the light did not turn on outside of the room. Resident #39 further stated she would like her call light to work in case she needed something or assistance. <BR/>Interview on 01/21/25 at 2:17 PM with the Maintenance Director revealed he was not aware the call light was not working. The Maintenance Director pushed the call light himself and it did not work. He said it appeared he needed to replace the cord. <BR/>Record review of the facility's Resident Call System policy, dated October 2022, reflected the following:<BR/>Policy<BR/>Residents are provided with means to call staff for assistance through communication system that directly calls a staff member or a centralized workstation <BR/> .3. The resident call system remains functional at all times