LAMUN-LUSK-SANCHEZ TEXAS STATE VETERANS HOME

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal (lunch meal) reviewed for palatability, attractiveness, and appetizing. <BR/>The dietary staff failed to provide food that was palatable and at an appetizing temperature for the lunch meal observed on 02/26/2025. Resident's #1, #2, #3, and #4 complained the food was served cold.<BR/>These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and food borne illnesses. <BR/>The findings included: <BR/>During an interview on 02/26/2025 at 09:30 AM, an anonymous family member stated, during a visit on 1/31/2025, a resident's meal was served cold. The family member stated she was assisting the resident eat and touched the food and it was cold. The family member stated the resident ate in the dining room on this date with other residents. <BR/>During an interview on 02/26/2025 at 10:55 AM, Resident #1 stated his meals were served cold almost every day. The resident stated he ate in the dining room daily. The resident stated his meals were rarely ever hot or warm enough. <BR/>During an interview on 02/26/2025 at 11:13 AM, Resident #2 stated his meals were served cold often. The resident stated he ate in the dining room daily. The resident stated meal services rarely ever had hot or warm food. The resident stated his food did not taste good because it was not hot or warm enough. <BR/>During an interview on 02/26/2025 at 11:22 AM, Resident #3 stated his food was served cold almost every day. The resident stated he ate in his room daily. The resident stated this had been an ongoing issue and most meals had been served cold. The resident stated he rarely ever received warm or hot food during meal services. <BR/>During an interview on 02/26/2024 at 11:30 AM, the KM stated they planned to serve lunch around 11:40 AM. A test tray was requested after all residents were served. <BR/>During an interview on 02/26/2024 at 12:37 PM MA stated residents complained often about food being cold. The MA stated residents' meal trays were delivered to the nursing station by the kitchen staff and the nursing staff had to double check each tray. The MA stated the trays were usually handed out immediately. The MA stated nursing staff had to reheat food often for residents who stated their food was cold. <BR/>During an observation on 02/26/2024 at 1:14 PM, a test tray was provided by the KM. The test tray contained a regular diet plate that included a slice of meatloaf, a serving of scalloped potatoes, a serving of green peas, a dinner roll, and a dessert of apple cake. The test tray also included a puree diet plate that included meatloaf, potatoes, green peas, and bread. The meatloaf on the regular diet plate was cold. The potatoes on the regular diet plate were slightly warm. The peas on the regular diet plate were slightly warm. The meatloaf on the puree diet plate was slightly warm. The potatoes on the puree diet plate were cold on top and slightly warm on the bottom. After stirring the potatoes, the potatoes were less than slightly warm. The peas on the puree diet plate were warm. The regular diet and puree diet plates were served on insulated clam shells on the test tray. <BR/>During an interview on 02/26/2025 at 2:15 PM. Resident #4 stated his meatloaf was served cold on this date. The resident stated he ate in his room most days. The resident stated his meals were served cold on a lot of days. The resident stated he had to request staff to warm up his food on numerous occasions due to the food being served cold when he first received it. <BR/>During an interview on 02/26/2025 at 2:22 PM. Resident #3 stated his lunch was served cold on this date. The resident stated he ate in his room on this date. The resident stated he had meatloaf and potatoes on this date for lunch. <BR/>Record Review of the facility's document titled, Service Line Checklist dated 2/26/2025 revealed the following under Food Temperatures : Lunch: Meat Dish (regular)- 188 degrees with a marked-out temperature that is illegible; Meat Dish (puree)- 180 degrees; Vegetable (regular)- 190 degrees; and Vegetable (puree)- 182 degrees.<BR/>During an interview on 02/26/2024 at 2:40 PM the KM stated residents always complained that their food was cold, and that was nothing new. The KM stated if food was not hot enough for a resident, it was reheated. The KM stated she took temperatures of each food item before it was served to ensure it was at a proper temperature. The KM stated temperature log was showing lunch was served at proper temperatures. The KM stated she verified the temperatures were adequate. The KM stated this was logged each meal including at lunch time on this date. The KM stated she did not know why the test tray contained food that was only slightly warm and/or cold. The KM stated the test tray was served after the last tray was served to the residents. The KM stated residents' meal trays were served to their room first, and then the residents in the dining room were served. The KM stated residents' room meal trays were taken to residents on a cart. The KM stated this cart was not heated. The KM stated the meal trays were taken to nursing staff at each hall and the nursing staff distributed the food to residents after the meals were checked for accuracy. The KM stated she did not know how long it took for nursing staff to distribute residents' room trays. The KM stated it was her expectation the trays were served as soon as they were delivered. The KM stated room trays were served on insulated clam shell plates. The KM stated the plates were heated as well to keep food warm. The KM stated she did not know why the residents complained of cold food since kitchen staff ensured food was at an adequate temperature before it was sent out to residents. The KM stated residents' room trays were served from the kitchen, and residents who eat in the dining room were served from the steam table in the dining room. The KM stated she did not know why residents who ate in the dining room would complain that their food was cold. The KM stated the temperature taken on this date were from the kitchen, not the serving line. The KM stated it was her expectation that residents were served hot food. The KM stated it was the kitchen staff's responsibility to ensure food was served hot. The KM stated if food was not served at a safe temperature residents could get sick. <BR/>During an interview on 02/26/2024 at 3:00 PM CNA A stated residents complained often about food being cold and nursing staff would heat up the food for the resident.<BR/>During an interview on 02/26/2024 at 3:43 PM LVN A stated residents did complain about food being cold sometimes and nursing staff would heat up the food for the resident. LVN A stated the nursing staff checked each resident's tray before it was delivered to them to ensure they were getting an approved meal. LVN A stated this was usually done right away after the kitchen staff delivered the trays to the nursing station. <BR/>During an interview on 02/26/2024 at 4:00 PM the ADM stated the KM was responsible for ensuring food was served at a proper temperature. The ADM stated cooks were responsible for ensuring food met proper temperatures. The ADM stated the KM was responsible for the cooks. The ADM stated they used an induction system to ensure food was served at proper temperatures. The ADM stated this included clam warmers for plates and two insulated food carts. The ADM stated nursing staff were responsible for handing out food trays after they were checked for accuracy to ensure residents receive their ordered diet. The ADM stated it was her expectation that food trays were served as soon as they were delivered to each hallway. The ADM stated all dietary staff were trained regarding safe food temperatures upon hire and through regular in-serves provided by the KM. The ADM stated if food was served cold or slightly warm, food may not be palatable since some residents would want their food to be hot. The ADM stated there was a concern for residents' safety and possible illness if food was not served at safe temperatures.<BR/>During an interview on 02/26/2024 at 4:15 PM CNA B stated residents did sometimes complain about food being cold and nursing staff would request an alternative for the resident or warm the food up for them. <BR/>During an interview on 02/26/2024 at 4:18 PM the DON stated she had not received any complaints about food being served cold. The DON stated some residents did prefer their food to be warmer than it was served, and they would heat up residents' food when needed. The DON sated the KM was over all kitchen staff and was ultimately responsible for ensuring food was served at proper temperatures. The DON stated residents' room trays were served on insulated shells. The DON stated when room trays were brought to the nursing staff to distribute, nursing staff were also responsible for ensuring food was not cold. The DON stated it was her expectation that food trays were served as soon as they were delivered to nursing staff. The DON stated if nursing staff were not available when meal trays were delivered to the nursing stations, the unit manager or the DON would also help distribute trays after they verified the meals were adequate for each resident's meal order. The DON stated all food should have been served at safe temperatures, and if food was cold a new tray should have been requested for the resident. The DON stated if food was not served at safe temperatures the resident could have been at risk of food borne illness or food may have not been pleasurable to the resident if it was not served warm enough. <BR/>Record Review of the facility's policy titled, Food: Quality and Palatability dated 5/2014 and last revised on 02/2023 revealed the following:<BR/>Policy Statement:<BR/>Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs.<BR/>Definitions<BR/>Proper (safe and appetizing) temperature Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns.<BR/>Procedures<BR/>2. The Cook(s) prepare food in a sanitary manner utilizing the principles of Hazard Analysis Critical Control Point (HACCP) and time and temperature guidelines as outlined in the Federal Food Code.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 29 residents (Residents #9 and #101) reviewed for advanced directives.<BR/>Residents #9 was listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. <BR/>Residents #101 was listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. <BR/>This failure could place residents at risk for not having their end of life wishes honored and incomplete records.<BR/>Findings included:<BR/>Resident #9<BR/>Record review of Resident #9's face sheet, dated [DATE], revealed an [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include Parkinson's (a progressive nervous system disease), dementia (progressive loss of intellectual functioning), atrial fibrillation (irregular or rapid heartbeat that causes poor blood flow),major depressive disorder and Alzheimer's (progressive disease that destroys memory and other mental functions)<BR/>Record review of Resident #9's face sheet, dated [DATE], revealed Advance Directive<BR/>DNR <BR/>Record review of Resident #09's physician order summary dated [DATE] revealed a DNR order dated [DATE] related to code status or advanced directive. <BR/>Record review of Resident #09's care plan, dated [DATE], revealed a care plan for DNR Status:<BR/>Focus: I/Family/RP has completed documentation for DNR status. I wish to be designated as DNR<BR/>Goal: Community will follow DNR status request.<BR/>Interventions: A physician's order for DNR is to be placed in my clinical record, Keep a copy of the OOHDNR form in my clinical record, Send a copy of the OOHDNR with me in the event of transfer to the hospital or other facility<BR/>Record review of Resident #09's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under Section B the medical power of attorney had not checked any of the check boxes that indicated why they were acting on the behalf of Resident #09. Section 3 was missing a date to indicate when the signatures were obtained. <BR/>Resident #101<BR/>Record review of Resident #101's face sheet, dated [DATE] revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include dementia (progressive loss of intellectual functioning), Atherosclerotic heart disease (buildup of fats and cholesterol plaque in the walls of the arteries) and anxiety disorder. <BR/>Record review of Resident #101's physician order summary dated [DATE] revealed an order for Do Not Resuscitate - DNR dated [DATE].<BR/>Record review of Resident #101's care plan, dated [DATE], revealed care plan for Advance Care Plan: <BR/>Focus: Resident/Family/RP does not have advance directives and elects Full Code Status. designating that the resident is a FULL CODE (CPR) status<BR/>Goal: Community will follow full code status through review date<BR/>Intervention: Initiate CPR if I am without a pulse Review code status at least annually and as indicated. The care plan did not indicate a DNR status update.<BR/>Record review of Resident #101's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under the Physician's Statement revealed there was no date. Further review revealed at the bottom of the form indicated All persons who have sign, acknowledging that this document has been properly completed. revealed there was no signature from either of the two witnesses and no signature from the notary.<BR/>An interview was conducted on [DATE] at 11:06 AM, the ADON said she had been at the facility for two months. She said she had been an RN for 20 years. She said resident DNR forms were everyone's responsibility and it was a team effort. She said the resident and the family work with the social worker, and the social worker was the one who completed the paperwork done. As the nurse, they would educate the family and the resident on what DNR meant. She said the form should be completed for the request to be valid. She said the signatures and the dates on the form indicated when the DNR became valid. She said the DNR would only be valid if all signatures were included. She said if the DNR form was invalid, then is the resident was considered a full code, and chest compression would be performed. She said if a resident wished to be a DNR and CPR was performed, then the facility would have been going against their wishes. She stated she was responsible for the C-wing in the facility and not the memory care unit. She stated the pharmacy nurse and DON typically cover the memory unit. She reviewed Resident #9's DNR and acknowledged that Section B was missing information and the date was missing at the bottom. She acknowledged that Resident #101's DNR was missing signatures at the bottom of the witness and the notary. She said she had not been trained specifically at the facility regarding DNRs but was handed a list of DNRs for her section in the facility. She said the potential negative outcome was the staff could perform CPR, and the caregiver could say it was not legit and become upset. She said she expected all appropriate and applicable places should be completed on the DNR form so that it was valid. She stated the doctor's signature and date were the most important. She said she was unsure why the middle of the form was not completed, why the bottom was not dated for Resident #9, and why Resident #101 was not completed. <BR/>An interview was conducted on [DATE] at 11:43 AM, the Social Worker (SW) said that she was responsible for completing the resident DNRs. She said another social worker at another facility would assist her and review her work since she was working under that worker's license. She said when a resident wishes to be DNR status, she has the nurse talk to the resident and their family so that they fully understand what they are requesting. Then, if they wanted to proceed, she would find someone not in the line of care to witness. She said after obtaining the doctor's signature and all appropriate signatures, she would make a copy and provide the DON with a copy. Lastly, she would upload the final copy into the resident's electronic file. She said the copy uploaded in the electronic file should be the final form. She said she expected all appropriate and applicable fields to be completed. She said if the relevant and appropriate fields were missing, the DNR was not valid. She said if the DNR is not valid, this would mean that the resident would be a full code. She said this could potentially go against the resident's wishes. She said that she had been trained on the completion of DNRs. She said she was unaware that Residents #9 and #101 had incomplete DNRs. She said that she audits the DNRs every couple of months. <BR/>An interview was conducted on [DATE] at 11:55 AM, the Pharmacy nurse said DNRs are usually taken care of by the SW. She said that the SW usually had one of the nurses look at the DNR when it comes from the physician. She said she was unaware of any issues. She said she had been trained on the facility's process for DNRs. She said she expected DNRs to be fully completed before scanning into the chart and that they should be updated throughout the chart to reflect the resident's status. She said if the DNR was not fully completed, then the DNR was not valid. She said the potential negative outcome would be that the resident's wishes would not be upheld. <BR/>An interview was conducted on [DATE] at 12:52 PM, the ADM said that she would have to check specifically for her facility but that, in her experience, social services were responsible. She said she had been trained on the completion DNRs and was unaware that some residents had incomplete DNRs. She said she expected the DNR to be complete and all appropriate and applicable areas on the form completed. She said the potential negative outcome would be the wishes of the veterans may not be fulfilled. However, she said if the form was in the electronic medical record, she understood it was complete and ready. <BR/>Record review of the facility's policy, Advance Directives, Revised February 2017, revealed the following documentation: <BR/> Compliance Guidelines<BR/> A copy of the advance directive and subsequent revisions will be included in the resident's medical record.<BR/>Advance Directive Modifications<BR/>The resident has the right to modify the advance directive at any time. Although the resident should advise the community whenever a change is made, it is the community's responsibility to ensure that it has current copies of all advance directives.<BR/>The community will survey its residents at least annually regarding any advance directives changes.<BR/>Record Review of the Instructions For Issuing An OOH-DNR Order (Undated) revealed the following:<BR/>INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER PURPOSE <BR/>IMPLEMENTATION: A competent adult person, at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: <BR/>Section B - If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, or proxy in a directive to physicians, the guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating it in Section B. <BR/>Section C - If the adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, or proxy, then a qualified relative may execute the OOH-DNR Order by signing and dating it in Section C . <BR/>Section F - If an adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, proxy, or available qualified relative to act on his/her behalf, then the attending physician may execute the OOH-DNR Order by signing and dating it in <BR/>In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR Order in the presence of a notary public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses. Witness or notary signatures are not required when two physicians execute the OOH-DNR Order in section F. The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals.

Based on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 32 residents;<BR/>The facility failed to address complaints for 2 of 10 confidential resident's that were interviewed and voiced concerns related to missing personal laundry<BR/>These problems could result in residents having a lack of personal clothing to wear and low self-esteem. <BR/>The findings included:<BR/>During a confidential resident and family interview, the family member stated the resident has problems with clothing coming back from the laundry. The family member stated all of the residents clothing was marked with their name, so it was unknown what the problem was. The family member stated staff members have been asked about the missing laundry, but nothing gets done. <BR/>During a confidential interview with a resident, it was stated that the resident had several missing clothing items and it had never been returned or found. The resident stated that when asked the nursing staff about the missing clothing that nothing gets done. The resident stated that no one from laundry brings the clothing around to the residents to locate missing clothing. The resident stated that their means of income was limited and the resident does not have the money to keep buying clothing. The resident stated that they would just like to have their clothing back. The resident stated that they do not feel that they have a choice if they are able to keep their clothing here or not because if it was sent to laundry that there was a big chance that it won't make it back. <BR/>During an observation of the laundry during survey process on 07/10/24 at 3:15 PM, it was determined that a plan for missing or lost laundry had not been acquired. There was a big bin in a room in the laundry sitting in the corner that had been piled up with clothes and the top was covered. <BR/>During an interview on 07/10/2024 at 5:15 PM, the ADM stated the laundry staff and housekeeping were responsible for ensuring the missing laundry or unmarked laundry gets back to the residents. The ADM stated the facility has a heat label maker for clothing and the residents should have their clothing marked with the heat label maker. The ADM stated the facility replaced any missing laundry but she was unaware of any laundry needing to be replaced recently. The ADM stated she did not know why the missing laundry bin became so large. The ADM stated a potential negative outcome to the residents was they would not have clothes to wear. <BR/>During an observation on 07/11/2024 at 1:44 PM. Observed a big bin in a separate area of the laundry room, parked in a corner with a covering over the top. The bin was filled with clothes that were lost or missing. Could not observed what kind of clothing was in the bin or how many. It was not open for residents to be able to easily view or look through.<BR/>During an interview on 07/11/2024 at 1:50 pm, the Laundry Staff Member stated that for missing clothing items that were missing labels they would put it in the bin until the residents came to get the item. She stated that the pile of clothes has been there for a long time but was unsure of how long exactly. She stated that they do not take the clothing around to the residents because they do not have time to do that. She stated that they have not always been able to locate the missing items. She stated that she was unsure of what the staff do if they can not locate the items in the missing clothing bin. She stated that sometimes the residents will get really mad if they were unable to locate their clothing. She stated that usually they would tell the nurse and then the nurse would go to the laundry and attempt to locate them. She stated that there was a possibility that if the nurse gets busy that she may forget to look for the items. <BR/>During an interview on 7/11/2024 at 2:28 pm, the Laundry Manager stated that the lost or missing clothing items program had not been effective when the washers broke and there were no labels on the clothing to be able to locate the owners. She stated that they had to just put it in the bin. She stated that if she had to say how many clothes were in the bin it would be approximately a few months' worth. She stated that they do have a place for lost or missing clothing by putting them in the big bin in the laundry room. She stated that they were waiting for the activity director to get back next week to be able to take the clothing into the dining room and lay it all out on the tables. She stated that the Administrator will usually ask the CNA's and nurses if anyone had reported missing clothing items and then the laundry staff will look through the items to see if they can locate something that matches that description. She stated that sometimes the residents will come to them and ask about the missing clothing. She stated that sometimes they were able to locate the missing item and sometimes they were not. She stated that they do not have a schedule to where they take the clothes around to the residents. She stated they can't take the clothes around to the residents because there were too many clothes to do that. She stated that when the resident's come to look for their missing clothing she needed a description of the color of the item and the size. She stated that if they did not know the size then she would have to look at the size of the person and just guess the size. She stated that if they could not locate the missing clothing that was in the bin then they would start to donate the clothing to the residents that do not have anything. She stated that the residents have an opportunity to realize if they were missing clothing and can ask about them. She stated that for the resident's that were unable to talk they could notify the nursing staff with the communication style that they used, report it to them, and the nursing staff would come to report it to the laundry staff. <BR/>During an interview on 07/11/2024 at 2:54 pm, the Account Manager stated that the facility does have a plan for the lost or missing plan. She stated that they did not have an effective plan before because the washer had broken, a staff shortage, the laundry just kept piling up and there were no labels on the clothes. She stated that the clothes that did not have a label were put into the lost or missing bin. She stated that the amount of clothing that was lost or missing had accumulated over the span of a few months, and it quickly became an overwhelming. She stated that there was no attempt to relocate the clothing because it quickly became overwhelming amount of clothing. She stated that they had come up with a plan as of last Monday (07/08/2024). She stated that the plan would start on Wednesday 07/17/2024, but if there were too many activities then it will have to wait until the next weekend. She stated that she had talked to the Administrator last week and the new plan would be to empty the large bin of missing or lost clothing out on the dining room tables in the dining room and let the residents come into the dining room and claim the clothing. If there were clothes that were unclaimed they would donate those clothes to the residents who do not have much or anything at all. She stated that they will start doing this plan once a week until all of the clothes were either located or donated. She stated that she believed the problem for not having an effective plan was a shortage in staff. She stated that when a resident came to look for their missing clothing, she would have to immediately look for it because her memory was not as good as it used to be and if she doesn't immediately do it then she will forget. She stated that they will work hard from now on to locate the missing laundry because she knew two residents on hall 600 that won't even leave their room if they do not have pants on. She stated that they did not attempt to locate the missing clothing due to a staff shortage. She stated that the negative potential outcome of residents clothing missing or lost was that they will begin to lose trust in the facility and begin to think that the facility is not capable of handling their items. She stated that it definitely impacted the resident's dignity when their clothes were missing or lost and could impact their dignity. <BR/>During an interview on 07/11/2024 at 3:09 PM, the Corporate District Manager stated that they did not have an effective plan for the laundry at the time but have since come up with a plan. She stated that she had just got to this facility just a few months ago. She stated that last Monday they pulled every piece of lost clothing out of the laundry room in the big missing bin and went through it. She stated that this past Monday all the clothes were pulled out to check for names so they could attempt to identify and they were just put back into the bins because of no names. She stated that the plan was this Wednesday (07/17/2024), all the missing clothes from the missing bin, would be put on racks in the dining room. She stated that the activity director would help a section of residents at a time to look through the clothing to see if they recognized anything as their clothing. She stated that if all the clothing is not located at that point, then the facility would take around to all residents to see if then they may recognize something as theirs. She stated that for residents that can not come out of their room, they would take the racks around to them. She stated that for the residents that can not communicate they would call the family members to see if the family can come up and go through the clothing to see if they might recognize something that belonged to their loved one. She stated that there should have been a better plan in place for missing or lost clothing. She stated that this would change as of now. She stated that the negative potential outcome was that it may make the residents unhappy and feel upset. She stated that hopefully with this plan they would have a better outcome and get issues resolved.<BR/>Record review of the facility policy title, Laundry Operations, revised 09/2017 reflected the following:<BR/> .In long-term care, no area of laundry management is more critical to patient care and dignity issues than they are of resident clothing. Residents, residents' families, admissions, social services, administration, and, of course, nursing are all involved with laundry in creating policies for getting resident clothing collected, washed, dried, and returned to residents on a timely basis .<BR/>If clothing is unmarked, do not let it accumulate in the laundry. All missing clothing grievances must be researched, answered, and clothing returned (either found or replaced) within 24-48 hours. Laundry employees must bring any unmarked clothing for the day up to the units for identification by the CNAs who are more familiar with the residents and their belongings. Once the owner of unmarked clothing is identified, label the garment immediately

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of thirty-two residents (Resident #109) reviewed for quality of care.<BR/>The facility failed to follow physician ordered skin treatments for edema to Resident #109's legs on 07/10/24.<BR/>These failures could place residents at risk for complications including skin break down, infection, or decreased physical and mental functioning. <BR/>Record review of Resident #109's undated face sheet reflected Resident #109 was an [AGE] year-old male whose admission date to the facility was on 1/18/24. Resident #109 had the following diagnoses: chronic obstructive pulmonary disease (airflow blockage and breathing-related problems), type 2 diabetes mellitus with unspecified complications (inability for the body to use insulin properly), chronic kidney disease stage 3B (moderate to severe loss of kidney function), essential primary hypertension (high blood pressure), chronic pain syndrome (symptoms beyond pain alone that interferes with daily life), hypothyroidism (underactive thyroid), mood disorder (mental health condition), anxiety disorder (mental health condition), and hyperlipidemia (excess of fat in the blood).<BR/>Record review of Resident #109's clinical record reflected his comprehensive MDS assessment was completed on 2/1/2024 listing him with a BIMS score of 13, which indicated he was cognitively intact. <BR/>Record Review of Resident #109's Care Plan, dated 1/18/24, revealed Resident #109 had an actual or would've been at risk for skin impairment: Pitting and weeping edema. Interventions were to apply treatment as ordered. <BR/>Record review of Resident #109's physician active orders dated 7/10/24 revealed an order dated 7/05/24 to cleanse bilateral lower extremities with normal saline/wound cleanser, or soap and water, pat dry. Apply moisturizing lotion to bilateral lower extremities and wrap with Kerlix (dressing for wounds to secure and prevent movement of primary dressing) daily from 0700 to 1900 one time a day for edema. <BR/>Record review of Resident #109's licensed nurse medication administration record (LNAR) dated 7/1/24 - 7/31/24 revealed to cleanse bilateral lower extremities with normal saline/wound cleanser, or soap and water, pat dry. Apply moisturizing lotion to bilateral lower extremities and wrap with Kerlix (dressing for wounds to secure and prevent movement of primary dressing) daily from 0700 to 1900 one time a day for edema, with a start date of 7/06/24 at 0700. Furthermore, on this order revealed documentation on 07/10/24 by LVN B that the ordered skin treatment task was completed.<BR/>During observation and interview on 7/9/24 at 3:34 PM, Resident #109 stated he arrived at the facility on 1/18/24 and had issues with his legs prior to entering the facility. He stated the facility was not consistent with the skin treatments on his legs which caused discomfort and itching. He stated they were supposed be wrapped from 7:00 AM to 7:00 PM, however they were not being done on time and sometimes staff came to wrap them several hours late. He stated he had received medication for pain as needed. He stated he was frustrated with these inconsistencies and felt this caused the condition of his legs not to improve. Resident #109's shin and ankle areas of both legs were observed to be wrapped with Kerlix wrap. <BR/>During observation and interview on 7/10/24 at 9:37 AM, Resident #109 stated staff had not done the skin treatment on his legs today. He stated his legs were itching. There was no wrap observed on Resident #109's shin and ankle areas of both legs.<BR/>During observation and interview on 7/10/24 at 2:27 PM, Resident #109 stated staff had not done the skin treatment on his legs today. He stated his legs were itching. There was no wrap observed on Resident #109's shin and ankle areas of both legs.<BR/>During observation and interview on 7/10/24 at 5:23 PM, Resident #109 stated staff had not done the skin treatment on his legs today. He stated his legs were itching. There was no wrap observed on Resident #109's shin and ankle areas of both legs.<BR/>During an interview on 7/10/24 at 5:24 PM, a Family Member stated she asked a staff that was passing out medications on the hall this morning around 10:10 AM if she was going to complete the skin treatment on Resident #109's legs and that staff member told her that was not her responsibility and was the responsibility of the TN. The Family Member stated she did not approach any other staff about it. The Family Member stated the facility had not been consistent with the skin treatment on Resident #109's legs since he admitted in January 2024. <BR/>During an interview on 7/10/24 at 5:34 PM, LVN B stated she was the charge nurse for Resident #109's hall. She stated there were orders for Resident #109 to self-administer Salvaderm Cream (skin moisturizer) on his legs as well as Triamcinolone Cream (steroid cream) as needed. She stated Resident #109 was prescribed Gabapentin for nerve pain in his legs. She stated there were physician orders for staff to clean, apply lotion, and wrap Resident #109's legs daily at 7:00 AM and remove at 7:00 PM. She stated the TN was responsible for completing the skin treatment orders. She stated she believed the skin treatment on Resident #109's legs were completed today. She stated she did not know where the notes of the completion of the treatment was documented in the EHR.<BR/>During an interview on 7/10/24 at 5:48 PM, the ADNS stated Resident #109 had physician orders for skin treatment on his legs. The ADNS stated the TN was responsible to complete those orders and she believed the skin treatment was completed today. She was trying to confirm with the TN but had not been able to get ahold of her. She stated the orders indicated the skin treatment was to be done at 7:00 AM and then the Kerlix wrap was to be removed at 7:00 PM daily. She stated Resident #109 had complained about the timing that staff had gone to wrap his legs. She explained to him that the time the TN could complete the skin treatment may fluctuate due to the demand of other residents in the facility. She stated Resident #109 was very particular and had refused medications and care in the past if they were not done exactly at the time listed on the order, which could be why he reported the skin treatment was not being done consistently. She stated Resident #109 was particular about staff that provided care to him. She stated she was not sure where the skin treatment task was documented in the EHR and would provide that information after she had spoken to the TN. She stated staff were supposed to document any refusal of care in the EHR and reported it to the NP and to hospice. She stated she had received training on the following physician orders and that the facility provided in-services to all staff. She stated the ADNS's as a team were responsible for ensuring staff followed physician orders. <BR/>During observation and interview on 7/10/24 at 6:00 PM, the ADNS asked Resident #109 if the skin treatment was completed on his legs today. Resident #109 replied that it was not and that his legs were itchy. The ADNS asked Resident #109 to raise his pant legs which he complied. There was no wrap observed on Resident #109's shin and ankle areas of both legs. The ADNS stated since there was no wrapping observed on Resident #109's legs, this meant the skin treatment was not completed today. She stated she would follow up with the TN to determine why it was not done but did not have an answer for why it was not done.<BR/>During observation and interview on 7/11/24 at 1:19 PM, Resident #109 stated staff completed skin treatment on his legs this morning around 7:00 AM. He stated staff never completed the skin treatment yesterday. Resident #109's shin areas of both legs were observed to be wrapped with Kerlix wrap. He stated he understood that staff cannot always come exactly at 7:00 AM to provide the skin treatment and had never refused the skin treatment when they come at a reasonable time. He stated he felt it was pointless for them to do it late in the afternoon when the orders say the wrap must be removed by 7:00 PM every evening.<BR/>During observation and interview on 7/11/24 at 1:34 PM, the TN stated she had not administered any physician ordered skin treatments to Resident #109's legs yesterday or today. She stated she was trained that her duties as the TN were to complete the orders listed on the TAR. She stated Resident #109's orders were listed on the LNAR, which were the responsibility for the charge nurses on duty to complete. The TN pulled up the LNAR on her screen which showed that Resident #109's skin treatments were listed on the LNAR. She stated LVN B approached her this morning and told her she completed the skin treatment orders on Resident #109 for her this morning, in which she responded to her that those orders were supposed to be completed by the charge nurse since they were on the LNAR. <BR/>During an interview on 7/11/24 at 2:45 PM, LVN B stated she was the charge nurse for halls 400 and 500 and worked from 6:00 AM to 6:00 PM. She stated she began working at the facility about a month and a half ago. She stated she was not sure who was responsible to complete the skin treatment on Resident #109's legs but she did not think it was her responsibility. She stated she thought it was the TN's responsibility, due to hospice ordering it. She stated charge nurses were responsible to complete physician orders listed on the LNAR and TN's completed orders listed on the TAR. She stated on the LNAR the task would turn green on the screen when the task was completed and would turn red if the task did not get completed. She observed the LNAR and verified that her initials were on the LNAR on 7/10/24, which indicated that she completed the skin treatment task for Resident #109. She stated she had not completed that task. She stated she did not know why it was not done yesterday. She stated she knew the skin treatment was supposed to be done daily for Resident #109. She stated the TN would not have done it because the task was on the LNAR because charge nurses were responsible for completing the tasks on the LNAR. She stated she checks the LNAR daily because she knew the tasks on it were her responsibility as the charge nurse. She stated she had received training that she must follow physician orders. She stated she was trained on her 2nd day of working at the facility. She stated she did not think pre-charting was best nurse practice. She stated she was trained that items on the LNAR were her duties. She stated a potential negative outcome of Resident #109 not receiving his skin treatment was that he could develop cellulitis due to scratching the itch which could cause a progression of the disease and more health complications. She stated a potential negative outcome of not documenting accurately was that the staff may not remember to go back and change the task if it was not done or of the resident refused it. She stated another negative outcome was that the staff may not remember what exactly happened in that situation.<BR/>During an interview on 7/11/24 at 3:20 PM, the ADNS stated there were physician orders to wrap Resident #109's legs daily. She stated usually the TN did them, but the regular TN was out this week, so they had another one filling in. That was why it was not done yesterday. She stated the skin treatment was moved to the LNAR for the charge nurse to do it because of the amount of time it took to complete the task. She stated it was a failure on her part because the TN told her she was going to put it on the LNAR, and she forgot to relay the information to the charge nurse. She stated charge nurses were trained that they were responsible to complete tasks on the LNAR, but she also should have told her. She stated she was able to confirm the skin treatment for Resident #109 was not completed yesterday because she observed that his legs were not wrapped, and she asked him, and he said they were not. She stated she was not aware Resident #109's skin treatment was not done yesterday prior to the state surveyor intervention. She stated staff were not trained to chart a task on the LNAR before the treatment had taken place and they should not have done that. She stated herself, the TN, and charge nurses train other staff. She stated she expected for staff to document tasks completed on the LNAR after the task had been completed. She stated the facility policy stated they must follow doctor orders. She stated they use the EHR as their system for tracking when tasks were due, completed, or not completed. She stated the screen would show the item as yellow for tasks that were scheduled to be done. She stated the screen would show green when completed and red when it was not completed and past due. She stated a potential negative outcome was that the resident's EHR would be inaccurate because you don't know what the outcome would be, the order could get missed, and the resident would not get the care they were supposed to get. This could prevent wounds from healing and cause them to worsen. <BR/>During an interview on 7/11/24 at 4:28 PM the DON stated she expected staff to follow physician orders. She stated herself, administrative nurses, and charge nurses were responsible for ensuring physician orders were followed. She stated charge nurses were trained that they were responsible for completing tasks on the LNAR. She stated staff should not chart (document) they completed a task in the EHR task before it was completed, it should be charted afterwards. She stated the TN was responsible for tasks on the TAR not the LNAR. She stated staff were provided this training during orientation and as needed. She stated staff were provided this training when they were getting trained on the floor by other nurses, herself, and the pharmacy nurse. She stated she was not aware staff were not following physician orders and that they were pre-charting. She stated Resident #109's skin treatment was put on the LNAR because he was particular on the times of when his care was done. She stated it was put on the LNAR for charge nurses to do so he would have it when he wanted. She stated Resident #109 gets irate when he did not get things when he wanted them done and he was very particular about his treatment. She stated a potential negative outcome was that it decreases the facility's credibility with the resident and that residents won't get the care they deserve.<BR/>During an interview on 7/11/24 at 4:28 PM the ADM stated she expected staff to follow physician orders. She stated she did not know exactly what the policy said for following physician orders. She stated a potential negative outcome was that residents may not get the services they need because they think the task was completed.<BR/>Record review of facility provided policy titled, Quality of Care dated February 2017, and revised January 2023 revealed: Compliance Guidelines: Quality of care is a fundamental principle that applies to all treatment and care provided to community residents. Based on the comprehensive assessment of a resident, the community will ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: <BR/>Skin integrity: Pressure ulcers. Based on the comprehensive assessment of a resident, the community will ensure that: A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, in that 1 of 29 residents (Resident #9) continued to receive psychotropic medications PRN for more than 14 days without a physician addressing the continued use of the medication:<BR/>- Resident #9 continued to have a PRN order for Lorazepam concentrate 2mg/ml after 14 days without an evaluation by the physician for continued treatment.<BR/>This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions. <BR/>The findings include:<BR/>Record review of Resident #9's face sheet, dated 05/17/23, revealed an [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include Parkinson's (a progressive nervous system disease), dementia (progressive loss of intellectual functioning), atrial fibrillation (irregular or rapid heartbeat that causes poor blood flow),major depressive disorder and Alzheimer's (progressive disease that destroys memory and other mental functions)<BR/>Record review of Resident #9's quarterly MDS, dated [DATE], revealed Section N - Medication Section N0410 - Medications Received: B - Antianxiety - Given 7 out of 7 days. <BR/>Record review of Resident #09's physician order summary dated 05/17/23 revealed an order start date 11/25/22 with an indefinite end date for Lorazepam Concentrate 2 MG/ML Give 0.5 ml by mouth every 2 hours as needed for Anxiety/Agitation <BR/>Record review of Resident #1's MAR for the past 90 days revealed Lorazepam 1mg give 1 tablet by mouth every 4 hrs. as needed for anxiety was administered on 04/24/23 <BR/>Record review of the pharmacy consultant book dated March 2023 revealed Resident #9 was receiving hospice, comfort, or palliative care services and had an active order for Lorazepam PRN. The Pharmacy Consultant Recommended the following on 03/02/23:<BR/>Even with hospice status, these orders would require 14 day stop date or indication of specific duration of therapy. There was no additional notes that indicate the response from the attending physician. <BR/>Record review of the pharmacy consultant book dated February 2023 revealed the Pharmacy Consultant Recommended the following on 02/02/23:<BR/>Even with hospice status, these orders would require 14 day stop date or indication of specific duration of therapy. There was no additional notes that indicate the response from the attending physician. <BR/>Record review of the pharmacy consultant book dated January 2023 revealed that Resident #9 was receiving hospice, comfort, or palliative care services and had an active order for Lorazepam PRN. The Pharmacy Consultant Recommended the following on 01/05/23:<BR/>Even with hospice status, these orders would require 14 day stop date or indication of specific duration of therapy. There was a handwritten note that indicated, recommendation declined per Attending Physician A and that the order would remain the same. No reason indicated as to why. <BR/>The Pharmacy Consultant had an order for Haldol (PRN w/o a stop date) and recommended that the medication be discontinued, or a stop date be added. The rationale for this recommendation indicated the following:<BR/> CMS requires that PRN orders for antipsychotic drugs be limited to 14 days. A new order should not be written without the prescriber directly examining the resident and assessing the residence condition and progress to determine if the PRN antipsychotic is still needed. Report of the residence condition from facility staff to the prescriber does not meet the criteria for an evaluation.<BR/>Record review of Resident #09's progress notes dated 05/10/23 at 12:06 PM, 6:07 PM; 05/03/23 at 11:52 AM, 11:32 AM; 05/01/23 11:06 AM, 3:06 PM; 03/25/23 8:21 AM; 11:22 AM revealed the following:<BR/>Note Text : LORazepam Concentrate 2 MG/ML<BR/>Give 1 ml by mouth every 2 hours as needed for Anxiety/Agitation PATIENT WILL REMAIN ON LORAZEPAM WHILE ON ACTIVE HOSPICE<BR/>CARE<BR/>PRN Administration was: Effective<BR/>Author: RN A, RN Nursing - Nursing [e-SIGNED]<BR/>Record review of Resident #09's progress notes revealed the following progress notes on dated 04/24/23 8:21 AM, 1:33 PM; revealed the following:<BR/>Note Text : LORazepam Concentrate 2 MG/ML<BR/>Give 0.75 ml by mouth every 2 hours as needed for Anxiety/Agitation PATIENT WILL REMAIN ON LORAZEPAM WHILE ON ACTIVE<BR/>HOSPICE CARE<BR/>PRN Administration was: Effective<BR/>Author: RN B, RN Nursing - Nursing [e-SIGNED]<BR/>An interview and observation was conducted on 05/19/23 at 11:06 AM, and the ADON said the nurses were responsible for documenting psychotropic medications. She said monitoring psychotropic medications was important because people could have side effects that come with taking psychotropic medications. She said it could create long-term neurological issues. She said she was not familiar with the PRN 14-day stop date rule. The ADON reviewed Resident #9's orders and acknowledged the order had no stop date and read indefinite. When asked what the purpose of the 14-day stop date was, she responded, I don't know the exact answer, but I can get the information She said she knew the DON had said 14 days and could not exceed that amount for psychotropic medications. She stated she was new to the facility. She said indefinite means anytime and forever. She said if the pharmacist or the doctor recommended that there should have been a stop date, then the facility should have taken that recommendation. <BR/>An interview was conducted on 05/19/23 at 11:55 AM, the Pharmacy nurse said the physician was responsible for ensuring the order was just for 14 days for PRN antipsychotics. The facility does not want them to be on the medications indefinitely. She said antipsychotics could have adverse side effects. She said she was unaware any residents were on PRN medications without a 14-day stop date. She said she had been trained on the expectation that PRN antipsychotics should have a 14-day stop date. She said the nurses at the facility were also aware that if they get an order, there should be a 14-day stop date. When asked specifically about Resident #9 being on hospice and the doctor not wanting to change it, she said he said hewould not change it because he was on hospice, and that was one of the hospice meds. The surveyor requested documentation supporting the doctor's refusal to add the 14-day stop date. No additional information provided.<BR/>An interview was conducted on 05/19/23 at 12:52 PM, the ADM said she was aware of 14 day stop date but was not aware that there were residents in the facility that was on PRN medications without a 14-day stop date. She said the DON and the nurse obtaining the order were responsible for ensuring that the PRN Antipsychotic had a 14-day stop date. She said she was unaware of any residents receiving PRN antipsychotics without the 14-day stop date. When asked about the potential negative outcome, she said those medications could have different side effects. She said she had been trained in general about PRN antipsychotic standards. She said her expectation was for there to be a 14-day stop date on all PRN antipsychotics. She said if the doctor chose not to change, she would call the medical director to see if he could prescribe something else or make it routine. <BR/>On 05/22/23 at 10:29 AM surveyor attempted to contact Attending Physician A he did not answer a message was left with the surveyor's contact information. <BR/>An interview was conducted on 05/22/23 at 10:36 AM, the Medical Director said it was important to have the 14-day stop date because research had shown that psychotropic medications contribute to increased death in elderly patients. He said he was unaware of any residents on PRN psychotropics without a 14-day stop date. He said even if the resident was a hospice resident and they had a PRN antipsychotic, they should have still had a 14-day stop date. He said hospice companies generally would not want to pay for anything outside of that. He said there would be no exception to the 14-day stop date for PRN antipsychotic medications.<BR/>On 05/23/23 at 11:04 AM surveyor attempted to contact Attending Physician A. He did not answer. A message was left with the surveyor's contact information. <BR/>An interview was conducted on 05/23/23 at 11:06 AM, the Pharmacy Consultant said he was familiar with PRN psychotropics having a 14-day stop date. He said this was important because there are a lot of times when residents do not need those medications after that time period and could experience side effects. He said if the resident does not have the 14-day stop date, then there should still be a stop date with specifications as to why they are exceeding the 14-day stop date. He said he was not at his computer at the time of the phone interview, so he could not speak specifically on the residents in question, but that he has brought to facility staff attention when he does catch PRN psychotropics without a 14-day stop date. He said when he had done this in the past, the staff addressed it immediately. <BR/>An interview was conducted on 05/23/23 at 02:48 PM, Attending Physician B was unaware any residents were on PRN medication with no 14-day stop date. She said if there were any, she did not order it. She said Resident #9 was on hospice, which would be a hospice issue. She said she provided basic needs but that she was not the person responsible for comfort medications. She said she was unsure of who his hospice doctor was. When asked if, in her experience, if there was an exception made for residents on hospice concerning PRN psychotropic medications, she said she was unsure, but she graduated in 1997. She said they do not receive updates, texts, or emails on any new regulations. She said she would think in a hospice situation that, they would not worry about the potential negative outcomes, such as addiction or abuse, because the resident was dying. She said she was not familiar with strict regulations for hospice patients.<BR/>An interview was conducted on 05/24/23 at 03:33 PM, and RN A said she was aware of the 14-day stop date for PRN psychotropic medications. She said the 14-day stop date was important because psychotropic medications' effects on the elderly could be detrimental. She said it was her understanding when a person was in hospice, this was not the case because the focus was keeping the resident comfortable. She said each time there was a progress note in the electronic medical record regarding the PRN Lorazepam, the PRN medication was administered. She said she has not spoken with the hospice doctor. When asked why medication administration was not on the MAR, she said it should have been. She said once the medication was checked on the MAR, which was what generated the progress note. She said she was unaware of why it would not appear on the MAR.<BR/>On 05/26/23 09:54 AM surveyor attempted to contact Attending Physician A. He did not answer. A message was left with the surveyor's contact information.<BR/>Record Review of the Pharmacy Consultant book included the following document: Quality improvement: Consultant Pharmacist Summary dated 03/01/23-03/31/23 signed by the Pharmacy Consultant on 03/22/23 revealed the following:<BR/>Psychotropic Drugs<BR/>(d) documentation is appropriate for PRN non-antipsychotic psychotropic drug used greater than 14 days: No irregularities observed.<BR/>(e) PRN antipsychotic drug use does not continue beyond 14 days without prescriber assessment and new order: No irregularities observed.<BR/>Record Review of the Pharmacy Consultant book included the following document: Quality improvement: Consultant Pharmacist Summary dated 02/01/23-02/28/23 signed by the Pharmacy Consultant on 02/26/23 revealed the following:<BR/>Psychotropic Drugs<BR/>(d) documentation is appropriate for PRN non-antipsychotic psychotropic drug used greater than 14 days: No irregularities observed.<BR/>(e) PRN antipsychotic drug use does not continue beyond 14 days without prescriber assessment and new order: No irregularities observed.<BR/>Record Review of the Texas Health and Human Services document titled Quality Monitoring Program Limiting the use of PRN Psychotropic Medications dated June 2018 revealed the following:<BR/>PRN use of psychotropic is limited to 14 days. The psychotropic orders may be extended beyond 14 days if the prescribing practitioner: believes it is appropriate to extend the order, and provides a specific duration of use (this could be indicated by a stop date listed on the MAR), and documents clinical rationale for the extension.<BR/>There are no exclusions for PRN psychotropic orders once the resident is admitted to a nursing facility.<BR/>Inform all prescribing practitioners including Hospice care agencies that new orders for PRN and psychotropic medications must comply with CMS requirements.<BR/>Record Review of facility policy, Psychotropic Medications & Gradual Dose Reduction revised January 2023<BR/> STANDARDS <BR/>The community is expected to make every effort to comply with state and federal regulations related to the use of psychotropic medications in the community to include diagnosis, targeted behavior or clinical indications for use, prescriber's specified dosage frequency and duration of therapy, consent must be received and noted in the medical record for any use of psychotropic medications. Additionally, the prescriber must provide specific rational for use, clinical indications for use, risks and/or benefits of therapy and informed consent as per defined content in the Texas 3713 form for all antipsychotic or neuroleptic drug therapy. <BR/>o <BR/>o The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. <BR/>PHARMACIST and/or CONSULTING PHARMACIST <BR/>1. Monitors psychotropic drug use in the community to ensure that medications are not used in excessive doses or for excessive duration. <BR/>2. Notifies the physician and the nursing management team if whenever a psychotropic medication is past due for review. <BR/>Record review of the facility's policy titled Pharmacy Services: Provision of Medications and Biologicals with a revised date of November 2023 revealed the following:<BR/>Compliance Guidelines<BR/>The community is responsible for the timely acquisition and administration of medications and biologicals. A drug, whether prescribed on a routine, emergency, or as-needed basis, must be provided in a timely manner.<BR/> Pharmacist service consultation <BR/> Pharmacist and consultant reports <BR/>The consultant pharmacist submits a monthly report to the director of nursing that identifies the existence of problems, issues, or irregularities with recordkeeping and the acquisition and dispensing of medications. <BR/>Within three (3) business days of conducting a drug regimen review, the pharmacist will provide a summary report to the attending physician and the community's director of nursing who (a) documents no irregularity was identified, or (b) reports any irregularities. The pharmacist and community agree on a procedure to apply when an attending physician does not respond to such report or fails to document the basis for his/her disagreement with such report.<BR/>The report also suggests changes to resident drug regimens and updates the community of the latest regulatory news (e.g., medications approved or not approved for certain diagnoses, restrictions, or warnings on use). <BR/>The director of nursing advises the attending physician of any suggested drug regime changes. <BR/>Neither the director of nursing nor the attending physician is required to agree with or implement the consultant pharmacist's recommendations. Unless state law requires an explanation of acceptance or rejection, neither the director of nursing nor physician is required to provide a rationale for not implementing the recommendations. <BR/>However, there will be documentation that the director of nursing and attending physician reviewed the report and acted.<BR/>Repeated or frequent rejections of the consultant pharmacist's recommendations indicate that there should be a review the community's drug management program.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure 1 of 1 resident (Resident #106) reviewed for medication administration were free of significant medication errors.<BR/>1. The facility failed to administer eye drops (Brimonidine Tartrate Ophthalmic Solution 0.2%) according to physician orders for Resident #106. <BR/>Findings included:<BR/>Resident #106:<BR/>Record Review of Resident #106 face sheet, date retrieved on 07/11/2024, revealed a [AGE] year-old male, admitted on [DATE] with diagnoses of: type 2 diabetes, absolute glaucoma bilateral, (is the final stage of glaucoma in which increased intraocular pressure results in permanent vision loss or blindness) hepatomegaly (enlarged liver), vitamin D deficiency, orthostatic hypotension (is a sudden drop in blood pressure), primary open-angle glaucoma (is a subset of the glaucoma's defined by an open, normal appearing anterior chamber angle and raised intraocular pressure), idiopathic peripheral autonomic neuropathy (damage to the peripheral nerves where cause cannot be determined), esophageal obstruction (narrowed or blocked and can result in damage to the esophagus), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), dysphagia (difficulty swallowing), presence of intraocular lens (the presence of a lens implant), cataract extractions status, right eye, and cataract extractions status, left eye.<BR/>Record Review of Resident 106's Care Plan dated 11/28/2023, revealed: <BR/>Resident #106 was at risk for vision loss/impairment: Blindness with interventions of: coordinate appointments and transportation to appointments as indicated, ensure glasses were clean and in good repair for use, medications as ordered, and refer to eye doctor as indicated. <BR/>Record Review of Resident 106's Care Plan no date provided revealed: Resident #106 has a self-care deficit due to diabetes, blindness. <BR/>Record Review of Resident 106's Care Plan dated 11/28/2023 revealed: Resident #106 was at risk for falls due to blindness, weakness. <BR/>Record Review of Resident 106's Care Plan dated 11/28/2023 revealed: Resident #106 was at risk for complications associated with diabetes: frequent infections, diabetic wounds, vision impairment, hyper/hypoglycemia, renal failure, and cognitive/physical impairment. <BR/>Record review of Resident #106's Physician Orders with active orders as of 04/25/2024 indicated that Resident #106 was given orders for Ophthalmology care PRN.<BR/>Record review of Resident #106's Physician orders, date retrieved 07/11/2024 revealed:<BR/>Brimonidine Tartrate Ophthalmic Solution 0.2%, dated 02/10/2024, Instill 1 drop in both eyes two times a day related to primary open angled glaucoma bilateral, severe stage, (Give eye drops at least 5 minutes apart), Start date: 02/10/2024).<BR/>Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 % (Dorzolamide HCl-Timolol Maleate), dated 02/10/2024, Instill 1 drop in both eyes two times a day related to PRIMARY OPEN-ANGLE GLAUCOMA, BILATERAL, SEVERE STAGE (H40.1133) (Give Eye Drops at least 5 Minutes apart) Orders showed to be active. <BR/>Latanoprost Solution 0.005 %, dated 01/25/2024, Instill 1 drop in both eyes at bedtime related to PRIMARY OPEN-ANGLE GLAUCOMA, BILATERAL, SEVERE STAGE (H40.1133) (Give Eye Drops at least 5 Minutes apart), Orders show on hold. <BR/>Record review of Resident #1's Medication Administration Record for 07/01/24 - 07/31/24 indicated on <BR/>07/07/2024, he was scheduled to receive Brimonidine Tartrate Ophthalmic Solution 0.2% for night shift and did not receive the medication. On 07/08/2024, he was scheduled to receive the medication for the day and night shift and was not given the medication. On 07/09/2024, was scheduled to receive the medication on both the day and night shift and had not received the medication. On 07/10/2024, he was scheduled to receive the medication on day and night shift and did not receive the medication for the day shift but did receive the medication on the night shift. <BR/>Record review of Resident #1's Medication Administration Record for 07/01/24 - 07/31/24 indicated on <BR/>07/08/2024, he was scheduled to receive Latanoprost Solution 0.005%, for night shift and was not administered. On 07/09/2024, he was scheduled to receive the eye drops for the night shift and it was not administered due to being on hold. <BR/>During an interview on 07/09/24 at 3:10 PM Resident #106 stated that he had not had 2 of the 3 eye drops in several days. Resident #106 stated that he had asked staff about not getting the eye drops and was told that he was out of them. He stated that when he asked when he would get some more the nursing staff would state that they were unsure. Resident #106 stated that if his eye pressures go up then he could go blind, and it could be irreversible. He stated that this was very stressful when they let the medication run out. This failure could cause the resident to go blind if his pressure's in his eye had gotten too high. <BR/>During an interview on 07/11/2024 at 2:50 PM the DON stated that all medications were expected to be given. She stated staff have been trained on medication administration by computer-based training and in-services, quarterly. She stated that the negative potential outcome of not administrating medication was missed medication. <BR/>During a record review the facility policy, labeled, Medication Errors, date not provided, date retrieved 07/11/2024, revealed: Medication Errors: The communities medication management system is designed and managed to ensure that the community is free of medication errors. The nursing team members will report drug errors and adverse drug reactions to the resident's physician in a timely manner, as warranted by an assessment of the resident's condition, and record them in the resident's record. An incident report must be completed. Medication errors include, but are not limited to administering the wrong medication, administering the wrong time, administering the wrong dosage strength, administering by the wrong route, omitting a medication, and/or administering to the wrong resident.

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored in locked under proper temperature controls and permit only authorized personnel to have access to the keys for 3 medication carts (Medication carts #1, #2 and #3) reviewed for medication storage.<BR/>1. The facility failed to ensure Medication carts #1, #2 and #3 were locked when unattended. <BR/>2. The facility failed to ensure Medications were secured in the medication cart when not in use. <BR/>These failures could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. <BR/>Findings include:<BR/>During an observation and interview on 6/7/23 at 10:26 a.m., in A Wing, revealed Medication Cart #1 with the key lock not pushed in, which indicated the cart was unlocked parked at the nurses station with the drawers facing outward towards the open area. RN A was observed sitting behind the nurses station with her head down documenting. The State Surveyor approached the medication cart, opened the top two right drawers, RN A did not stop or look up. The top right drawer contained several bottles of resident prescription bottles containing medications and the second top right drawer contained a locked box. RN A stated she was assigned to Medication Cart #1. RN A stated she was in visual of the medication cart and stated, I am confident I could see if someone was near the cart. RN A stated the cart should be locked but because she was behind the nurses station, she did not feel there was an issue. RN A stated she was unaware of the policy regarding medication cart security. RN A walked from inside the nurses station to the cart and pushed the key lock in. <BR/>During an observation on 6/7/23 at 10:26 a.m., several residents were observed in the dining room/activity room to the left of the nurses station, and 1 resident observed approaching the nurses station where the medication cart was parked. <BR/>During an interview on 6/7/23 at 10:54 a.m., the Pharmacy LVN stated if a nurse or medication aide walked away from the medication cart and the drawers were not in eyesight, the cart must be locked. The Pharmacy LVN stated RN A used to be the ADON on A Wing and was trained to lock the medication cart. The Pharmacy LVN stated if the cart was parked at the nurses station and not being used, it was to be turned with the drawers facing the nurses station as an extra way to keep the cart secured besides locking it. The Pharmacy LVN stated if RN A did not see the State Surveyor open the drawers, then RN A did not have a visual of the medication cart and it was not secured. The Pharmacy LVN stated the risk of not locking the medication cart was residents could go inside the cart and take something, if they ingested a medication, it could be fatal, and at least harmful to the resident. The Pharmacy LVN stated RN A was a nurse for several years and knew better than to keep the medication cart unlocked. The Pharmacy LVN stated nurses and medication aides were taught during orientation and during job training on the floor the importance of medication cart security. <BR/>During an interview on 6/7/23 at 11:02 a.m. with RN A, in Wing A with the Pharmacy LVN present, RN A stated she did not see the State Surveyor open the medication cart top two drawers when the medication cart was unlocked at the nurses station. RN A stated the top right drawer contained bottles of prescription resident medication and the second drawer contained the locked box. RN A stated, I guess I didn't have visual of it. RN A stated the medication cart should be locked at all times when not in use, so residents do not get into the medication. RN A was asked what the risk was of the medication cart being unlocked and RN A stated I don't know what you want me to say. How would I know if I didn't see what they took. The Pharmacy LVN stated, the risk could be harm or death, the resident could have an adverse reaction and we would not know what they took. <BR/>During an interview on 6/7/23 at 11:15 a.m. with the Pharmacy LVN stated RN A told her she left the medication cart unsecured. The Pharmacy LVN stated RN A knew better than to keep the medication cart unlocked and because she had been the ADON, there was no reason for her not to know that the cart needed to be secured. <BR/>During an interview on 6/7/23 at 1:40 p.m., RN B stated if RN A was behind the nurses station and could not see the drawers to the medication cart, then RN A did not have visual of the cart, and it was unsecured. RN B stated medication carts were supposed to be locked at all times when the drawers were not in visual. RN B stated the risk of the medication cart being unsecured was a resident could take medications, sharps, thermometers, or supplies that could cause harm. RN B stated if a resident took a medication, the resident could have interactions, allergic reactions and it could cause physical harm to the resident. RN B stated if a resident took sharps or supplies such as scissors, the resident could use those items to harm themselves. RN B stated RN A was an ADON in the facility until recently and had been trained to secure the medication cart at all times. RN B stated if a resident was in a wheelchair in front of the medication cart and RN A was behind the nurses station, there would have been no way she would have seen a resident open a drawer. <BR/>During on observation and interview on 6/7/23 at 1:55 p.m. in A Wing, Medication Aide C was observed standing on the outside of a partition wall assisting 2 unidentified residents with medications. Upon approach to the hallway on the left, 2 medication carts (#2 and #3) were observed unlocked on the opposite side of the partition wall and a resident walking towards the medication carts. Cart #2 was observed to have an unsecured partially filled medication card of Celecoxib 100mg left on top of the Cart #2. The MA was observed to come from behind the medication partition wall to where the Medication Carts were parked. MA stated she was assigned to both carts and left them unlocked because she was assisting a resident who she thought was sliding out of her wheelchair. MA C stated she also left the medication on top of Cart #1. MA C stated she should lock the carts when she was not using them, and she was trained to keep the medication carts locked. MA C stated after unlocking a medication cart, she was supposed to lock it back up and both carts should not be unlocked. MA C stated, I am sorry, I am human and make mistakes and then MA C started to walk away. The State Surveyor asked MA C if she was going to lock up the Celecoxib medication before leaving the area. MA C grabbed the medication card and locked it inside Cart #2. MA C stated Celecoxib was used for pain, but it was not a controlled substance. <BR/>During an interview on 6/7/23 at approximately 2:30 p.m., the Human Resources Director stated all staff were trained on medication cart security. The Human Resources Director stated she did the orientation with new staff and then when staff were put on the floor they were partnered with a nurse and taught medication security and to keep the medication carts locked at all times. The Human Resources Director stated RN A and the MA were trained on medication cart security and part of their job duties included dispensing and storing medications.<BR/>During an interview on 6/7/23 at 2:45 p.m., the Pharmacy LVN stated she was informed by the MA C that she left a medication on the cart and left both medication carts unlocked. The Pharmacy LVN stated the MA C told her she thought a resident was falling out of her wheelchair and went to assist the resident. The Pharmacy LVN stated both medication carts should not have been unlocked at the same time nor should medication have been left on top of the cart. The Pharmacy LVN stated having 2 different staff (RN A and MA C) in the same wing (A) leaving medication carts unsecured was a problem and would be addressed. <BR/>During an interview on 6/7/23 at 3:15 p.m., the ADM stated she was aware RN A and the MA C failed to secure the medication carts by keeping them locked. The ADM stated staff would be in-serviced on locking medication carts and the importance of medication cart security. The ADM stated staff knew medication carts should be locked at all times when not in use to prevent residents, staff, or visitors from taking medications that were not theirs. <BR/>Record review of the facility provided Charge Nurse job description, dated 7/1/2020, revealed the following: Results Statement: To contribute to the success of the community by providing quality nursing care to residents and to coordinate total nursing care for residents by implementing specific procedures/programs and being in compliance with all (insert facility name) policies and procedures, state regulations and federal regulations. <BR/>-Order, receive and store medications appropriately. <BR/>Record review of the facility provided Certified Medication Aide job description, dated 7/1/2020, revealed the following: Results statement: To support the community by ensuring residents are well cared for and receive accurate medications as ordered by the physician/physician extender in accordance with established nursing standards, standards of medication aide practices, state and federal requirements, and guidelines of the community related to medication administration. <BR/>Record review of the facility's policy titled Medication Cart Use and Storage, dated 3/15/2019, reflected the following: Compliance Guidelines: <BR/>Security: <BR/>-The medication cart and its storage bins are kept locked until the specified time of medication administration. <BR/>-If an emergency occurs during the medication pass, the nurse/mediation aide securely locks the medication cart before attending to the emergency situation.<BR/>-During routine administration of medications, the cart may be kept in the doorway of the resident's room with: Drawers unlocked and facing inward, and within sight of the nurse. No medications are kept on top of the cart . <BR/>Procedure: <BR/>-Lock the medication cart.

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal (lunch meal) reviewed for palatability, attractiveness, and appetizing. <BR/>The dietary staff failed to provide food that was palatable and at an appetizing temperature for the lunch meal observed on 02/26/2025. Resident's #1, #2, #3, and #4 complained the food was served cold.<BR/>These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and food borne illnesses. <BR/>The findings included: <BR/>During an interview on 02/26/2025 at 09:30 AM, an anonymous family member stated, during a visit on 1/31/2025, a resident's meal was served cold. The family member stated she was assisting the resident eat and touched the food and it was cold. The family member stated the resident ate in the dining room on this date with other residents. <BR/>During an interview on 02/26/2025 at 10:55 AM, Resident #1 stated his meals were served cold almost every day. The resident stated he ate in the dining room daily. The resident stated his meals were rarely ever hot or warm enough. <BR/>During an interview on 02/26/2025 at 11:13 AM, Resident #2 stated his meals were served cold often. The resident stated he ate in the dining room daily. The resident stated meal services rarely ever had hot or warm food. The resident stated his food did not taste good because it was not hot or warm enough. <BR/>During an interview on 02/26/2025 at 11:22 AM, Resident #3 stated his food was served cold almost every day. The resident stated he ate in his room daily. The resident stated this had been an ongoing issue and most meals had been served cold. The resident stated he rarely ever received warm or hot food during meal services. <BR/>During an interview on 02/26/2024 at 11:30 AM, the KM stated they planned to serve lunch around 11:40 AM. A test tray was requested after all residents were served. <BR/>During an interview on 02/26/2024 at 12:37 PM MA stated residents complained often about food being cold. The MA stated residents' meal trays were delivered to the nursing station by the kitchen staff and the nursing staff had to double check each tray. The MA stated the trays were usually handed out immediately. The MA stated nursing staff had to reheat food often for residents who stated their food was cold. <BR/>During an observation on 02/26/2024 at 1:14 PM, a test tray was provided by the KM. The test tray contained a regular diet plate that included a slice of meatloaf, a serving of scalloped potatoes, a serving of green peas, a dinner roll, and a dessert of apple cake. The test tray also included a puree diet plate that included meatloaf, potatoes, green peas, and bread. The meatloaf on the regular diet plate was cold. The potatoes on the regular diet plate were slightly warm. The peas on the regular diet plate were slightly warm. The meatloaf on the puree diet plate was slightly warm. The potatoes on the puree diet plate were cold on top and slightly warm on the bottom. After stirring the potatoes, the potatoes were less than slightly warm. The peas on the puree diet plate were warm. The regular diet and puree diet plates were served on insulated clam shells on the test tray. <BR/>During an interview on 02/26/2025 at 2:15 PM. Resident #4 stated his meatloaf was served cold on this date. The resident stated he ate in his room most days. The resident stated his meals were served cold on a lot of days. The resident stated he had to request staff to warm up his food on numerous occasions due to the food being served cold when he first received it. <BR/>During an interview on 02/26/2025 at 2:22 PM. Resident #3 stated his lunch was served cold on this date. The resident stated he ate in his room on this date. The resident stated he had meatloaf and potatoes on this date for lunch. <BR/>Record Review of the facility's document titled, Service Line Checklist dated 2/26/2025 revealed the following under Food Temperatures : Lunch: Meat Dish (regular)- 188 degrees with a marked-out temperature that is illegible; Meat Dish (puree)- 180 degrees; Vegetable (regular)- 190 degrees; and Vegetable (puree)- 182 degrees.<BR/>During an interview on 02/26/2024 at 2:40 PM the KM stated residents always complained that their food was cold, and that was nothing new. The KM stated if food was not hot enough for a resident, it was reheated. The KM stated she took temperatures of each food item before it was served to ensure it was at a proper temperature. The KM stated temperature log was showing lunch was served at proper temperatures. The KM stated she verified the temperatures were adequate. The KM stated this was logged each meal including at lunch time on this date. The KM stated she did not know why the test tray contained food that was only slightly warm and/or cold. The KM stated the test tray was served after the last tray was served to the residents. The KM stated residents' meal trays were served to their room first, and then the residents in the dining room were served. The KM stated residents' room meal trays were taken to residents on a cart. The KM stated this cart was not heated. The KM stated the meal trays were taken to nursing staff at each hall and the nursing staff distributed the food to residents after the meals were checked for accuracy. The KM stated she did not know how long it took for nursing staff to distribute residents' room trays. The KM stated it was her expectation the trays were served as soon as they were delivered. The KM stated room trays were served on insulated clam shell plates. The KM stated the plates were heated as well to keep food warm. The KM stated she did not know why the residents complained of cold food since kitchen staff ensured food was at an adequate temperature before it was sent out to residents. The KM stated residents' room trays were served from the kitchen, and residents who eat in the dining room were served from the steam table in the dining room. The KM stated she did not know why residents who ate in the dining room would complain that their food was cold. The KM stated the temperature taken on this date were from the kitchen, not the serving line. The KM stated it was her expectation that residents were served hot food. The KM stated it was the kitchen staff's responsibility to ensure food was served hot. The KM stated if food was not served at a safe temperature residents could get sick. <BR/>During an interview on 02/26/2024 at 3:00 PM CNA A stated residents complained often about food being cold and nursing staff would heat up the food for the resident.<BR/>During an interview on 02/26/2024 at 3:43 PM LVN A stated residents did complain about food being cold sometimes and nursing staff would heat up the food for the resident. LVN A stated the nursing staff checked each resident's tray before it was delivered to them to ensure they were getting an approved meal. LVN A stated this was usually done right away after the kitchen staff delivered the trays to the nursing station. <BR/>During an interview on 02/26/2024 at 4:00 PM the ADM stated the KM was responsible for ensuring food was served at a proper temperature. The ADM stated cooks were responsible for ensuring food met proper temperatures. The ADM stated the KM was responsible for the cooks. The ADM stated they used an induction system to ensure food was served at proper temperatures. The ADM stated this included clam warmers for plates and two insulated food carts. The ADM stated nursing staff were responsible for handing out food trays after they were checked for accuracy to ensure residents receive their ordered diet. The ADM stated it was her expectation that food trays were served as soon as they were delivered to each hallway. The ADM stated all dietary staff were trained regarding safe food temperatures upon hire and through regular in-serves provided by the KM. The ADM stated if food was served cold or slightly warm, food may not be palatable since some residents would want their food to be hot. The ADM stated there was a concern for residents' safety and possible illness if food was not served at safe temperatures.<BR/>During an interview on 02/26/2024 at 4:15 PM CNA B stated residents did sometimes complain about food being cold and nursing staff would request an alternative for the resident or warm the food up for them. <BR/>During an interview on 02/26/2024 at 4:18 PM the DON stated she had not received any complaints about food being served cold. The DON stated some residents did prefer their food to be warmer than it was served, and they would heat up residents' food when needed. The DON sated the KM was over all kitchen staff and was ultimately responsible for ensuring food was served at proper temperatures. The DON stated residents' room trays were served on insulated shells. The DON stated when room trays were brought to the nursing staff to distribute, nursing staff were also responsible for ensuring food was not cold. The DON stated it was her expectation that food trays were served as soon as they were delivered to nursing staff. The DON stated if nursing staff were not available when meal trays were delivered to the nursing stations, the unit manager or the DON would also help distribute trays after they verified the meals were adequate for each resident's meal order. The DON stated all food should have been served at safe temperatures, and if food was cold a new tray should have been requested for the resident. The DON stated if food was not served at safe temperatures the resident could have been at risk of food borne illness or food may have not been pleasurable to the resident if it was not served warm enough. <BR/>Record Review of the facility's policy titled, Food: Quality and Palatability dated 5/2014 and last revised on 02/2023 revealed the following:<BR/>Policy Statement:<BR/>Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs.<BR/>Definitions<BR/>Proper (safe and appetizing) temperature Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns.<BR/>Procedures<BR/>2. The Cook(s) prepare food in a sanitary manner utilizing the principles of Hazard Analysis Critical Control Point (HACCP) and time and temperature guidelines as outlined in the Federal Food Code.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, maintained medical records on each resident that were complete and accurately documented for one (Resident #109) of thirty-two residents reviewed. <BR/>The facility failed to ensure the LNAR was accurately documented for physician ordered skin treatments that were not provided.<BR/>This failure could place residents at risk for complications including skin break down, infection, or decreased physical and mental functioning. <BR/>Record review of Resident #109's undated face sheet reflected Resident #109 was an [AGE] year-old male whose admission date to the facility was on 1/18/24. Resident #109 had the following diagnoses: chronic obstructive pulmonary disease (airflow blockage and breathing-related problems), type 2 diabetes mellitus with unspecified complications (inability for the body to use insulin properly), chronic kidney disease stage 3B (moderate to severe loss of kidney function), essential primary hypertension (high blood pressure), chronic pain syndrome (symptoms beyond pain alone that interferes with daily life), hypothyroidism (underactive thyroid), mood disorder (mental health condition), anxiety disorder (mental health condition), and hyperlipidemia (excess of fat in the blood).<BR/>Record review of Resident #109's clinical record reflected his comprehensive MDS assessment was completed on 2/1/2024 listing him with a BIMS score of 13, which indicated he was cognitively intact. <BR/>Record Review of Resident #109's Care Plan, dated 1/18/24, revealed Resident #109 had an actual or would've been at risk for skin impairment: Pitting and weeping edema. Interventions were to apply treatment as ordered. <BR/>Record review of Resident #109's physician active orders dated 7/10/24 revealed an order dated 7/05/24 to cleanse bilateral lower extremities with normal saline/wound cleanser, or soap and water, pat dry. Apply moisturizing lotion to bilateral lower extremities and wrap with Kerlix (dressing for wounds to secure and prevent movement of primary dressing) daily from 0700 to 1900 one time a day for edema. <BR/>Record review of Resident #109's licensed nurse medication administration record (LNAR) dated 7/1/24 - 7/31/24 revealed to cleanse bilateral lower extremities with normal saline/wound cleanser, or soap and water, pat dry. Apply moisturizing lotion to bilateral lower extremities and wrap with Kerlix (dressing for wounds to secure and prevent movement of primary dressing) daily from 0700 to 1900 one time a day for edema, with a start date of 7/06/24 at 0700. Furthermore, on this order revealed documentation on 07/10/24 by LVN B that the ordered skin treatment task was completed.<BR/>During observation and interview on 7/9/24 at 3:34 PM, Resident #109 stated he arrived at the facility on 1/18/24 and had issues with his legs prior to entering the facility. He stated the facility was not consistent with the skin treatments on his legs which caused discomfort and itching. He stated he was frustrated with these inconsistencies and felt this caused the condition of his legs not to improve. <BR/>During an interview on 7/10/24 at 5:34 PM, LVN B stated she was the charge nurse for Resident #109's hall. She stated there were physician orders for staff to clean, apply lotion, and wrap Resident #109's legs daily at 7:00 AM and remove at 7:00 PM. She stated she believed the skin treatment on Resident #109's legs were completed today. She stated she did not know where the notes of the completion of the treatment was documented in the EHR.<BR/>During an interview on 7/10/24 at 5:48 PM, the ADNS stated the TN was responsible to complete those orders and she believed the skin treatment was completed today. She stated she was not sure where the skin treatment task was documented in the EHR and would provide that information after she had spoken to the TN. She stated staff were supposed to document any refusal of care in the EHR, report it to the NP, and to hospice. <BR/>During observation and interview on 7/11/24 at 1:19 PM, Resident #109 stated staff never completed the skin treatment yesterday. <BR/>During observation and interview on 7/11/24 at 1:34 PM, the TN stated she was trained that her duties as the TN were to complete the orders listed on the TAR. She stated Resident #109's orders were listed on the LNAR, which were the responsibility for the charge nurses on duty to complete. <BR/>During an interview on 7/11/24 at 2:45 PM, LVN B stated she was the charge nurse for halls 400 and 500 and worked from 6:00 AM to 6:00 PM. She stated charge nurses were responsible to complete physician orders listed on the LNAR and TN's completed orders listed on the TAR. She stated on the LNAR the task would turn green on the screen when the task was completed and would turn red if the task did not get completed. She observed the LNAR and verified that her initials were on the LNAR on 7/10/24, which indicated that she completed the skin treatment task for Resident #109. She stated she had not completed that task but did not know how her initials showed that she had completed it. She stated she had not recalled documenting that, but she could have accidentally marked it as completed when she was checking other boxes of other tasks, she had done that day. She stated she must use her login credentials in order to login to the EHR and document her initials. She stated she had received training on how to chart (document) in the EHR where the LNAR. She stated she was trained on her 2nd day of working at the facility. She stated she did not think pre-charting was best nurse practice. She stated she was trained that items on the LNAR were her duties. She stated a potential negative outcome of pre-charting or not documenting accurately was that the staff may not remember to go back and change the task if it was not done or if the resident refused it. She stated another negative outcome was that the staff may not remember what exactly happened in that situation.<BR/>During an interview on 7/11/24 at 3:20 PM, the ADNS stated there were physician orders to wrap Resident #109's legs daily. She stated charge nurses were trained that they were responsible to complete tasks on the LNAR. She stated she was able to confirm the skin treatment for Resident #109 was not completed yesterday because she observed that his legs were not wrapped, and she asked him, and he said they were not. She stated staff were not trained to chart a task on the LNAR before the treatment had taken place and they should not have done that. She stated herself, the TN, and charge nurses train other staff. She stated she expected for staff to document tasks completed on the LNAR after the task had been completed. She stated they use the EHR as their system for tracking when tasks were due, completed, or not completed. She stated the screen would show the item as yellow for tasks that were scheduled to be done. She stated the screen would show green when completed and red when it was not completed and past due. She stated a potential negative outcome was that the resident's EHR would be inaccurate because you don't know what the outcome would be, the order could get missed, and the resident would not get the care they were supposed to get. This could prevent wounds from healing and cause them to worsen. She stated she observed LVN B's initials were documented on the LNAR for Resident #109's skin treatment task on 7/10/24, which indicated the skin treatment was completed by LVN B.<BR/>During an interview on 7/11/24 at 4:28 PM the DON stated charge nurses were trained that they were responsible for completing tasks on the LNAR. She stated staff should not chart (document) they completed a task in the EHR task before it was completed, it should be charted afterwards. She stated staff were provided this training during orientation and as needed. She stated staff were provided this training when they were getting trained on the floor by other nurses, herself, and the pharmacy nurse. She stated she was not aware staff were pre-charting. She stated tasks initialed on the LNAR indicated that the task was done. She stated a potential negative outcome was that it decreases the facility's credibility with the resident and that residents won't get the care they deserve.<BR/>During an interview on 7/11/24 at 4:28 PM the ADM stated she did not know exactly what the policy said for accurate documentation. She stated a potential negative outcome was that residents may not get the services they need because they think the task was completed.<BR/>Record review of facility provided policy titled, Quality of Care dated February 2017, and revised January 2023 revealed: Compliance Guidelines: Quality of care is a fundamental principle that applies to all treatment and care provided to community residents. Based on the comprehensive assessment of a resident, the community will ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: <BR/>Skin integrity: Pressure ulcers. Based on the comprehensive assessment of a resident, the community will ensure that: A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.<BR/>During an email on 7/23/2024 at 3:07 PM the ADM stated facility did not have a policy regarding documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3( #52, #78, and #79) out of 31 residents. <BR/>1. <BR/> RN B failed to perform hand hygiene prior to gathering wound care supplies. <BR/>2. <BR/> Wound care nurse RN B failed to perform hand hygiene during wound care. <BR/>3. <BR/> LVN A failed to clean the medication cart, nurses' station, or the bottom of the caddy to prevent the possibility of infection from spreading.<BR/>These failures could result in the spread of infections to the residents in the facility. <BR/>The findings included:<BR/>Record review of Resident #79's face sheet revealed a [AGE] year-old male resident with an admission date of 05/24/2016 and a readmission date 01/10/2022 with the following diagnosis: high blood pressure, vitamin D deficiency, frequent heartburn, type 2 diabetes with high blood sugar, dementia, too many lipids (fats) in the blood, anxiety disorder, Diverticulitis (inflammation or infection in one or more small ouches in the digestive tract), Mononeuropathy (damage to a nerve outside the brain and spinal cord), vitamin B12 deficiency anemia, difficulty walking, muscle weakness, major depressive disorder, post-traumatic stress disorder, Alzheimer's disease, history of thrombosis (blood clot) . <BR/>Record review of Resident #79's quarterly MDS dated [DATE] revealed Resident #79's BIMS (Brief Interview for Mental Status) of 06, which indicated very severe impairment.<BR/>Record review of Resident #52 face sheet revealed a [AGE] year old male resident with an admission date of 08/19/2020 with the following diagnosis: benign prostatic hyperplasia (age-related prostate gland enlargement that can cause urination difficulty), hyperlipidemia (too many lipids (fats) in the blood), neuromuscular dysfunction of bladder (lacks bladder control due to brain or spinal nerve problems), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath).<BR/>Record review of Resident #52's annual MDS dated [DATE] under section C revealed Resident #52's BIMS (Brief Interview for Mental Status) of 9, which indicated the resident was moderately impaired. Resident #52 was at risk for pressure ulcers and developing pressure ulcers and it indicated that the resident does have a stage 2 pressure ulcer. The MDS indicated that pressure ulcer/injury care of application of non-surgical dressings and application of ointments/medications. <BR/>Record review of Resident #52's physician orders dated 03/23/2022 and start date of 03/23/2022 indicated: Stage II PI to Coccyx; Cleans with NS or wound cleanser, pat dry, collagen and foam dressing and prn until healed as needed for Wound Healing. <BR/>Record review of Resident #52's care plan indicated in part: (1.) My skin is fragile, and I am at risk for skin injury--new or worsening skin condition. Stage II Coccyx. Date Initiated: 02/02/2022 . I will have intact skin, free of redness, blisters, or discoloration by/through review date . Date Initiated: 08/20/2020. Keep clean & dry and apply skin barrier cream as indicated.<BR/>Record review of Resident #78's face sheet revealed a [AGE] year old male resident with an admission date of 05/23/2017 and a previous admission date of 07/23/2015 with the following diagnosis: non-Hodgkin lymphoma lymph nodes of multiple sites (cancer that starts in the lymphatic system), congestive heart failure, hypertension (high blood pressure), alcohol dependence, hyperlipidemia (too many lipids (fats) in the blood). <BR/>Record review of Resident #78's annual MDS dated [DATE], under section C- Cognitive Patterns indicated that Resident #78 had a BIMs (Brief Interview for Mental Status) of 15, which indicates intact cognition. It also indicated that Resident #78 is at risk for developing pressure ulcers/injuries. <BR/>Record review of Resident #78's physician orders dated on 03/12/2022 and start date of 03/13/2022 indicated: Cleanse wound to left forehead with NS/wound cleanser, pat dry and LOTA until healed. If area is bleeding, cover with non-adherent dressing until controlled. every day shift for Wound Healing. <BR/>Record review of Resident #78's physician orders dated on 03/12/2022 and start date of 03/13/2022 indicated: Cleanse wound to left [NAME] with NS/Wound Cleanser, pat dry, LOTA until healed. If area is bleeding, cover with non-adherent dressing until healed. every day shift for Wound Healing.<BR/>Observation and interview on 03/23/2022 at 07:34 AM, LVN A conducted a glucose check on Resident #79. LVN A took a blue carrying caddy into the Resident's room with necessary glucose materials and set it on the Resident's table where his belongings were located. LVN A did not clean the table or provide a barrier before placing the caddy on the table. LVN A conducted the glucose check then proceeded to leave the room with the caddy to acquire insulin for the Resident#79. LVN A took the caddy and set it on another medication cart, then took the same caddy and put it on the nurses' station. LVN A then came back to Resident #79's room to administer insulin and set the same caddy back on top of the Resident's table. LVN A did not clean the medication cart, nurses' station, or the bottom of the caddy. LVN A stated, she did not clean the caddy and that leaves the potential of passing an infection if not cleaned properly.<BR/>During an interview with the DON on 03/23/2022 at 9:11 AM,. the DON stated that if a carrying caddy was used, there should be a barrier between the caddy and the resident's table, or the caddy needs to be cleaned upon leaving the room to prevent the spread of infection.<BR/>During an observation and interview of wound care of Resident #52's pressure ulcer to center coccyx, stage 2, with RN B on 03/23/22 at 9:59 am. RN B conducted wound care on Resident #52 back lower buttock area. RN B gathered supplies to conduct wound care on Resident #52 and did not wash her hands or use hand sanitizer prior to gathering supplies. RN B cleaned the bedside table with a disinfectant wipe, placed a barrier on the bedside table and then placed her supplies on the barrier of the bedside table. RN B then washed her hands, put on clean gloves. RN B removed Resident #52's brief and turned Resident #52 to the right side. RN B stopped and laid Resident #52 on his back and then raised Resident#52's bed. RN B stated that the bed was too low. RN B removed old gloves and replaced with a new pair of gloves. RN B raised bed and then turned Resident #52 to the right side to remove the old foam bandage. Observed that old bandage was dated 3/22/22 and initialed. RN B did not use hand sanitizer or wash hands prior to replacing gloves from removing the old bandage and cleaning the wound. RN B used the 4 X 4 gauze that was soaked with wound wash to begin cleaning the wound. RN B stated that she did not remember seeing an order to dress the wound. RN B stopped the wound care and placed a clean brief on Resident #52 without dressing the wound. RN B removed old gloves and RN B washed her hands after cleaning the wound. RN B immediately reached out to the Nurse Practitioner using the computer for orders to dress the wound. RN B stated that it could take a couple of hours to get orders placed to be able to dress the wound. <BR/>During an observation of wound care of Resident #78 wound to left [NAME] and left side forehead, with RN B on 03/23/22 at 10:43 am. RN B conducted wound care on Resident #78 left side forehead. RN B gathered supplies to conduct wound care on Resident #78 and did not wash her hands or use hand sanitizer prior to gathering supplies to conduct wound care. RN B wiped off the bedside table with a disinfectant wipe and placed wax paper on the bedside table for a barrier. RN B placed all supplies on the barrier on the bedside table. RN B washed her hands and placed on clean gloves. RN B used 4 x 4 gauze that was soaked with wound wash to clean Resident #78 wound on left side of forehead. RN B used dry gauze to pat dry the wound. RN B left the wound open to air as instructed by orders. RN B removed dirty gloves and disposed in the designated trash. RN B washed hands and removed trash from Resident #78 room. <BR/>Interview with RN B (wound care nurse) on 03/23/2022 at 11:12 am. RN B stated that today was her first day in doing the wound care position and she was nervous. RN B stated that she does realize that she should have washed her hands prior to gathering her supplies and during the wound care procedure but was not thinking about it. RN B stated that when she had to stop the wound care because of the bed and then because of the orders threw off the procedure and stated she lost track. She stated that she has been trained in hand washing throughout school and often in the facility. RN B stated that the negative potential outcome for the resident was the spread of infection to the residents. <BR/>Interview with (Intern DON) on 03/24/2022 8:10 am DON stated that RN B should have known better because she used to be a DON in another facility, and she should have known to wash her hands. DON stated that she does understand that the RN B has not been in the position of wound care nurse for very long, but she should already know to wash her hands and that she will do an in-service with her. DON stated that RN B has been trained through school and the facility do skills checks for hand washing monthly and the staff have in-services as well. DON stated that it was the responsibility of herself and the administrator to make sure that the skills checks are completed and up to date. DON stated that the potential negative outcome for the resident's would be that by not washing hands it could possibly cause infection and spread from resident to resident. <BR/>Interview with Administrator on 03/24/2022 8:42 am, Administrator stated that she does expect that a nurse should know to wash her hands prior to gathering supplies and treating wounds. Administrator stated that the facility has been in the middle of hiring new people to fill the positions that have been empty, and the wound care nurse position is one of those positions. Administrator states that it was nursing 101 to automatically know to wash your hands. Administrator stated that the staff members were trained and do have skills checks and matter of fact the facility just conducted a skill check on 03/ 10/2022 for hand washing. Administrator stated that the facility provides reliase which is a computer-based training provided monthly and the facility also provides monthly revolving schedule for different kinds of checks such as handwashing. Administrator stated that it was the responsibility of her and the DON but mainly the DON to make sure that these trainings were completed and up to date. Administrator stated that the facility also makes sure to conduct a skill check upon hire to make sure that the staff member does know how to do what they are asked. Administrator stated that the potential negative outcome for the residents would be the transfer of infection. Administrator stated that if she had been treating and infected wound, she could have transferred that infection to another resident. <BR/>Record Review of the facility provided policy titled; Infection Control dated July 2014 revealed.<BR/>2) C. Establish guidelines for implementing Isolation precautions, including Standard and Transmission-Based Precautions. <BR/>4) All personnel will be trained on out infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.<BR/>Record Review of the facility provided policy titled; Infection Control & Prevention no date labeled, revealed:<BR/>Skill: Hand-Hygiene:<BR/>Purpose: To prevent cross contamination and the spread of infection. <BR/>Guidelines and Precautions: <BR/>1. <BR/>Handwashing is the single most important method in the prevention and control of infection. <BR/>2. <BR/>Handwashing should be done at the following times:<BR/>B). Before and after caring for each resident. <BR/>C). Before applying gloves and after removing gloves. <BR/>E). After contact with blood, body fluids, and contaminated items. <BR/>F). Whenever hands are obviously soiled. <BR/>Record Review of the facility skills checks provided titled; SVH COVID Contact & Documentation Tracker no date labeled revealed:<BR/>1. <BR/>On 11/23/2021-Hand Hygiene skill performed.<BR/>2. <BR/>On 03/10/2022- Hand Hygiene skill performed.

Based on observation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 laundry room in that:<BR/>1. The facility failed to maintain clean lint traps in all 3 dryers in the laundry room by failing to clean the lint traps per policy. <BR/>These failures could place residents at risk for receiving cold meals/coffee and at risk for fire emergencies.<BR/>The findings included:<BR/>Observation on 07/11/2024, at 1:50 PM with Laundry Manager. The Laundry Manager was asked to pull out the lint traps in all three dryers to check for compliance. All three dryers were deeply covered with lint underneath the lint baskets on the bottom of the dryers and all around the fan motor. When Laundry manager began to clean the lint from the bottom of the dryers, she had to sweep it all together and it filled a five-gallon bucket. Laundry Manager had gotten a shop vac to finish cleaning the lint traps in all three dryers due to the amount of debris left from the lint. The laundry Manager stated that she could not believe that the lint traps had not been cleaned because they have been taught to clean after every load. The Laundry Manager stated that the process for checking and cleaning the lint traps is that staff is supposed to clean after every load or after every hour. <BR/>During an interview on 07/11/2024 at 2:54 PM with Administrator. She stated that she expects staff to clean per policy. She stated that the policy stated that the lint traps should be cleaned after every load and every hour. She stated that the staff have been trained by in-services quarterly. She stated that the negative potential outcome is a fire could start. <BR/>During an interview on 07/11/2024 at 3:08 PM with Corporate District Manager. She stated that she expects staff to clean the lint traps every hour and every two hours at the most. She stated that it is a potential fire hazard. She stated that staff is aware to make sure that lint traps are cleaned every hour. She stated that the staff all have been trained through in-services. She stated that during the in-services they went over lint trap, how and when to clean them. She stated if it needs it, then get the vacuum between every, nook and cranny. She stated that the negative potential outcome is that a fire could start and endangering the residents safety. She stated, 'It's a big concern and probably the biggest.<BR/>During a record review of facility provided in-service, labeled, Lint Trap Cleaning, dated 07/11/2024, revealed: <BR/>Purpose: To teach laundry personnel the proper way to clean dryer lint screens, how often they should be cleaned, and how to properly document their maintenance. A lint screen is installed in the bottom compartment of all commercial dryers. The air that leaves the dryer passes through the filter, catching lint prior to coming in contact with the filter, catching lint prior to coming in contact with the heating element as it exists the machine. If the lint is not removed frequently, it can result in extended dry times and, more importantly, create a potential fire hazard. It is highly important that the lint scree is brushed and cleaned every 2 hours. Always defer to State and Local regulations as they supersede these guidelines. <BR/>To Clean Lint Screens-this should be done every 2 hours. <BR/>1. Ensure dryer is turned off. <BR/>2. Unlatch and open lint collection area of the dryer (on some models remove the lint screen). Using a broom or brush, clean the accumulated lint from the screen and surrounding areas (undercarriage of drum/bottom of lint trap area). <BR/>3. Discard accumulated lint cleaned from the dryer in the nearest trash receptacle. <BR/>4. Upon completion, return the lint screen to the lint trap area if removed and always secure the lint trap door. <BR/>5. Document the time and date on the Lint Screen cleaning log. <BR/>During a record review of portion of facility provided policy, no title listed, dated 09/05/2017, revealed: <BR/>Lint: A lint screen is installed in the bottom compartment of all commercial dryers. Lint that falls from the linen as it dries is caught by the lint screen, preventing lint from moving directly through the vent and blowing all over the outside of the building. These lint screens must be brushed and cleaned after every load and every hour. If not, the screen will become packed with lint. When this occurs, the warm air moving through the system is blocked, raising the temperatures in the basket and causing a potentially dangerous situation, i.e., where one spark on lint can cause a fire. Torn or improperly fitted screens must be reported to the facility-to-facility maintenance personnel via work order for immediate repair. <BR/>Lint may also: <BR/>a). Build-up between the drum and the side of the dryers is the root cause for many dryer fires. This may cause a problem because in many dryers there is a heat sensor there. This sensor reads the heat of the basket and is programmed to shut the dryer down if the temperature gets too hot. If this sensor is covered with lint, the lint acts as insulation and fools the sensor into thinking the basket is not as hot as it really may be. So, instead of shutting the dryer down. It allows heat to continue to pour in. It is extremely important that you remove the entire front of the dryer and vacuum the entire interior. <BR/>b). Build-up on the top compartment of the dryer. This is dangerous because the heat source is here.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food that accommodated resident allergies, intolerances, or preferences for 3 of 12 residents (Resident #1, #2, #6) reviewed for meal preferences.<BR/>1. <BR/> The facility failed to ensure there was no cheese or Resident #1's sandwich, a documented allergy, resulting in Resident #1 having anaphylaxis symptoms and receiving an epi-pen (epinephrine, a medication that can help decrease a body's allergic reaction) on 12/15/2024.<BR/>2. <BR/>The facility gave Resident #2, Resident #6's meal tray, and Resident #2 consumed the incorrect tray on 12/17/2024.<BR/>3. <BR/>The facility gave Resident #6, Resident #2's meal tray, and Resident #6 consumed the incorrect tray on 12/17/2024.<BR/>An Immediate Jeopardy (IJ) was identified on 12/18/24 at 9:22 AM. The IJ template was provided to the facility on [DATE] at 9:22 AM. While the IJ was removed on 12/18/24 at 6:55PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern because all staff had not been trained on 12/18/2024. <BR/>This failure placed residents at risk for not having their dietary restrictions and allergy restrictions followed which can result in anaphylaxis. <BR/>The findings include:<BR/>During an interview on 12/17/2024 at 9:12 AM with the DON and ADM, the DON stated she had been notified of Resident #1's incident on 12/15/2024 a little after 2pm. The DON stated Resident #1 had come down the hall stating he had eaten cheese and he felt like his throat was getting tight. She stated RN A assessed him, notified the FNP on call and administered an epi-pen. The DON stated RN A monitored Resident #1 for about an hour, and she followed him outside to smoke. The DON stated Resident #1 was very upset and he made some threats, and he notified the police. The DON stated the facility took immediate action and began their investigation. The DON stated she spoke to the kitchen staff, and they had all stated there was no cheese on the plate. The ADM and DON stated Resident #1 brought out a 75% eaten sandwich with ham and cheese but they could not verify where the cheese had come from. The DON stated Resident #1's allergy is posted on his meal ticket and there had been multiple steps in place to prevent cheese from being on his plate. The DON stated there had been instances where there was cheese on his plate that the facility staff had caught. The DON stated CNA A had taken the lid off Resident #1's tray and saw sandwich with meat and bread but did not see cheese. She stated CNA A did not disassemble Resident #1's sandwich but when she removed Resident #3's lid, his sandwich had cheese on it. She stated CNA A did not believe to have switched the trays because she remembered seeing the cheese on Resident #3's plate. The DON stated Resident #1 had complained of cheese being on his tray even on days they did not serve cheese with the meals, and he had ordered pizza before. The DON and ADM stated they had begun a multi focal training and education with their staff. The DON stated they had Resident #1's picture and a colored picture of a no cheese sign to make it more visible, on the serving line in the kitchen. She stated the kitchen would have a sign off sheet that they have to physically sing off what comes out of the kitchen and the nurses on the floor will have to sing off on his tray saying it had been checked as well. The DON stated the FNP did not believe Resident #1 needed to be sent to the ER as he was monitored by RN A, and his symptoms had resolved. <BR/>Resident #1<BR/>Record review of Resident #1's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #1 had a medical history of type 2 diabetes, lumbago(lower back pain), schizophrenia (a serious mental health condition that affects how people think, feel and behave), bipolar disorder(a mental health condition that causes extreme mood swings), post-traumatic stress disorder(a mental health condition that's caused by an extremely stressful or terrifying event) , and [NAME] encephalopathy (a neurological disorder induced by thiamine, vitamin B1, deficiency). Resident #1 had a listed allergy of gabapentin metformin, cheese, and milk. <BR/>Record review of Resident #1's annual MDS dated [DATE], section C- Cognitive patterns revealed a BIMS score of 15 which indicated Resident #1 was cognitively intact. <BR/>Record review of Resident #1's care plan revealed a focus initiated on 6/13/2024, of Allergic to gabapentin, metformin, milk cheese. Interventions included administer medication or allergies as ordered by MD. <BR/>Record review of Resident #1's physician orders revealed EpiPen 2-Pak injection solution auto-injector 0.3mg/0.3ml (Epinephrine (Anaphylaxis) (a severe, life-threatening allergic reaction that can happen seconds or minutes after exposure to an allergen). <BR/>Record review of Resident #1's a communication form dated 6/17/2024 revealed Resident #1's name, other (checked box): Allergies. Diet order: No cheese or Milk (Allergies). Message/comments: IF there is cheese or milk in any meal, please give substitute. <BR/>Record review of Resident #1's progress note dated 10/08/2024 at 10:31AM revealed IDT held care plan with Resident #1. Resident will remain a DNR. Medications, weights, and diagnosis were discussed. Resident states that he no longer has faith in the facility because he keeps getting served cheese, resident states the next time he gets served cheese he is going to go to the nurse's station and eat it and for them to call 911. Resident was educated on not eating cheese as he is allergic to it. Resident was educated on the importance of taking his medication consecutively, pharmacy nurse did ask resident what medications he would like changed and resident stated he did not care because he was not going to take any of them. Resident states that he has applied to be moved to another facility. Resident is refusing to complete care plan and left the meeting.<BR/>Record review of Resident #1's progress note dated 12/15/2024 13:20 by RN A, resident #1 came to nurses' station frantic after eating cheese, was served one piece of bread with ham ontop-cheese was not seen when given to resident. resident folded bread and had two bites when he realized there was a piece of cheese under the ham. Resident states feels like my throat is closing (noted to have a hoarse voice) staff member states he has anaphylaxis to cheese. EpiPen given to right thigh at 1322 (1:32pm) , heart rate increased from 80's up to 108. within a minute residents state throat isn't feeling tight. 1340 (1:40pm) resident states throat is just a little sore no longer feeling like throat is swelling. lung fields clear to auscultation. resident stayed with nurse until 1355 (1:55pm), went to his room without further incident- call light within reach- no further complaints of throat tightness, heart rate in 80's 1400 (2:00pm) resident outside to smoke tolerating without difficulty. no increased throat discomfort- tolerated smoking without incident contacted FNP for prn orders, she states no need to send to ER. Supervisor, DNS, RN on call aware of incident. <BR/>Record review of Resident #1's progress note dated 12/15/2024 at 1511 (3:11pm) by RN A revealed BSPD officer arrived on scene to speak with resident-resident insistent on charging kitchen staff. Officer explained could not press charges and issue was a facility issue. officer states would give him a complaint number for his records. this nurse spoke with officer and resident- resident raised his voice towards the officer, this nurse was able to calm resident with light touch and speaking with him. 1530 (3:30pm) resident states I have to go to the store and get out of here before I kill someone 1545 (3:45pm) resident returned from the store.<BR/>Record review of Resident #1's progress note dated 12/15/2024 at 1549 (3:49pm) by RN A revealed resident returned from front of facility stated, the ADM was here and now she's gone- this is bullshit asked resident if he was ready for his pain medications he stated, I'm not taking a fucking thing, not eating not taking anything from this fucking place. <BR/>Record review of Resident #1's progress note dated 12/16/2024 at 12:19pm by the ADON revealed this writer went to talk to resident in his room to discuss the plan and his refusal to eat in dining room. inquired what happened over the weekend. resident stated, 'they gave me a fucking cheese' and showed me the sandwich, it has cheese in it. this writer apologized and sympathetic to resident, and stated the plan of action, resident raised his left arm and verbalized ' Stop! stop lying to yourself!' 'I have been given cheese for the last six months' 'Admin is not doing anything'. 'I am done, I am not going to eat here' this writer clarified if he wants to eat in the dining room or his room or is he going to eat outside the facility, resident verbalized 'No! I am not going to eat at all, I will starve myself to death'. writer tried to ask further but resident said, ' I am done' and left his room via scooter.' DNS made aware.<BR/>Record review of Resident #1's progress note dated 12/16/2024 at 1305 (1:05pm) by the SW revealed Social worker was speaking to resident to see how he is feeling after eating cheese over the weekend. Resident stated that his throat still hurts and he is pissed When the resident was asked if he was depressed, resident that put his hand up and stated, I'm done talking. SW then left the room.<BR/>Record review of Resident #1's progress note dated 12/16/2024 at 2346 (11:46pm) by LVN B revealed Resident rolled up on his scooter at supper time and looked at his tray and refused. This writer acknowledged that there was no cheese on the tray. He still declined the tray and stated that someone had purchased wings he was waiting on.<BR/>Record review of Resident #1's progress note dated 12/17/2024 at 2155 (9:55pm) by the DON revealed Met with resident to discuss his verbalized fears of dying and being unsafe in the facility. Resident states that he feels safe in his room and at night but feels unsafe during mealtimes and when any food is served to him. He continues to believe that the kitchen staff is trying to kill him and does not feel safe eating the food here. When he was asked what would make him feel safe, he stated that moving to another facility would be the only thing. He states that he is willing to move anywhere else to get away from here. He denied three different times that he feels unsafe or like he is going to die right now or tonight. He stated that he will not be eating the food from here, but that we should continue to send him his trays. <BR/>Record review of RN A's undated statement revealed the following On 12/15 about 1320 (1:20pm), veteran Resident #1 came to nursing station via electric wheelchair, with roommate right behind him. Resident #1 was yelling they put fucking cheese on my sandwich, and I didn't know. I didn't fucking know. I ate it! I didn't fucking know Resident grabbing at his throat saying I'm allergic to fucking cheese! My throat feels like it is getting tighter Residents face appears reddened, with noted shaking of hands. Instructed on slowing breathing, residents face getting red, noted to have tears. EpiPen injected to right thigh. Within minutes residents facial color returned to normal and no longer had complaints of throat tightness. Once resident had calmed, attempted to educate resident but was interrupted by him and he refused to listen to anything this writer had to say. I monitored him post incident and he did not have adverse reactions. I spoke with the cnas regarding the incident. The cna who served the meal stated she inspected the sandwich and did not see cheese. Document signed but RN A. <BR/>Resident #3<BR/>Record review of Resident #3's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #3 had a medical history of peripheral vascular disease, chronic hepatitis, liver disease, and polyneuropathy (when multiple peripheral nerves become damaged). <BR/>Record review of Resident #3's annual MDS dated [DATE], section C- Cognitive patterns revealed a BIMS score of 14 which indicated Resident #3 was cognitively intact. <BR/>During an interview on 12/17/2024 at approximately 10:00AM, Resident #3 stated he was roommates with Resident #1 and was in the room on Sunday 12/15/2024, when Resident #1 ate cheese. Resident #3 stated Resident #1 had made a comment about his sandwich only having one slice of bread on the bottom. He stated they even joked about the other piece of bread having the cheese on it and so they must have taken it off. Resident #3 stated he saw Resident #1 rolled the sandwich up and took a bite of the sandwich. He stated soon after Resident #1 stated his throat was closing up and he was shaking and could not talk very well. He stated what he saw was bread on the bottom, cheese, and ham. Resident #3 stated he knew Resident #1 had received an injection to his leg and has not seen him eat much since the incident. Resident #3 stated at no point were the trays switched because he ate his entire meal and, his plate had a sandwich with two slices of bread, cheese, and ham. <BR/>Resident #2<BR/>Record review of Resident #2's face sheet, dated 12/17/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis to include unspecified dementia with mood disturbance (impaired ability to remember with mood concerns), type 2 diabetes mellitus with diabetic polyneuropathy (inability to regulate blood sugar levels), anxiety disorder (mental health concern), chronic respiratory failure with hypoxia disturbance (lack of oxygen in the blood), and other allergy, initial encounter (an allergy to an uncommon substance). Additionally, the allergies listed were Atorvastatin (medication for cholesterol), calcium/polysorbate 80 (calcium supplement with a soluble stabilizer), iodine (mineral), and shellfish.<BR/>Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed under Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. <BR/>Record review of Resident #2's Care Plan, dated 12/14/24 revealed a focus area, initiated on 6/14/24, the resident's current diet was regular texture, thin/regular consistency with large protein portions. Further review revealed a focus area, initiated on 5/30/24, that the resident was allergic to Iodine, Atorvastatin, Calcium/Polysorbate 80, and shellfish. The goal was the resident would not have any adverse reactions to allergies. The interventions initiated on 5/30/24 were to ensure a list of allergies go with the resident to the physician, pharmacy, and hospital and to ensure dietary was notified of any food allergies when he was admitted . Additional interventions were that the resident was severely allergic to shellfish (prior anaphylactic reaction), keep EpiPen available for shellfish allergy, administer medication for allergies as ordered by the medical doctor, and to notify the doctor of unresolved allergy symptoms as needed. <BR/>Record Review of Resident #2's physician orders, dated 12/17/24, revealed a prescription for EpiPen 2-pak injection solution, auto-injector 0.3 MG/0.3ML (Epinephrine Anaphylaxis). Inject 1 application intramuscularly every 24 hours as needed for allergies. Physician orders further revealed, Resident #2 was on an RCS (Reduced concentrated sweets) diet with a regular texture, thin/regular consistency, provide large protein portions with meals.<BR/>Record Review of Resident #2's Communication form with the dietary department, dated 5/30/24, revealed Resident #2 had a diet order of Regular and regular liquid. Additionally, the document indicated Resident #2 had an Iodine allergy and no shrimp.<BR/>Resident #6<BR/>Record review of Resident #6's face sheet, dated 12/18/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on e 9/23/24 with diagnosis to include bipolar disorder (mental health concern), vascular dementia (impaired ability to remember), and type 2 diabetes mellitus without complications (inability to regulate blood sugar levels). Additionally, Resident #6 had no known allergies. <BR/>Record review of Resident #6's Comprehensive Minimum Data Set, dated [DATE], revealed under Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. <BR/>Record review of Resident #6's Care Plan, dated 12/18/24 revealed a focus area, initiated on 3/22/24, the resident's current diet was regular texture, thin/regular consistency and that the resident was at risk for nutritional deficits and/or dehydrations risks related to therapeutic diet. <BR/>During an interview on 12/17/24 at 12:22 PM, Resident #2 stated he had lived here for about 3 months. He stated the facility was clean. He stated food was alright but lacked flavor and the staff was polite. He stated he was a diabetic and he was highly allergic to shrimp and all crustaceans. He stated he found out he was allergic when he was in the navy. He stated he had been served shrimp at this facility three times, but he saw it and did not eat it. He stated he told staff, and they brought him something else to eat. He stated he listed his allergies on his admission paperwork. He stated he could get choked up and die if he eats shrimp or crustaceans. He stated he was offered snacks such as sandwiches between meals. He stated he had no concerns of abuse or neglect. He stated he had no additional concerns to report.<BR/>During a dining observation on 12/17/24 at 1:03 PM in the memory care unit with the following: The food was brought to the memory care unit in an insulated rolling food warmer. There were two meals on each food tray. RN C was observed looking at each tray ticket, she picked up the plate cover to observe the food, then she put that tray on the counter where she prompted the CNA's that they were inspected and ready to be passed out. The CNAs were observed performing hand hygiene and then took the trays and passed them out to the residents. During the lunch observation the surveyor observed Resident #2 eating in the dining room and had eaten about 75% of his food, as the surveyor approached him it was observed that the tray ticket had the name of Resident #6 on it. The surveyor asked Resident #2 if the name on the tray ticket was his and he said it was not. The surveyor then stopped RN C as she passed out drinks and told her that Resident #2's tray ticket had another person's name on it. RN C apologized to Resident #2 for getting the wrong plate and took the plate. CNA C stated she handed Resident #2 the wrong tray. Resident #6 was observed eating his food in the dining room as well and staff took his tray. It was observed that he had eaten about 50% of the food on the plate and the tray ticket had Resident #2's name. <BR/>During an interview on 12/17/24 at 1:16 PM, Resident #6 stated he had not noticed another person's name was on the tray ticket and was not happy that he was served someone else's food. Resident #6 stated this happened to him before.<BR/>During an interview with CNA A on 12/17/2024 at 2:39pm, she stated on 12/15/2024 she had finished assisting residents in the dinning hall for lunch and began helping pass out trays. She stated she saw they were having grilled cheese sandwiches and noticed Resident #1's was different. She stated it was plain ham with a piece of bread underneath it. She stated she did not see any cheese at that point and did not want to pick up his food. She stated Resident #1s meal ticket was underneath the plate and had his allergies listed. She stated she took the plate to Resident #1's room and he had asked aren't we having alfredo? and she responded no. She stated she saw him pick up the sandwich and fold it in half but exited the room before he took a bite of it. She stated Resident #3's sandwich had cheese on it and two pieces of bread while Resident #1's only had one piece of bread and that is why she assumed there was no cheese on Resident #1's sandwich. She stated Resident #1 began having symptoms about 10 minutes later and received an EpiPen to his leg. She stated this has happened a lot of times where they put cheese on his tray and Resident #1 catches it and gets upset and yells at them to go fix it. She stated sometimes it is meals like ravioli which have cheese inside or mac and cheese. She stated the mac and cheese is usually caught before being served to Resident #1. She stated they have been in-serviced on his allergies, but she believes the issue comes from the kitchen. She stated the staff will let the kitchen know but it just gets brushed off and nothing happens. She stated she is not sure why there was sandwiches for that meal. On 12/18/2024 at 6:19pm CNA A stated Resident #1's meal ticket showed a smothered turkey patty not a sandwich. CNA A stated the meal and ticket did not match up, and the meals are usually verified by the nurse, but they had not been verified that day and she is not sure why. CNA A stated she witnessed Resident #1 pick up the sandwich and fold it before exiting the room. She stated at no point did she see Resident #1 tamper with the tray, and she did not see anyone else tamper with the tray cart (the rolling cart that holds the meals for transport). CNA A stated there had been about three other incidents where Resident #1 had cheese served on his tray but does not recall the dates or times. She stated she remembers Resident #1's sandwich was not grilled and had a missing piece of bread while Resident #3's was grilled and had two pieces of bread and she is sure the trays did not get switched. <BR/>During an interview with Resident #1 on 12/17/2024 at 3:20 PM he stated, I have been here 6 months and told them I'm allergic to cheese. I told them one of these days I'm going to eat cheese and wind up dead. It feels like they are trying to kill me, and it is premeditated murder because they have known about it for months and it keeps happening. On Sunday they gave everyone ham and cheese. I got two pieces of ham and 1 piece of bread. I joked and said I bet the other bread had the cheese on it. I folded it up and took a bite. I knew something was wrong because my throat felt weird, so I went up to the nurse's station and they gave me an epi pen. The cheese was yellow, and it was below the ham when I took it apart. I have had epi pens twice in my life, both from eating cheese accidently. I don't know exactly why I'm allergic to cheese, I think it has something to do with the enzymes in it, but milk doesn't give me the same reaction. Milk makes my stomach upset and diarrhea. I think the facility just didn't believe me. I don't think they believed I was really allergic to cheese. I am still mad about it. After the epi pen, I did feel better, but my throat is sore. I have avoided eating cheese my whole life, I'm glad I did notice because what if I had passed out and stopped breathing and didn't tell anyone. I did call law enforcement because I felt like it was attempted murder. Everyone has been kissing my ass and being nice since the incident. I feel unsafe and disrespected, and I haven't eaten since then. I don't trust them. Yes, I have bought pizza before, but I usually order it for the other residents, and I'll get myself some wings or a burger. I have also ordered pizza without cheese; people are surprised when I tell them it's pizza without cheese . I did not leave the facility on Sunday prior to the incident. I have an ice box and my roommate does not and he stores his pimento cheese in my ice box but that's my fridge and I let him.<BR/>During an interview on 12/17/24 at 4:31 PM, the Director of Dining Services stated she spoke with Resident #1 about what happened, and he told her that he would never eat the food here anymore. She stated she asked if she could buy him dinner and he agreed so she bought him chicken wings. She stated there were twos staff that were witnesses. She stated she had bought other residents' food before. She stated Resident #1 refused his food trays yesterday and did not eat. He asked for a steak, and he got wings. She stated he was kind during their conversation. She stated she was not aware of him being served cheese before. She stated she came three times a month from [NAME]. She stated once the food comes out of the kitchen, a licensed nurse checked the trays, and the CNAs passed out the trays. She stated the Dietary Manager provides training to staff. She stated the dietary staff, and the cook were responsible for ensuring trays were correct. She stated the cook places the food on the trays. She stated staff called the tray tickets out to the cook when plating the trays. She stated a potential negative outcome was that they could get a stomachache.<BR/>During an interview on 12/17/24 at 5:47 PM, with RN C she stated she was responsible to ensure residents were served the right texture in their diet during meals. She stated she looked at the tray tickets for their name, texture, and allergies and then she looked at the food to ensure the order was correct and allergies were correct. She stated then she passed the trays to the CNAs who were then responsible to pass trays to residents after she had checked them out. She stated the CNAs were supposed to ensure they give trays to the correct resident. She stated she was given an in-servicing on tray passing recently to herself and all her staff, yesterday and the day before. She stated she became aware that Resident #2 was served the wrong food tray when she passed out the drinks and saw that he had the wrong tray ticket. She stated normally they pass drinks before the food but today the drinks were late, so she passed the drinks after the food today. She stated Resident #2 and Resident #6 were served each other's meals by CNA C. She stated she was not aware if either of those two residents had any food allergies but they both ate regular diet texture. She stated Resident #2 had eaten about 20-30% of the food by the time she discovered it. She stated dietary staff were responsible to ensure the correct food was on the tray, she was responsible to double check it, and the CNAs were responsible to pass trays to the correct resident. She stated she expected staff to deliver trays to the correct residents. She stated a potential negative outcome was they could have an anaphylactic reaction or an allergy, or an obstruction from their throat swelling, or they could develop hives. She stated also if someone were to eat the incorrect diet texture, they could have difficulty swallowing the food or people that don't have teeth may not be able to eat the food. She stated she was responsible to ensure CNAs were providing care to residents according to their treatment plans. She stated she was not responsible to ensure the CNAs gave resident's the correct tray. She stated the CNAs also received training for this and she could not see everything going on in the facility. She stated after today's incident at lunch, she had a huddle meeting with the DON and the staff and reviewed the recent in-service.<BR/>During an interview on 12/17/24 at 6:04 PM, CNA C stated she worked on the D-wing Memory Unit. She stated she was overstimulated today when passing the food trays during lunch because her pig tails on her hair were pulling. She stated she also felt rushed by RN C. She stated she accidentally served Resident #6 and Resident #2 each other's trays for lunch. She stated their plates were on the same tray and she switched them. She stated they both eat the same regular diet texture so luckily there was no allergy mix-up. She stated when she passed out food trays, first the nurse read every tray ticket and she compared it to the food on the plate to ensure it was correct. Then the nurse would let them know it was approved to serve to the residents. She stated she knew all the residents and did not need to ask their names to verify their identities. She stated she was aware Resident #2 had a shellfish allergy. She stated she was not aware of him being served shellfish or shrimp before. She stated a potential negative outcome could have been itching or the worst-case scenario was the resident could experience anaphylaxis or death, however it would depend on the severity of the allergy. She stated she was trained on abuse and neglect recently and received additional trainings once a month. She stated she received an in-service yesterday on tray tickets and passing out trays. She stated she went and told the DON that she mixed up the two resident's food trays today and was not given additional instructions. She stated she was made aware of the mix up when RN C told her. She stated Resident #2 had eaten about 75 % of the food on the plate and Resident #6 had eaten about 50% of his food.<BR/>During an interview with RN A on 12/17/2025 at 6:13pm, she stated on Sunday 12/15/2024, Resident #1 had come up to the nurses stating saying they fucking gave me cheese again, they are trying to kill me. She stated she asked Resident #1 to slow down and explain what had happened and he explained he had eaten some cheese that was served on his sandwich. She stated the CNA's (she didn't remember who) said they didn't see the cheese. She stated one of the CNA's told her he was allergic to cheese, and she asked if he was having symptoms. She stated Resident #1 told her his throat was closing up, he had tears in his eyes, was breathing fast and was clutching his throat. She stated she notified the FNP, grabbed the epi pen from the medication cart and administered the epi pen. She stated she did check his lungs prior to, and he had clear lung sounds but did not want to risk waiting because anaphylaxis symptoms can occur rapidly. She stated she had no idea how his sandwich ended up with cheese because she had been told the food was looked at. She stated that CNA who checked it remembers checking it because it only had the one slice of bread. She stated Resident #1 had told her this was not the first time they had put cheese on his meal, but she has not been present for those other times. She stated the kitchen checks his plate, the staff checks his plate, and he checks his plate so she is unsure how it could have been missed. <BR/>During an interview with the FNP on 12/18/2024 at 9:45AM, she stated she had been called on 12/15/2024 about Resident #1 having eaten cheese and having an allergy to cheese. She stated the RN A told her his vitals were normal and he did not appear hypoxic (low levels of oxygen in body tissue), so she ordered a dose of epinephrine to be given. She stated she checked back about 15 minutes later and Resident #1's symptoms had resolved and was smoking, and she did not feel he needed to go to the ER. She stated the RN A's actions were appropriate and she had no concerns with the way the situation had been handled. She stated she is not sure how he was given cheese, but his dietary restrictions need to be followed to prevent this from occurring again. <BR/>During an interview on 12/18/24 at 11:49AM, Resident #3 stated he had never seen Resident #1 eat cheese. He stated he had never seen Resident #1 store cheese in his refrigerator. He stated the pimento cheese in Resident #1's refrigerator belonged to him. He stated Resident #1 did not put cheese in his sandwich, he would never have done that because he was allergic to cheese. He stated on the day of the incident Resident #1 complained to him that he only had one bread, then he folded the sandwich in half and ate it. He stated Resident #1 did not tamper with the sandwich.<BR/>During an interview on 12/18/24 at 12:00 PM, Resident #1 stated the facility provided [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 29 residents (Residents #9 and #101) reviewed for advanced directives.<BR/>Residents #9 was listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. <BR/>Residents #101 was listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. <BR/>This failure could place residents at risk for not having their end of life wishes honored and incomplete records.<BR/>Findings included:<BR/>Resident #9<BR/>Record review of Resident #9's face sheet, dated [DATE], revealed an [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include Parkinson's (a progressive nervous system disease), dementia (progressive loss of intellectual functioning), atrial fibrillation (irregular or rapid heartbeat that causes poor blood flow),major depressive disorder and Alzheimer's (progressive disease that destroys memory and other mental functions)<BR/>Record review of Resident #9's face sheet, dated [DATE], revealed Advance Directive<BR/>DNR <BR/>Record review of Resident #09's physician order summary dated [DATE] revealed a DNR order dated [DATE] related to code status or advanced directive. <BR/>Record review of Resident #09's care plan, dated [DATE], revealed a care plan for DNR Status:<BR/>Focus: I/Family/RP has completed documentation for DNR status. I wish to be designated as DNR<BR/>Goal: Community will follow DNR status request.<BR/>Interventions: A physician's order for DNR is to be placed in my clinical record, Keep a copy of the OOHDNR form in my clinical record, Send a copy of the OOHDNR with me in the event of transfer to the hospital or other facility<BR/>Record review of Resident #09's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under Section B the medical power of attorney had not checked any of the check boxes that indicated why they were acting on the behalf of Resident #09. Section 3 was missing a date to indicate when the signatures were obtained. <BR/>Resident #101<BR/>Record review of Resident #101's face sheet, dated [DATE] revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include dementia (progressive loss of intellectual functioning), Atherosclerotic heart disease (buildup of fats and cholesterol plaque in the walls of the arteries) and anxiety disorder. <BR/>Record review of Resident #101's physician order summary dated [DATE] revealed an order for Do Not Resuscitate - DNR dated [DATE].<BR/>Record review of Resident #101's care plan, dated [DATE], revealed care plan for Advance Care Plan: <BR/>Focus: Resident/Family/RP does not have advance directives and elects Full Code Status. designating that the resident is a FULL CODE (CPR) status<BR/>Goal: Community will follow full code status through review date<BR/>Intervention: Initiate CPR if I am without a pulse Review code status at least annually and as indicated. The care plan did not indicate a DNR status update.<BR/>Record review of Resident #101's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under the Physician's Statement revealed there was no date. Further review revealed at the bottom of the form indicated All persons who have sign, acknowledging that this document has been properly completed. revealed there was no signature from either of the two witnesses and no signature from the notary.<BR/>An interview was conducted on [DATE] at 11:06 AM, the ADON said she had been at the facility for two months. She said she had been an RN for 20 years. She said resident DNR forms were everyone's responsibility and it was a team effort. She said the resident and the family work with the social worker, and the social worker was the one who completed the paperwork done. As the nurse, they would educate the family and the resident on what DNR meant. She said the form should be completed for the request to be valid. She said the signatures and the dates on the form indicated when the DNR became valid. She said the DNR would only be valid if all signatures were included. She said if the DNR form was invalid, then is the resident was considered a full code, and chest compression would be performed. She said if a resident wished to be a DNR and CPR was performed, then the facility would have been going against their wishes. She stated she was responsible for the C-wing in the facility and not the memory care unit. She stated the pharmacy nurse and DON typically cover the memory unit. She reviewed Resident #9's DNR and acknowledged that Section B was missing information and the date was missing at the bottom. She acknowledged that Resident #101's DNR was missing signatures at the bottom of the witness and the notary. She said she had not been trained specifically at the facility regarding DNRs but was handed a list of DNRs for her section in the facility. She said the potential negative outcome was the staff could perform CPR, and the caregiver could say it was not legit and become upset. She said she expected all appropriate and applicable places should be completed on the DNR form so that it was valid. She stated the doctor's signature and date were the most important. She said she was unsure why the middle of the form was not completed, why the bottom was not dated for Resident #9, and why Resident #101 was not completed. <BR/>An interview was conducted on [DATE] at 11:43 AM, the Social Worker (SW) said that she was responsible for completing the resident DNRs. She said another social worker at another facility would assist her and review her work since she was working under that worker's license. She said when a resident wishes to be DNR status, she has the nurse talk to the resident and their family so that they fully understand what they are requesting. Then, if they wanted to proceed, she would find someone not in the line of care to witness. She said after obtaining the doctor's signature and all appropriate signatures, she would make a copy and provide the DON with a copy. Lastly, she would upload the final copy into the resident's electronic file. She said the copy uploaded in the electronic file should be the final form. She said she expected all appropriate and applicable fields to be completed. She said if the relevant and appropriate fields were missing, the DNR was not valid. She said if the DNR is not valid, this would mean that the resident would be a full code. She said this could potentially go against the resident's wishes. She said that she had been trained on the completion of DNRs. She said she was unaware that Residents #9 and #101 had incomplete DNRs. She said that she audits the DNRs every couple of months. <BR/>An interview was conducted on [DATE] at 11:55 AM, the Pharmacy nurse said DNRs are usually taken care of by the SW. She said that the SW usually had one of the nurses look at the DNR when it comes from the physician. She said she was unaware of any issues. She said she had been trained on the facility's process for DNRs. She said she expected DNRs to be fully completed before scanning into the chart and that they should be updated throughout the chart to reflect the resident's status. She said if the DNR was not fully completed, then the DNR was not valid. She said the potential negative outcome would be that the resident's wishes would not be upheld. <BR/>An interview was conducted on [DATE] at 12:52 PM, the ADM said that she would have to check specifically for her facility but that, in her experience, social services were responsible. She said she had been trained on the completion DNRs and was unaware that some residents had incomplete DNRs. She said she expected the DNR to be complete and all appropriate and applicable areas on the form completed. She said the potential negative outcome would be the wishes of the veterans may not be fulfilled. However, she said if the form was in the electronic medical record, she understood it was complete and ready. <BR/>Record review of the facility's policy, Advance Directives, Revised February 2017, revealed the following documentation: <BR/> Compliance Guidelines<BR/> A copy of the advance directive and subsequent revisions will be included in the resident's medical record.<BR/>Advance Directive Modifications<BR/>The resident has the right to modify the advance directive at any time. Although the resident should advise the community whenever a change is made, it is the community's responsibility to ensure that it has current copies of all advance directives.<BR/>The community will survey its residents at least annually regarding any advance directives changes.<BR/>Record Review of the Instructions For Issuing An OOH-DNR Order (Undated) revealed the following:<BR/>INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER PURPOSE <BR/>IMPLEMENTATION: A competent adult person, at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: <BR/>Section B - If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, or proxy in a directive to physicians, the guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating it in Section B. <BR/>Section C - If the adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, or proxy, then a qualified relative may execute the OOH-DNR Order by signing and dating it in Section C . <BR/>Section F - If an adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, proxy, or available qualified relative to act on his/her behalf, then the attending physician may execute the OOH-DNR Order by signing and dating it in <BR/>In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR Order in the presence of a notary public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses. Witness or notary signatures are not required when two physicians execute the OOH-DNR Order in section F. The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 6 residents (Residents #7, 59, 36, 62, and 96) reviewed for PASRR screening, in that:<BR/>Resident #7 did not have an accurate PASRR Level 1 assessment when he had a diagnosis of major depressive disorder.<BR/>Residents #59 and #62 did not have accurate PASRR Level 1 assessment when they had a diagnosis of post-traumatic stress disorder (PTSD) and Major Depressive Disorder.<BR/>Residents #36, #62, and #96 did not have accurate PASRR Level 1 assessment when they had a diagnosis of post-traumatic stress disorder (PTSD).<BR/>These failures could place residents with an inaccurate PASRR Level 1 evaluation at risk for not receiving care and services to meet their needs.<BR/>The findings were:<BR/>Resident #7:<BR/>Record review of Resident #7's electronic face sheet revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnoses Information, major depressive disorder (MDD). <BR/>Record review of Resident #7's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of depression. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 8 indicating the resident was mildly cognitively impaired. <BR/>Record review of Resident #7's most recent care plan, undated, revealed a focus area and diagnosis of Major Depressive Disorder. <BR/>Record review of Physician progress notes for Resident #7 dated 05/19/2023 revealed under current medications, documentation indicated the resident was prescribed Paroxetine (antidepressant) 10mg once daily. <BR/>Record review of Resident #7's Preadmission Screening and Resident Review Level One (PL1) form dated 03/24/2021 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. <BR/>Resident #59:<BR/>Record review of Resident #59's electronic face sheet revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnosis Information a diagnoses of Chronic Post-Traumatic Stress Disorder (PTSD) and Recurrent and Severe Major Depressive Disorder. <BR/>Record review of Resident #59's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of depression and post-traumatic stress disorder. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 15 indicating the resident was mildly cognitively impaired. <BR/>Record review of Resident #59's most recent care plan, undated, revealed a focus area with problem onset date of 11/17/2021 which read in part that Resident #59 is at high risk for side effects due to a diagnoses of Post-Traumatic Stress Disorder and Major Depressive Disorder. Appropriate interventions are in place to assist with the behaviors associated with Major Depressive Disorder and Post Traumatic Stress Disorder. <BR/>Record review of Physician progress notes for Resident #59 dated 05/19/2023 revealed under Current Diagnosis, diagnoses including PTSD and MDD. Resident #59 is not currently prescribed medications for depression, trauma, and anxiety. <BR/>Record review of Resident #59's Preadmission Screening and Resident Review Level One (PL1) form dated 10/29/2021 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. <BR/>Resident #36:<BR/>Record review of Resident #36's electronic face sheet dated 5/24/23 revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnosis indicated diagnoses of post-traumatic stress disorder (PTSD), Intermittent Explosive Disorder, Anxiety Disorder, Cognitive Communication Deficit. <BR/>Record review of Resident #36's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses of dementia, anxiety disorder, and post-traumatic stress disorder (PTSD). Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 14 indicating the resident was mildly cognitively impaired. <BR/>Record review of Resident #36's most recent care plan, undated, revealed a focus area with problem onset date of 11/14/2022 which read in part that Resident #36 is at high risk for side effects due to a diagnosis of Post-Traumatic Stress Disorder. Appropriate interventions are in place to assist with the behaviors associated with Post Traumatic Stress Disorder.<BR/>Record review of Physician progress notes for Resident #36 dated 05/19/2023 revealed under Current Diagnosis, a diagnoses including post-traumatic stress disorder (PTSD), Intermittent Explosive Disorder, Anxiety Disorder, Cognitive Communication Deficit. Resident #36 was currently prescribed Buspirone 10MG three times a day for anxiety and Thiamine 100MG a day for Dementia. <BR/>Record review of Resident #36's Preadmission Screening and Resident Review Level One (PL1) form dated 08/20/2020 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. <BR/>Resident #62<BR/>Review of Resident #62's face sheet revealed an [AGE] year-old-female with an admission date of 02/19/2021 with a primary diagnoses of Post Traumatic Stress Disorder, Major Depressive Disorder, and Anxiety Disorder, and Insomnia. <BR/>Record of Resident #62 physician orders dated 05/19/23 revealed Sertraline HCL 100mg tablet give 1.5 tabs (=75mg) by mouth daily for depression dated 01/27/21.<BR/>Record review of Resident #62's most recent care plan, undated, revealed a focus area of Resident #62 was at high risk for side effects due to a diagnoses of Post-Traumatic Stress Disorder, anxiety, and Major Depressive Disorder. Appropriate interventions are in place to assist with the behaviors associated with Post Traumatic Stress Disorder.<BR/>Review of Resident #62's PASRR assessment Level 1 Screening dated 10/26/21, under Section C0100 revealed documentation indicating Resident #62 did not have a mental illness. <BR/>Review of Resident #62's Annual MDS assessment dated [DATE], revealed under section I Active Diagnoses of anxiety disorder, depression, and post-traumatic stress disorder (PTSD). Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 15 indicating the resident was mildly cognitively impaired. <BR/>Resident #96<BR/>Review of Resident #96's face sheet revealed a [AGE] year-old-female with an admission date of 10/13/22 with a primary diagnosis of Post-Traumatic- Stress Disorder, Chronic. <BR/>Record of Resident #96 physician orders dated 05/19/23 revealed Cymbalta 60mg by mouth daily for Post-Traumatic Stress Disorder dated 12/14/22.<BR/>Review of Resident #96's PASRR assessment Level 1 Screening dated 10/13/22, under Section C0100 revealed documentation indicating Resident #96 did not have a mental illness. <BR/>Review of Resident #96's Annual MDS assessment dated [DATE], revealed under section I Active Diagnoses of Post-Traumatic- Stress Disorder, Chronic. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 13 indicating the resident was mildly cognitively impaired. <BR/>Record review of Resident #96's most recent care plan, undated, revealed a focus area of Resident #96 was at high risk for side effects due to a diagnosis of Post-Traumatic Stress Disorder. Appropriate interventions are in place to assist with the behaviors associated with Post Traumatic Stress Disorder. <BR/>During an interview with the ADM conducted on 05/19/23 at 9:48 AM, she said it was the Admissions' nurses' responsibility to review enter PL1 into electronic records. The ADM stated the CMS nurse was responsible for comparing the PL1s to the residents' medical records to ensure accuracy. The ADM confirmed residents #7, #96, #62, #36, and #59 did not have a PASRR Evaluation completed, she also confirmed the PL1s for these residents was not accurate; due to Major Depression and PTSD being diagnoses. The ADM stated the facility does not have a process for updating the PL1 if a resident was diagnosed with a new diagnosis because she did not know the PL1 would need to be updated due to a new diagnosis. The ADM stated she knew PTSD and Major Depression warrant a positive PL1. When asked what the risks for a resident could be if they did not receive an accurate PL1 or subsequent PL2 evaluation, she said the residents are at risk of not receiving proper services. <BR/>During an interview with the MDS Coordinator on 05/19/23 at 9:37 AM, she said Resident #14 had admitted to the facility from home and the PL1 had been completed by a family member. She said the facility staff were still responsible for verifying that the PL1 was accurate. She said Resident #14 had a diagnosis of dementia. When asked if he should have had a positive PL1 due to his diagnosis of MDD she said she was not sure because his PL1 was done in 2020 before she was working at the facility. She said she had a meeting in the past with the local mental health authority to try and get a better understanding of what diagnoses should be triggering a positive PL1 and subsequent level two evaluation. When asked if a diagnosis of dementia would be considered when completing the PL1 or when the evaluation was being completed by the LMHA, she was unsure. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 3 of 29 residents (Residents #98, #101, and #213) reviewed for care plans as follows:<BR/>*Resident #98 did not have a care plan for urinary and nutritional needs.<BR/>*Resident #101 was classified as a DNR status and did not have a care plan for DNR status. <BR/>*Resident #213 did not have a care plan for visual and urinary needs. <BR/>These failures could place residents at risk of not receiving the care required to meet their Individualized needs. <BR/>Findings include:<BR/>Resident #98<BR/>Record review of Resident #98's face sheet dated [DATE] revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to dementia (progressive loss of intellectual functioning), type II diabetes, schizoaffective disorder (mental health disorder) and urinary tract infection.<BR/>Record review of Resident #98's physician order summary dated [DATE] revealed the following:<BR/>[DATE] Regular diet Regular Texture texture, Thin/Regular consistency<BR/>[DATE] 2.0 Supplement two times a day for supplement (Give 90ml)<BR/>Record review of Resident 98's Comprehensive MDS, dated [DATE], revealed the following: <BR/>*Section C BIMS revealed a score of 12, which indicated the resident's cognition was moderately impaired. <BR/>H0300. Urinary Continence<BR/>9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days<BR/>*Section V Care Area Assessment (CAA) Summary:<BR/>CAA Results: <BR/>(06)Urinary<BR/>(12)Nutritional<BR/>Record review of Resident #98's care plan, dated [DATE], revealed there was no care plan for urinary or nutritional needs.<BR/>Resident #101<BR/>Record review of Resident #101's face sheet, dated [DATE] revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include dementia (progressive loss of intellectual functioning), Atherosclerotic heart disease (buildup of fats and cholesterol plaque in the walls of the arteries) and anxiety disorder. <BR/>Record review of Resident #101's admission MDS, dated [DATE], revealed Section C BIMS revealed a score of 00, which indicated the resident's cognition was severely impaired. <BR/>Record review of Resident #101's physician order summary dated [DATE] revealed an order Do Not Resuscitate - DNR dated [DATE].<BR/>Record review of Resident #101's care plan, dated [DATE], revealed a care area for Advance Care Plan that indicated the following: <BR/>Focus: Resident/Family/RP does not have advance directives and elects Full Code Status. designating that the resident is a FULL CODE (CPR) status<BR/>Goal: Community will follow full code status through review date<BR/>Intervention: Initiate CPR if I am without a pulse . Review code status at least annually and as indicated<BR/>Further review of the care plan did not indicate a DNR status update.<BR/>Record review of Resident #101's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under Physician's Statement was undated. At the bottom of the form where it indicates All persons who have sign, acknowledging that this document has been properly completed. Revealed there was no signature from either of the two witnesses and no signature from the notary. <BR/>Resident #213<BR/>Record review of Resident #213's face sheet dated [DATE] revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include Parkinson's (a progressive nervous system disease), dementia (progressive loss of intellectual functioning) and dietary vitamin B12 deficiency (anemia/ reduction in red blood cells).<BR/>Record review of Resident #213's Annual MDS, dated [DATE], revealed Section C BIMS revealed a score of 06, which indicated the resident's cognition was severely impaired. <BR/>Record review of Resident #213's care plan, dated [DATE], had no care plan for urinary or visual needs.<BR/>Section B1000. Vision<BR/>1. <BR/>Impaired<BR/>Section H0300. Urinary Continence<BR/>1. <BR/>Occasionally incontinent<BR/>An interview was conducted on [DATE] at 11:06 AM, the ADON said she was beginning to work on the care plans on her wing. She said the nurses and the MDS nurses are responsible for the nursing portion of the care plan. She said a care plan was a plan that was initiated with goals and interventions for the residents based on their needs. She said she had been trained in care plans since working at the facility. She said she had not dealt with the memory unit and this is where the residents resided at the time of the interview. She said the triggered areas from the MDS are what went into the care plan. She said she was not aware the facility had had any issues with missing care plans. She said if triggered areas are not care planned, the potential negative outcome could be those care areas could fall through the cracks, which could affect the resident in a way that could result in injury. She said all nursing staff and therapists use the care plan. However, she said she was unsure if the CNA utilized the plan. <BR/>An interview was conducted on [DATE] at 11:54 AM, MDS A said she was responsible for the residents in hall 700 . She said the residents in questioned resided on the memory care unit and she had worked with them. She said she had been trained regarding care plans and the training was ongoing. She said the training was basic. When asked how she decided what was included in the care plan, she said she included information based on drugs, care area assessments from the MDS, and the resident's diagnosis. When asked if there are systems in place to monitor the completion of care plans, she said audits are done by the DON, regional team, and clinical team. She said she was not aware of any issues with care plans at the time of the interview. She said she expected the care plan to include pertinent information such as medications, care area assessments from the MDS, and resident diagnosis. She said everyone in the building mainly used a care plan, which was a plan of care for what a resident needs or wants. She said the care plan was the best way to take care of the resident on a personal level. She said a potential negative outcome of not including the triggered areas from the MDS was the residents could not get the care that they need. She said DNRs should be care planned accurately because if they are not, then staff may not know the resident's code status. She said then the staff could potentially go against the resident's wishes. When asked what the potential negative outcome for the missed care areas was, she said if a person triggered for urinary, they could be at risk for UTI or even pressure ulcers. She said that if they were triggered for visual, then the resident could be at risk for falls.<BR/>An interview was conducted on [DATE] at 11:55 AM, the Pharmacy nurse said she had been trained in care plans. When asked what information went into a care plan, she said that she worked the floor often and looked at things more personally. She said she would include pertinent information that came from observations. She said she expected the CAAs from the MDS were care planned. When asked if there was a system to monitor care plan accuracy, she said the corporate team, DON and ADON monitored it. She said she was not aware of any missing care plans. When asked what a care plan was, she explained that every day was different and that different perspectives could be taken when caring for a resident. She said the care plan should be able to be given to staff, and the staff would know the resident on a personal level. She said she expected observations and the CAA triggered from the MDS to go into the care plan. She said anyone who provided care used the care plan to care for the resident. She said a care plan was a simple instruction on how to care for the resident. She said it included their likes, dislikes, and how they like things done. She said it outlined how to care for that specific resident. She said failure to include triggered areas could have hindered the resident's care, ability to perform ADLs or overall quality of life. When asked about DNRs and if they should be care planned accurately, she said the resident's code status should have been planned accurately. She said the potential negative outcome of not care planning the resident's code status accurately then the resident's wishes may not be upheld. When asked specifically for the areas that were not triggered in the resident's care plans, she said if a resident was triggered for urinary and not care planned, then staff would not be aware of the resident's extra care needs, and those needs would not be met. She said if the resident triggered for visual and it was not care planned, the staff would not be aware of the extra care the resident needs in that area. She said that the MDS nurses and the entire IDT were responsible for the completion and accuracy of care plans. <BR/>An interview was conducted on [DATE] at 11:57 AM, and MDS B said she was responsible for the residents in hall 800. She stated she had been trained on care plans but that it was basic training. When asked how she determined what to put in the care plan, she said she looked at assessments, progress notes and conducted interviews with the resident and the aides. She said she also used the information from the MDS. She said that she used the care area assessments, and if they triggered, those also would go into the care plan. When asked if there was a system in place to monitor the care plans, she said yes and that the facility clinical team, DON, and she and the MDS Nurse A look at one another's care plans. She said she was unaware of any issues with care plans during the interview. She said her expectation was for the care plan to include the triggered CAAs and all the pertinent information she gathered from progress notes, assessments, and interviews with staff. She said the clinical staff used the care plan, which included the resident's dislikes, medications, diagnosis, and who they are. She said the care plan gave the staff a picture of who the resident was. When asked what the potential negative outcome was, she said that failure to care plan for the resident's needs could hinder their care and may not know how to care for the resident as a clinical team. She said DNRs should be care planned accurately. She said if a code status was not care planned accurately, proper care may not have been given correctly. When asked for the specific missed care areas, she said failure to care plan urinary could result in UTI, infections, or skin issues. She said failure to care plan visual for a resident could result in increased falls. <BR/>An interview was conducted on [DATE] at 12:52 PM, the ADM said the MDS was ultimately responsible for the resident's care plans, but the IDT and direct care also contribute. When asked where the information would come from for the care plan, she said it comes from the CAAs triggered in the MDS. She said she had been trained on care plans to the extent of the ADM. She said it was just a general overview but could not complete an MDS as effectively as an MDS nurse. She said everyone uses the care plan to provide care to the residents. She said if the triggered items are not care planned, they may not have provided the best care for the resident. <BR/>Record review of the facility's policy Care Plans, Comprehensive Person-Centered, Implemented February 2017, revealed the following documentation: <BR/> Comprehensive Care Plans<BR/>The community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan will describe:<BR/>the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;<BR/>any services that would otherwise be required but that are not provided due to the resident's exercise of rights, including the right to refuse treatment.<BR/>The comprehensive assessment consists of a variety of data and information elements, including the following:<BR/>Components of a Comprehensive Resident Assessment<BR/>The comprehensive assessment allows for the development of plan of care that addresses all of the resident's care needs. It also identifies the interventions that may be required to overcome barriers to the provision of resident care.<BR/>Vision: Resident's visual acuity, limitations, and difficulties and appliances used to enhance vision<BR/>Physical functioning and structural problems: Resident's physical functional status, ability to perform activities of daily living, and the resident's need for team member assistance and assistive devices or equipment to maintain or improve functional abilities.<BR/>Continence: Resident's patterns of bladder and bowel continence (control), pattern of elimination, and appliances used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse for 1 of 5 residents (Resident #1), reviewed for abuse. <BR/>The facility failed to ensure a safe environment free from abuse when Activities worker A called Resident #1 a Llorona (Spanish for crybaby or weeping woman) in the dining room. <BR/>This failure could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotion distress, serious harm, and death. <BR/>Findings include: <BR/>Record Review of Resident #1's face sheet dated 12/01/23 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses to include type 2 diabetes mellitus (high blood sugar), chronic obstructive pulmonary disease (lung disease), and essential hypertension (high blood pressure). <BR/>Record review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #1 was understood and had a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. <BR/>During an interview on 12/01/23 at 10:40 AM, Resident #1 stated an incident happened with Activities worker A during lunch around Thanksgiving, she could not remember the exact date. Resident #1 stated she approached Activities worker A in the dining room and wanted to know what was on the menu for lunch. Resident #1 stated Activities worker A told her, What do you want Llorona (Spanish for crybaby or weeping woman)? Resident #1 stated she told Activities Worker A that she could not call her by that name, she needed to call her by her real name. Resident #1 stated she did not like being called a crybaby in Spanish and it made her upset. Resident #1 stated she did not know if anyone else heard this and she did not tell any of the staff members. Resident #1 stated she called the State (HHSC) right away because she knew she shouldn't be treated like this. Resident #1 stated she feels uncomfortable being around Activities worker A.<BR/>During an interview on 12/01/23 at 11:18 AM, Activities worker A was asked if she called Resident #1 a Llorona during a lunch meal. Activities worker A stated during their Thanksgiving meal, unknown the exact date, she went to the facility to help pass out the food. Activities worker A stated Resident #1 approached her and she did call Resident #1 a Llorona. Activities worker A stated she did not mean it to be rude and thought she was playing/joking with Resident #1. Activities worker A stated she has been trained to call Residents by their real names, not by a nickname. Activities worker A stated she should not have called Resident #1 a Llorona and she will not do it again. <BR/>During an interview on 12/01/23 at 11:37 AM, the Adm stated she was not aware of the incident that happened between Activities worker A and Resident #1. The Adm stated she expects staff to call residents by their real name, not any other name. The Adm stated as the abuse coordinator for the facility, she was responsible for ensuring staff were following the abuse policies. The Adm stated she knows Activities worker A has completed abuse training at the facility and she will have to look up the dates. The Adm stated the potential negative outcome to a resident being called a negative name was they could feel bad about themselves. The Adm stated she will follow the facility policy regarding abuse allegations now that she was aware of the incident between Resident #1 and Activities worker A. <BR/>Record review of a facility document titled, Orientation Framework and Checklist for Activities worker A with a hire date of 08/02/23 reflected:<BR/>Resident Abuse Reporting: Relias (online training)- Preventing, Recognizing & Reporting Abuse was completed on 08/02/23.<BR/>Record review of a facility in-service training attendance sheet, dated 10/13/23, regarding Reporting Abuse and Neglect: If you witness or suspect abuse or neglect, it is your responsibility to report it to the administrator immediately! If you do not report it immediately, you are just as guilty as the person who is suspected or is committing the act. The administrator is the abuse coordinator. In the event they are not available, report to the DON immediately. Activities worker A's signature was noted on the attendance sheet. <BR/>Record review of a facility in-service training attendance sheet, dated 11/30/23, regarding Abuse Guidance . reflected Activities worker A's signature was noted on the attendance sheet. <BR/>Record review of facility policy, titled Abuse Guidance: Preventing, Identifying and Reporting, with a revised date of 10/22 reflected the following:<BR/>Compliance Guidelines: Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals .<BR/>-If anyone harms or threatens to harm a resident/patient, neglects their care, takes their property, or violates their dignity, the resident, has the right to file a complaint with the community administrator or with the Texas Department of Aging and Disability Services by calling [PHONE NUMBER].<BR/>Types of Abuse<BR/>-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing .<BR/>-Verbal abuse is the use of oral, written, or gestured language that willfully includes the use of disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include threats of harm or frightening a resident by telling a resident that he or she will never be able to see his or her family again .<BR/>-Mental abuse includes humiliation, harassment, threats of punishment, or deprivation

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored in locked under proper temperature controls and permit only authorized personnel to have access to the keys for 3 medication carts (Medication carts #1, #2 and #3) reviewed for medication storage.<BR/>1. The facility failed to ensure Medication carts #1, #2 and #3 were locked when unattended. <BR/>2. The facility failed to ensure Medications were secured in the medication cart when not in use. <BR/>These failures could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. <BR/>Findings include:<BR/>During an observation and interview on 6/7/23 at 10:26 a.m., in A Wing, revealed Medication Cart #1 with the key lock not pushed in, which indicated the cart was unlocked parked at the nurses station with the drawers facing outward towards the open area. RN A was observed sitting behind the nurses station with her head down documenting. The State Surveyor approached the medication cart, opened the top two right drawers, RN A did not stop or look up. The top right drawer contained several bottles of resident prescription bottles containing medications and the second top right drawer contained a locked box. RN A stated she was assigned to Medication Cart #1. RN A stated she was in visual of the medication cart and stated, I am confident I could see if someone was near the cart. RN A stated the cart should be locked but because she was behind the nurses station, she did not feel there was an issue. RN A stated she was unaware of the policy regarding medication cart security. RN A walked from inside the nurses station to the cart and pushed the key lock in. <BR/>During an observation on 6/7/23 at 10:26 a.m., several residents were observed in the dining room/activity room to the left of the nurses station, and 1 resident observed approaching the nurses station where the medication cart was parked. <BR/>During an interview on 6/7/23 at 10:54 a.m., the Pharmacy LVN stated if a nurse or medication aide walked away from the medication cart and the drawers were not in eyesight, the cart must be locked. The Pharmacy LVN stated RN A used to be the ADON on A Wing and was trained to lock the medication cart. The Pharmacy LVN stated if the cart was parked at the nurses station and not being used, it was to be turned with the drawers facing the nurses station as an extra way to keep the cart secured besides locking it. The Pharmacy LVN stated if RN A did not see the State Surveyor open the drawers, then RN A did not have a visual of the medication cart and it was not secured. The Pharmacy LVN stated the risk of not locking the medication cart was residents could go inside the cart and take something, if they ingested a medication, it could be fatal, and at least harmful to the resident. The Pharmacy LVN stated RN A was a nurse for several years and knew better than to keep the medication cart unlocked. The Pharmacy LVN stated nurses and medication aides were taught during orientation and during job training on the floor the importance of medication cart security. <BR/>During an interview on 6/7/23 at 11:02 a.m. with RN A, in Wing A with the Pharmacy LVN present, RN A stated she did not see the State Surveyor open the medication cart top two drawers when the medication cart was unlocked at the nurses station. RN A stated the top right drawer contained bottles of prescription resident medication and the second drawer contained the locked box. RN A stated, I guess I didn't have visual of it. RN A stated the medication cart should be locked at all times when not in use, so residents do not get into the medication. RN A was asked what the risk was of the medication cart being unlocked and RN A stated I don't know what you want me to say. How would I know if I didn't see what they took. The Pharmacy LVN stated, the risk could be harm or death, the resident could have an adverse reaction and we would not know what they took. <BR/>During an interview on 6/7/23 at 11:15 a.m. with the Pharmacy LVN stated RN A told her she left the medication cart unsecured. The Pharmacy LVN stated RN A knew better than to keep the medication cart unlocked and because she had been the ADON, there was no reason for her not to know that the cart needed to be secured. <BR/>During an interview on 6/7/23 at 1:40 p.m., RN B stated if RN A was behind the nurses station and could not see the drawers to the medication cart, then RN A did not have visual of the cart, and it was unsecured. RN B stated medication carts were supposed to be locked at all times when the drawers were not in visual. RN B stated the risk of the medication cart being unsecured was a resident could take medications, sharps, thermometers, or supplies that could cause harm. RN B stated if a resident took a medication, the resident could have interactions, allergic reactions and it could cause physical harm to the resident. RN B stated if a resident took sharps or supplies such as scissors, the resident could use those items to harm themselves. RN B stated RN A was an ADON in the facility until recently and had been trained to secure the medication cart at all times. RN B stated if a resident was in a wheelchair in front of the medication cart and RN A was behind the nurses station, there would have been no way she would have seen a resident open a drawer. <BR/>During on observation and interview on 6/7/23 at 1:55 p.m. in A Wing, Medication Aide C was observed standing on the outside of a partition wall assisting 2 unidentified residents with medications. Upon approach to the hallway on the left, 2 medication carts (#2 and #3) were observed unlocked on the opposite side of the partition wall and a resident walking towards the medication carts. Cart #2 was observed to have an unsecured partially filled medication card of Celecoxib 100mg left on top of the Cart #2. The MA was observed to come from behind the medication partition wall to where the Medication Carts were parked. MA stated she was assigned to both carts and left them unlocked because she was assisting a resident who she thought was sliding out of her wheelchair. MA C stated she also left the medication on top of Cart #1. MA C stated she should lock the carts when she was not using them, and she was trained to keep the medication carts locked. MA C stated after unlocking a medication cart, she was supposed to lock it back up and both carts should not be unlocked. MA C stated, I am sorry, I am human and make mistakes and then MA C started to walk away. The State Surveyor asked MA C if she was going to lock up the Celecoxib medication before leaving the area. MA C grabbed the medication card and locked it inside Cart #2. MA C stated Celecoxib was used for pain, but it was not a controlled substance. <BR/>During an interview on 6/7/23 at approximately 2:30 p.m., the Human Resources Director stated all staff were trained on medication cart security. The Human Resources Director stated she did the orientation with new staff and then when staff were put on the floor they were partnered with a nurse and taught medication security and to keep the medication carts locked at all times. The Human Resources Director stated RN A and the MA were trained on medication cart security and part of their job duties included dispensing and storing medications.<BR/>During an interview on 6/7/23 at 2:45 p.m., the Pharmacy LVN stated she was informed by the MA C that she left a medication on the cart and left both medication carts unlocked. The Pharmacy LVN stated the MA C told her she thought a resident was falling out of her wheelchair and went to assist the resident. The Pharmacy LVN stated both medication carts should not have been unlocked at the same time nor should medication have been left on top of the cart. The Pharmacy LVN stated having 2 different staff (RN A and MA C) in the same wing (A) leaving medication carts unsecured was a problem and would be addressed. <BR/>During an interview on 6/7/23 at 3:15 p.m., the ADM stated she was aware RN A and the MA C failed to secure the medication carts by keeping them locked. The ADM stated staff would be in-serviced on locking medication carts and the importance of medication cart security. The ADM stated staff knew medication carts should be locked at all times when not in use to prevent residents, staff, or visitors from taking medications that were not theirs. <BR/>Record review of the facility provided Charge Nurse job description, dated 7/1/2020, revealed the following: Results Statement: To contribute to the success of the community by providing quality nursing care to residents and to coordinate total nursing care for residents by implementing specific procedures/programs and being in compliance with all (insert facility name) policies and procedures, state regulations and federal regulations. <BR/>-Order, receive and store medications appropriately. <BR/>Record review of the facility provided Certified Medication Aide job description, dated 7/1/2020, revealed the following: Results statement: To support the community by ensuring residents are well cared for and receive accurate medications as ordered by the physician/physician extender in accordance with established nursing standards, standards of medication aide practices, state and federal requirements, and guidelines of the community related to medication administration. <BR/>Record review of the facility's policy titled Medication Cart Use and Storage, dated 3/15/2019, reflected the following: Compliance Guidelines: <BR/>Security: <BR/>-The medication cart and its storage bins are kept locked until the specified time of medication administration. <BR/>-If an emergency occurs during the medication pass, the nurse/mediation aide securely locks the medication cart before attending to the emergency situation.<BR/>-During routine administration of medications, the cart may be kept in the doorway of the resident's room with: Drawers unlocked and facing inward, and within sight of the nurse. No medications are kept on top of the cart . <BR/>Procedure: <BR/>-Lock the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 5 residents (Resident#1) reviewed for misappropriation of property, in that:<BR/>The facility failed to implement their abuse policy related to misappropriation of resident property once the Facility became aware Resident #1 narcotics were missing.<BR/>This failure could place residents at risk of not receiving medications as prescribed for pain. <BR/>Findings include: <BR/>Record review of Resident #1's undated face sheet, indicated the resident was admitted to the facility on [DATE]. His diagnosis includes unspecified dementia, Psychotic disorder with delusions, Heart failure, Hypertension, Lack of coordination, History of healed traumatic fracture. <BR/>Record review of a Resident #1's quarterly MDS dated [DATE] indicated a BIMS of 3 indicating a severe cognitive impairment. <BR/>Record review of Resident #1's orders revealed an active order for Acetaminophen ordered on 8/28/23; Assess level of pain every shift on 0-10 scale; Hydrocodone-Acetaminophen 7.5-3.25 ordered on 2/4/21.<BR/>Record review of the pharmacy shipment summary for Resident #1 revealed the facility received an order on 7/8/22 at 4:13 p.m. for Hydrocodone-ACET 7.5-325 MG (Norco) tablet quantity of 15. <BR/>During an interview on 3/30/23 11:01 a.m. the DON stated he became aware of the 15 missing Norco pills on 3/29/23 at approximately 8:30 a.m. when LVN A called her and reported that Resident #1's card of 15 Norco pills was not in the medication cart. The DON stated LVN A started her shift on 3/29/23 at 6 a.m. and it was during a medication cart count with LVN C that LVN A questioned what happened to Resident #1's card of 15 count Norco. The DON stated LVN A stated LVN C had no idea about the missing medication for Resident #1. The DON stated the med count sheet that accounted for the 15 count Norco was also missing. The DON stated LVN A should have immediately notified her (DON) of the suspected missing medication and should not have allowed LVN C to go home, nor should LVN A have signed for the cart. The DON stated LVN C signed onto the medication cart on 3/28/23 at 6 p.m. when she came onto her shift and took responsibility of the cart from LVN B whose shift ended on 3/28/23 at 6 p.m. The DON stated per facility policy LVN A was trained to immediately notify the DON of any suspected medications and to make sure the previous LVN (LVN C) did not leave the facility until she (DON) showed up to investigate. The DON stated LVN A called LVN D who overseas pharmacy/medication services in the facility. The DON stated LVN A also contacted LVN B to see if the medications were in the cart when she signed onto and off the cart on 3/28/23 and LVN B confirmed the medication was accounted for during LVN B's count with LVN C. The DON stated that LVN A stated that LVN B confirmed the controlled medication count with LVN C and then handed responsibility of the cart and medications to LVN C. The DON stated that both LVN A and LVN B were drug tested by the facility and both LVN A and LVN B were negative for all substances. The DON stated she has attempted to contact LVN C numerous times and either LVN C stated that she was on the way to the facility or refused to answer or return calls and texts from her. The DON stated LVN C had not had a drug test yet because LVN C had not come to the facility as requested. The DON stated that Resident #1's Norco was PRN and Resident #1 rarely asked for pain medication. The DON stated the facility was still investigating the missing medications for Resident #1. The DON stated that she and LVN D both counted all medications on the carts and found no discrepancies with missing medications or on any other medication cart in the building. The DON stated the LVN medication cart contained the PRN pain medications for residents and the CNAs/Medication Aides did not have access or the keys to the LVN PRN medication cart. <BR/>During an interview on 3/30/23 1:17 p.m. LVN A stated her assigned shift is 6 a.m. to 6 p.m. and she was the one who identified that Resident #1's hydrocodone blister pack of 15 tablets was missing from the cart on 3/29/23. LVN A stated she had not worked on 3/27/23 or 3/28/23 but the last time she worked on 3/26/23 the blister pack was in the medication cart. LVN A stated when shift change occurs, the oncoming and off going nurse have to count the PRN narcotics in the lock box and on 3/29/23 she noticed that Resident #1 was missing 15 tablets of Norco's. LVN A stated she counted with LVN C on 3/29/23 at 6 a.m. and there is a binder with count sheets for each resident's narcotic for each blister pack. LVN A stated that because she has worked at the facility for a long time, she had counted the controlled substances in the cart numerous times she has remembered the order of the sheets and count for Resident #1's Norco. LVN A stated that the count for Resident #1's Norco rarely changed because Resident #1 rarely takes a pain pill. LVN A stated she has remembered the order of the sheets and count. LVN A stated the order of the count of PRN narcotics in the book go in the order of 8, 15, 30 and Resident #1 has a blister pack of Norco with 8 tablets left and another blister pack for 15 tablets. LVN A stated the 8-tablet count sheet was in the book and the 8-tablet blister pack was in the cart. LVN A stated the 15-tablet count sheet, and the 15-tablet blister pack were both missing. LVN A stated she asked LVN C what happened to the 15-count sheet and blister pack of Resident #1's Norco and LVN C told her she did not know about the 15-tablet blister pack and that when she signed onto the cart at 6 p.m. on 3/28/23 there was no 15-tablet blister pack. LVN A stated the 15-tablet count sheet and blister pack had been in the cart for several months and she thought that maybe it was discontinued and pulled from the cart on her days off but that the PRN order was still in the computer. LVN A stated she called LVN B to see if she knew what happened to the 15 Norco and LVN B stated they were in the cart when she ended her shift at 6 p.m. on 3/28/23. LVN A stated she then texted the Pharmacy LVN at 6:34 a.m. and asked about it and the Pharmacy LVN stated she did not pull the medication from the cart. LVN A stated she did not suspect they were taken and thought that someone must have pulled and discontinued the medication when she did the count, so she told LVN C to go home and she (LVN A) signed onto the cart taking accountability of it. LVN A stated she did not immediately report to the DON as required because she did not initially think there was a missing medication issue. LVN A stated without the narcotic count sheet for Resident #1 and the medication not being in the cart, that no one would have realized the medication was supposed to be in the cart. LVN A stated she only realized the medication and count sheet were missing because the count had been the same on the PRN narcotics for several months. LVN A stated if she would have suspected a medication error or missing medication she would have immediately reported to the DON as required by policy and training. LVN A stated she was written up by the facility for not immediately reporting the suspected missing medication to the DON, and allowing LVN C to leave without having the missing medication investigated by the DON. <BR/>LVN A stated, I have been trained on med counts and to report immediately to the DON. But I didn't want to think someone took them. I thought maybe they had been removed from the cart between my days off. If medications that are controlled are removed from the cart meaning discontinued, there is nowhere I would know to look for that information and would find out by speaking to people about it. <BR/>During a phone interview on 3/30/23 at 1:39 p.m. LVN B stated she worked on 3/28/23 from 6 a.m. to 6 p.m. and she took responsibility of the cart at 6 a.m. Resident #1's 8 count of Norco's were in the medication cart. LVN B stated at 6 p.m. on 3/28/23 she did a medication count with LVN C and Resident #1's 15 count of Norco were in the cart and the med count sheet was in the book. LVN B stated in the book of med count sheets, she remembers that the count goes in order of 8, 15, 30. LVN B stated that Resident #1 has the 8 count and 15 count of Norco with different strengths based on the level of pain and they are separate sheets and separate blister packs for the 8 count and the 15 count. LVN B stated that the order of the med count sheets correlates with the order of the blister packs in the cart and when a med count is done, they look in the book and see an 8-count left and confirm that it is in the cart. LVN B stated the next sheet shows 15 remaining pills in the blister pack and it is confirmed that is what is locked in the cart. LVN B stated that the next medication is a 30 count and again it is confirmed that there are 30 pills left in the blister pack in the medication cart. LVN B stated that because she has counted and verified that the medications were in the count, she has remembered the order of which comes first, 8, then 15, then 30. LVN B stated LVN A called her on 3/29/23 and asked if she had pulled Resident #1's 15 count tablets of hydrocodone from the cart and put in the disposable medication box, and LVN B stated she did not. LVN B stated, I would not accept count if there was a question about a medication that had previously been in the cart. LVN B stated she would probably call the Pharmacy nurse first and then the DON and would not sign onto the medication cart book because she did not want to be responsible or sign onto ownership for the cart if there was a question about missing medications. <BR/>During an interview on 3/30/23 at 2:10 p.m. the DON stated LVN A should not have signed onto the cart because even if she suspected something was missing, she was trained to report to the DON. call her. The DON stated LVN A is to notify her immediately and should not sign onto a medication cart if she had any suspicion that there was a medication missing. The DON stated if LVNA A had reasonable suspicion that something was wrong, or something was missing she should have immediately called her, not signed onto the cart, and told LVN C to stay until she arrived. The DON stated she would have immediately come to the facility to investigate and would have called the police to determine if the missing medication was on site, or in any staff vehicle in the parking lot. <BR/>During an interview on 3/30/23 at 2:56 p.m. LVN C stated she had worked for three weeks at the facility but has been a nurse for over 10 years. LVN C stated she and LVN A were counting medications on 3/29/23 at 6 a.m. when her shift ended and LVN A was starting her shift. LVN C stated a medication cart count is performed on all of the controlled substances in the nurse medication cart and that includes the PRN controlled substances. LVN C stated during the count, LVN A asked her where Resident #1's count sheet for Norco was and where the blister pack of 15 pills went. LVN C stated she told LVN A she did not know about the missing medication for Resident #1. LVN C stated she did not know she was not supposed to leave when there was a medication count discrepancy and did not know she was supposed to notify the DON immediately. LVN C stated she did not notify the DON and she left the facility at approximately 6:30 a.m. that morning. LVN C stated she was not aware of the policy and did not have training on what to do when there was a medication count issue. LVN C stated she did not take the missing Norco and that today the facility conducted a drug test on her prior to this interview and she has no concerns regarding the drug test results. LVN C stated she did not take any medications from the facility, and she did not take any of Resident #1's PRN Norco. <BR/>During an interview on 3/30/23 at 4:17 p.m. with Resident #1; was observed in his wheelchair in C hall in the common areas. Resident #1 did not respond to verbal prompts by investigator and did not acknowledge the investigator during an attempt to interview. <BR/>During an interview on 3/31/23 at 8:51 a.m. the DON stated Resident #1's scheduled pain medications are in a different medication cart and administered by the medication aides. The DON stated PRN pain medications are stored in the nurse medication cart and only the nurse assigned to the cart at that time have the keys to it. <BR/>During a phone interview on 3/31/23 at 10:41 a.m. with LVN C; stated that she has been a nurse for 19 years and has been trained on how to administer and document PRN medications. The LVN C stated that she has been trained to first review the order in the computer to verify if there is an active order, then to document on the narcotic count sheet and pull the narcotic from the blister pack. The LVN C stated that there is a pain scale that she has to enter in the medication administration record in the computer. The LVN C stated that she does not know what happened to Resident #1's missing Norco pills from the medication cart. The LVN C stated that she has been assigned to C hall and the medication cart in that hallway. The LVN C stated that although she was trained to document in the MAR and controlled substance sheet, she believed that she has forgotten to enter it into the MAR on several occasions. The LVN C stated that she believed that she has forgotten to document in the MAR more than 5 times but less than 10 times and that she believed it had happened with at least 5 residents. The LVN C stated she knew better and there is no excuse really to not document it in the MAR and on the controlled substance sheets. <BR/>During an interview on 3/31/23 at 11:05 a.m. The Pharmacy nurse stated LVN C started work at the facility on 3/14/23 and would have been assigned to another nurse for training that included medication carts and administering and documenting medications and PRN pain medications. The Pharmacy nurse stated when there is a concern or suspicion of missing medications, the nurse who identified the issue must notify the DON immediately. The Pharmacy nurse stated after the DON is notified, the DON would notify her as well and an investigation would be conducted. The Pharmacy nurse stated she was notified of Resident #1's suspected missing Norco controlled sheet and the blister pack of 15 pills. The Pharmacy nurse stated all nurses and medication aides are trained on medication diversion, counting controlled substances and to immediately report any suspicion of error to the DON. <BR/>Record Review of the facility's Resident Abuse Policy, revised July 2018; revealed: <BR/>Policy statement: It is the responsibility of our team members, community consultants, attending physicians, family members, visitors etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to community management. <BR/>-Team member shall report any suspected abuse or incidents of abuse to the community designated abuse coordinator promptly. The Administrator and Director of Nurses services shall be notified immediately and if incidents occur or are discovered after hours, the Administrator and Director of Nurses shall be called at home or be paged and notified of such incident. <BR/>-Investigating Incidents of Theft and/or Misappropriation of Resident Property: <BR/>-Policy statement: All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated. Misappropriation of resident property is defined as the pattern or deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. <BR/>Record Review of the facility's Loss or Theft of Medications; revised on 5/1/22 reflected, for Suspected Diversion: The employee discovering an alleged diversion will report immediately to the nursing supervisor/Director of Nurses. The DON will direct an investigation including full accounting of controlled substances. <BR/>Record Review of the facility's Medication: Controlled Drugs policy, implemented on 3/15/19 revealed: <BR/>-Compliance Guidelines: To provide guidance on the process where Controlled drugs are inventoried and administered as required by state and federal agencies. <BR/>When administering a controlled medication, identify the medication in the resident eMar, review the control sheet and write in the remaining doses on the sheet. Administer the medication and sign the eMar once administered. <BR/>-Reconcile the declining inventory record at the beginning and end of each shift. Reconciliation shall be performed by a physical count of the remaining medication and a visual of the card/bottle contents by two persons who are legally authorized to administer medications. <BR/>In case of a discrepancy: <BR/>-Report any discrepancy in the count to the DON at the time it identified. <BR/>-Nurse and med-aides are not to leave the community until a member of the clinical management team comes in to investigate and rectify/correct the count.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of all medications to meet the needs of the residents for 3 of 3 residents reviewed for pharmaceutical services in that:<BR/>LVN A failed to immediately notify the DON of missing PRN pain medications for Resident #1 during the medication count with LVN C on 3/29/23. <BR/>The facility failed to have a system in place to ensure accurate documenting and dispensing of controlled medications for Resident #2 and Resident #3. <BR/>These failures could place residents at risk of having their medications diverted and/or receiving the incorrect dosage because of improper secured storage or receiving medications that may not be safe and effective.<BR/>Findings include: <BR/>Record review of Resident #1's undated face sheet, indicated the resident was admitted to the facility on [DATE]. His diagnosis includes unspecified dementia, Psychotic disorder with delusions, Heart failure, Hypertension, Lack of coordination, History of healed traumatic fracture. <BR/>Record review of a Resident #1's quarterly MDS dated [DATE] indicated a BIMS of 3 indicating a severe cognitive impairment. <BR/>Record review of Resident #1's orders revealed an active order for Acetaminophen ordered on 8/28/23; Assess level of pain every shift on 0-10 scale; Hydrocodone-Acetaminophen 7.5-3.25 ordered on 2/4/21.<BR/>Record review of Resident #2's undated face sheet, indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnosis include: Chronic Obstructive Pulmonary Disease, Alzheimer's Disease, Post Traumatic Stress disorder, Chronic Kidney Disease, Heart failure and low back pain. <BR/>Record review of Resident #2's MDS dated [DATE] indicated a BIMS of 13 indicating cognitively intact. <BR/>Record review of Resident #2's orders revealed an active order for Norco Tablet 7.5-325 MG; Give 1 tablet by mouth every six hours as needed for Degeneration of Lumber intervertebral disc related to low back pain, Start Date: 10/6/22<BR/>Record review of Resident #2's Medication Administration Record, dated March 1, 2023-March 30, 2023; revealed an active order for Norco Tablet 7.5-325 MG; administered on 3/8/23 with a pain level of 4/10. <BR/>Record review of Resident #2's PRN controlled drug administration record for Norco 7.5-325 mg revealed; LVN C documented she administered Resident #2's PRN medication on 3/18/23, 3/19/23, 3/20/23, 3/21/23 and 3/22/23. <BR/>Record review of Resident #3's undated face sheet, indicated the resident was admitted to the facility on [DATE]. His diagnosis include: Respiratory failure, Dementia, Major Depressive Disorder, Poly osteoarthritis, Chronic Kidney disease. <BR/>Record review of a Resident #3's MDS dated [DATE] indicated a BIMS of 11 indicating a moderate impairment. <BR/>Record review of Resident #3's orders revealed an active order for Norco Tablet 10-325 MG; Give 1 tablet by mouth every six hours for pain Start Date: 3/8/23 and Norco Tablet 10-325 MG every four hours as needed for mild/moderate pain, start date: 12/19/22<BR/>Record review of Resident #3's Medication Administration Record, dated March 1, 2023-March 30, 2023; revealed an active order for Norco Tablet 10-325 MG; every 6 hours on all days and PRN Norco 10-325 administered on 3/18/23 with a pain level of 7/10 documented by LVN C. <BR/>Record review of Resident #3's PRN controlled drug administration record for Norco 10-325 mg revealed; LVN C documented she administered Resident #3's PRN medication on 3/18/23, 3/19/23, 3/20/23, 3/21/23, 3/22/23, 3/23/23, 3/24/23, 3/26/23, 3/27/23, 3/28/23 and 3/29/23. <BR/>Record review of the pharmacy shipment summary for Resident #1 revealed the facility received an order on 7/8/22 at 4:13 p.m. for Hydrocodone-ACET 7.5-325 MG (Norco) tablet quantity of 15. <BR/>During an interview on 3/30/23 11:01 a.m. the DON stated he became aware of the 15 missing Norco pills on 3/29/23 at approximately 8:30 a.m. when LVN A called her and reported that Resident #1's card of 15 Norco pills was not in the medication cart. The DON stated LVN A started her shift on 3/29/23 at 6 a.m. and it was during a medication cart count with LVN C that LVN A questioned what happened to Resident #1's card of 15 count Norco. The DON stated LVN A stated LVN C had no idea about the missing medication for Resident #1. The DON stated the med count sheet that accounted for the 15 count Norco was also missing. The DON stated LVN A should have immediately notified her (DON) of the suspected missing medication and should not have allowed LVN C to go home, nor should LVN A have signed for the cart. The DON stated LVN C signed onto the medication cart on 3/28/23 at 6 p.m. when she came onto her shift and took responsibility of the cart from LVN B whose shift ended on 3/28/23 at 6 p.m. The DON stated per facility policy LVN A was trained to immediately notify the DON of any suspected medications and to make sure the previous LVN (LVN C) did not leave the facility until she (DON) showed up to investigate. The DON stated LVN A called LVN D who overseas pharmacy/medication services in the facility. The DON stated LVN A also contacted LVN B to see if the medications were in the cart when she signed onto and off the cart on 3/28/23 and LVN B confirmed the medication was accounted for during LVN B's count with LVN C. The DON stated that LVN A stated that LVN B confirmed the controlled medication count with LVN C and then handed responsibility of the cart and medications to LVN C. The DON stated that both LVN A and LVN B were drug tested by the facility and both LVN A and LVN B were negative for all substances. The DON stated she has attempted to contact LVN C numerous times and either LVN C stated that she was on the way to the facility or refused to answer or return calls and texts from her. The DON stated LVN C had not had a drug test yet because LVN C had not come to the facility as requested. The DON stated that Resident #1's Norco was PRN and Resident #1 rarely asked for pain medication. The DON stated the facility was still investigating the missing medications for Resident #1. The DON stated that she and LVN D both counted all medications on the carts and found no discrepancies with missing medications or on any other medication cart in the building. The DON stated the LVN medication cart contained the PRN pain medications for residents and the CNAs/Medication Aides did not have access or the keys to the LVN PRN medication cart. <BR/>During an interview on 3/30/23 1:17 p.m. LVN A stated her assigned shift is 6 a.m. to 6 p.m. and she was the one who identified that Resident #1's hydrocodone blister pack of 15 tablets was missing from the cart on 3/29/23. LVN A stated she had not worked on 3/27/23 or 3/28/23 but the last time she worked on 3/26/23 the blister pack was in the medication cart. LVN A stated when shift change occurs, the oncoming and off going nurse have to count the PRN narcotics in the lock box and on 3/29/23 she noticed that Resident #1 was missing 15 tablets of Norco's. LVN A stated she counted with LVN C on 3/29/23 at 6 a.m. and there is a binder with count sheets for each resident's narcotic for each blister pack. LVN A stated that because she has worked at the facility for a long time, she had counted the controlled substances in the cart numerous times she has remembered the order of the sheets and count for Resident #1's Norco. LVN A stated that the count for Resident #1's Norco rarely changed because Resident #1 rarely takes a pain pill. LVN A stated she has remembered the order of the sheets and count. LVN A stated the order of the count of PRN narcotics in the book go in the order of 8, 15, 30 and Resident #1 has a blister pack of Norco with 8 tablets left and another blister pack for 15 tablets. LVN A stated the 8-tablet count sheet was in the book and the 8-tablet blister pack was in the cart. LVN A stated the 15-tablet count sheet, and the 15-tablet blister pack were both missing. LVN A stated she asked LVN C what happened to the 15-count sheet and blister pack of Resident #1's Norco and LVN C told her she did not know about the 15-tablet blister pack and that when she signed onto the cart at 6 p.m. on 3/28/23 there was no 15-tablet blister pack. LVN A stated the 15-tablet count sheet and blister pack had been in the cart for several months and she thought that maybe it was discontinued and pulled from the cart on her days off but that the PRN order was still in the computer. LVN A stated she called LVN B to see if she knew what happened to the 15 Norco and LVN B stated they were in the cart when she ended her shift at 6 p.m. on 3/28/23. LVN A stated she then texted the Pharmacy LVN at 6:34 a.m. and asked about it and the Pharmacy LVN stated she did not pull the medication from the cart. LVN A stated she did not suspect they were taken and thought that someone must have pulled and discontinued the medication when she did the count, so she told LVN C to go home and she (LVN A) signed onto the cart taking accountability of it. LVN A stated she did not immediately report to the DON as required because she did not initially think there was a missing medication issue. LVN A stated without the narcotic count sheet for Resident #1 and the medication not being in the cart, that no one would have realized the medication was supposed to be in the cart. LVN A stated she only realized the medication and count sheet were missing because the count had been the same on the PRN narcotics for several months. LVN A stated if she would have suspected a medication error or missing medication she would have immediately reported to the DON as required by policy and training. LVN A stated she was written up by the facility for not immediately reporting the suspected missing medication to the DON, and allowing LVN C to leave without having the missing medication investigated by the DON. <BR/>LVN A stated, I have been trained on med counts and to report immediately to the DON. But I didn't want to think someone took them. I thought maybe they had been removed from the cart between my days off. If medications that are controlled are removed from the cart meaning discontinued, there is nowhere I would know to look for that information and would find out by speaking to people about it. <BR/>During a phone interview on 3/30/23 at 1:39 p.m. LVN B stated she worked on 3/28/23 from 6 a.m. to 6 p.m. and she took responsibility of the cart at 6 a.m. Resident #1's 8 count of Norco's were in the medication cart. LVN B stated at 6 p.m. on 3/28/23 she did a medication count with LVN C and Resident #1's 15 count of Norco were in the cart and the med count sheet was in the book. LVN B stated in the book of med count sheets, she remembers that the count goes in order of 8, 15, 30. LVN B stated that Resident #1 has the 8 count and 15 count of Norco with different strengths based on the level of pain and they are separate sheets and separate blister packs for the 8 count and the 15 count. LVN B stated that the order of the med count sheets correlates with the order of the blister packs in the cart and when a med count is done, they look in the book and see an 8-count left and confirm that it is in the cart. LVN B stated the next sheet shows 15 remaining pills in the blister pack and it is confirmed that is what is locked in the cart. LVN B stated that the next medication is a 30 count and again it is confirmed that there are 30 pills left in the blister pack in the medication cart. LVN B stated that because she has counted and verified that the medications were in the count, she has remembered the order of which comes first, 8, then 15, then 30. LVN B stated LVN A called her on 3/29/23 and asked if she had pulled Resident #1's 15 count tablets of hydrocodone from the cart and put in the disposable medication box, and LVN B stated she did not. LVN B stated, I would not accept count if there was a question about a medication that had previously been in the cart. LVN B stated she would probably call the Pharmacy nurse first and then the DON and would not sign onto the medication cart book because she did not want to be responsible or sign onto ownership for the cart if there was a question about missing medications. <BR/>During an interview on 3/30/23 at 2:10 p.m. the DON stated LVN A should not have signed onto the cart because even if she suspected something was missing, she was trained to report to the DON. call her. The DON stated LVN A is to notify her immediately and should not sign onto a medication cart if she had any suspicion that there was a medication missing. The DON stated if LVNA A had reasonable suspicion that something was wrong, or something was missing she should have immediately called her, not signed onto the cart and told LVN C to stay until she arrived. The DON stated she would have immediately come to the facility to investigate and would have called the police to determine if the missing medication was on site, or in any staff vehicle in the parking lot. <BR/>During an interview on 3/30/23 at 2:56 p.m. LVN C stated she had worked for three weeks at the facility but has been a nurse for over 10 years. LVN C stated she and LVN A were counting medications on 3/29/23 at 6 a.m. when her shift ended and LVN A was starting her shift. LVN C stated a medication cart count is performed on all of the controlled substances in the nurse medication cart and that includes the PRN controlled substances. LVN C stated during the count, LVN A asked her where Resident #1's count sheet for Norco was and where the blister pack of 15 pills went. LVN C stated she told LVN A she did not know about the missing medication for Resident #1. LVN C stated she did not know she was not supposed to leave when there was a medication count discrepancy and did not know she was supposed to notify the DON immediately. LVN C stated she did not notify the DON and she left the facility at approximately 6:30 a.m. that morning. LVN C stated she was not aware of the policy and did not have training on what to do when there was a medication count issue. LVN C stated she did not take the missing Norco and that today the facility conducted a drug test on her prior to this interview and she has no concerns regarding the drug test results. LVN C stated she did not take any medications from the facility, and she did not take any of Resident #1's PRN Norco. <BR/>During an interview on 3/30/23 at 3:45 p.m. the DON stated they suspended LVN A, LVN B, and LVN C until they complete their investigation. The DON stated LVN A and LVN B had clear drug tests in all areas tested. The DON stated the areas tested included: Marijuana; Opiate-Morphine; Amphetamine; Barbiturates; Methadone; Tricyclic; Propoxyphene; Cocaine; Methamphetamine; Phencyclidine; Benzodiazepine; Ecstasy; Oxycodone; Alcohol The DON stated LVN C tested positive for 5 areas that included Amphetamine; Methadone; Methamphetamine; Benzodiazepine and Oxycodone. and the facility is sending the testing kit and results to an independent lab to confirm what substances LVN C was positive for and what medications LVN C is prescribed. The DON stated that per facility policy and HIPAA the facility cannot ask LVN C what medications she takes or if they would interfere with a drug test. <BR/>During an interview on 3/30/23 at 4:17 p.m. with Resident #1; was observed in his wheelchair in C hall in the common areas. Resident #1 did not respond to verbal prompts by investigator and did not acknowledge the investigator during an attempt to interview. <BR/>During an interview on 3/31/23 at 8:51 a.m. the DON stated Resident #1's scheduled pain medications are in a different medication cart and administered by the medication aides. The DON stated PRN pain medications are stored in the nurse medication cart and only the nurse assigned to the cart at that time have the keys to it. <BR/>During a phone interview on 3/31/23 at 10:41 a.m. with LVN C; stated that she has been a nurse for 19 years and has been trained on how to administer and document PRN medications. The LVN C stated that she has been trained to first review the order in the computer to verify if there is an active order, then to document on the narcotic count sheet and pull the narcotic from the blister pack. The LVN C stated that there is a pain scale that she has to enter in the medication administration record in the computer. The LVN C stated that she does not know what happened to Resident #1's missing Norco pills from the medication cart. The LVN C stated that she has been assigned to C hall and the medication cart in that hallway. The LVN C stated that she does not remember if she gave PRN pain medications to Resident #2 or Resident #3. The LVN C stated that although she was trained to document in the MAR and controlled substance sheet, she believed that she has forgotten to enter it into the MAR on several occasions. The LVN C stated that she believed that she has forgotten to document in the MAR more than 5 times but less than 10 times and that she believed it had happened with at least 5 residents. The LVN C stated she knew better and there is no excuse really to not document it in the MAR and on the controlled substance sheets. <BR/>During an interview on 3/31/23 at 11:05 a.m. The Pharmacy nurse stated LVN C started work at the facility on 3/14/23 and would have been assigned to another nurse for training that included medication carts and administering and documenting medications and PRN pain medications. The Pharmacy nurse stated when there is a concern or suspicion of missing medications, the nurse who identified the issue must notify the DON immediately. The Pharmacy nurse stated after the DON is notified, the DON would notify her as well and an investigation would be conducted. The Pharmacy nurse stated she was notified of Resident #1's suspected missing Norco controlled sheet and the blister pack of 15 pills. The Pharmacy nurse stated all nurses and medication aides are trained on medication diversion, counting controlled substances and to immediately report any suspicion of error to the DON. <BR/>During an interview on 3/31/23 at 11:45 a.m. with Resident #2 in C Hall; stated that he does not remember any nurse waking him up in the middle of the night for pain medications and stated it would be highly unusual if he has even taken 3 hydrocodone for pain in the last month or so. Resident #2 stated he does not wake up in the middle of the night for pain medications and if he did, he would just ask for a regular Tylenol. <BR/>During an interview on 3/31/23 at 11:49 a.m. with Resident #3 in C Hall; stated he gets his pain medications on a schedule every 6 hours and after he takes his scheduled medication he sleeps. Resident #3 stated that staff do not wake him up between midnight and 6 a.m. and he does not wake up asking for additional pain medications. <BR/>During an interview on 3/31/23 at 11:53 a.m. with LVN A in C hall; stated that Resident #3 has scheduled pain medications that are administered by the medication aide out of the medication cart assigned to the MA. The LVN C stated that Resident #3 has never asked for PRN medications during her shift. The LVN C stated that Resident #2 very rarely asks for his PRN pain medications and does not request Tylenol for pain either. The LVN C stated it would be abnormal for Resident #2 or Resident #3 to ask for PRN medications for pain. <BR/>Record Review of the facility's Loss or Theft of Medications; revised on 5/1/22 reflected, for Suspected Diversion: The employee discovering an alleged diversion will report immediately to the nursing supervisor/Director of Nurses. The DON will direct an investigation including full accounting of controlled substances. <BR/>Record Review of the facility's Resident Abuse Policy, revised July 2018; revealed: <BR/>Policy statement: It is the responsibility of our team members, community consultants, attending physicians, family members, visitors etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to community management. <BR/>-Team member shall report any suspected abuse or incidents of abuse to the community designated abuse coordinator promptly. The Administrator and Director of Nurses services shall be notified immediately and if incidents occur or are discovered after hours, the Administrator and Director of Nurses shall be called at home or be paged and notified of such incident. <BR/>-Investigating Incidents of Theft and/or Misappropriation of Resident Property: <BR/>-Policy statement: All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated. Misappropriation of resident property is defined as the pattern or deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. <BR/>Record Review of the facility's Resident Abuse Policy, revised July 2018; revealed: <BR/>Policy statement: It is the responsibility of our team members, community consultants, attending physicians, family members, visitors etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to community management. <BR/>-Team member shall report any suspected abuse or incidents of abuse to the community designated abuse coordinator promptly. The Administrator and Director of Nurses services shall be notified immediately and if incidents occur or are discovered after hours, the Administrator and Director of Nurses shall be called at home or be paged and notified of such incident. <BR/>-Investigating Incidents of Theft and/or Misappropriation of Resident Property: <BR/>-Policy statement: All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated. Misappropriation of resident property is defined as the pattern or deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. <BR/>Record Review of the facility's Medication: Controlled Drugs policy, implemented on 3/15/19 revealed: <BR/>-Compliance Guidelines: To provide guidance on the process where Controlled drugs are inventoried and administered as required by state and federal agencies. <BR/>When administering a controlled medication, identify the medication in the resident eMar, review the control sheet and write in the remaining doses on the sheet. Administer the medication and sign the eMar once administered. <BR/>-Reconcile the declining inventory record at the beginning and end of each shift. Reconciliation shall be performed by a physical count of the remaining medication and a visual of the card/bottle contents by two persons who are legally authorized to administer medications. <BR/>In case of a discrepancy: <BR/>-Report any discrepancy in the count to the DON at the time it identified. <BR/>-Nurse and med-aides are not to leave the community until a member of the clinical management team comes in to investigate and rectify/correct the count.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3( #52, #78, and #79) out of 31 residents. <BR/>1. <BR/> RN B failed to perform hand hygiene prior to gathering wound care supplies. <BR/>2. <BR/> Wound care nurse RN B failed to perform hand hygiene during wound care. <BR/>3. <BR/> LVN A failed to clean the medication cart, nurses' station, or the bottom of the caddy to prevent the possibility of infection from spreading.<BR/>These failures could result in the spread of infections to the residents in the facility. <BR/>The findings included:<BR/>Record review of Resident #79's face sheet revealed a [AGE] year-old male resident with an admission date of 05/24/2016 and a readmission date 01/10/2022 with the following diagnosis: high blood pressure, vitamin D deficiency, frequent heartburn, type 2 diabetes with high blood sugar, dementia, too many lipids (fats) in the blood, anxiety disorder, Diverticulitis (inflammation or infection in one or more small ouches in the digestive tract), Mononeuropathy (damage to a nerve outside the brain and spinal cord), vitamin B12 deficiency anemia, difficulty walking, muscle weakness, major depressive disorder, post-traumatic stress disorder, Alzheimer's disease, history of thrombosis (blood clot) . <BR/>Record review of Resident #79's quarterly MDS dated [DATE] revealed Resident #79's BIMS (Brief Interview for Mental Status) of 06, which indicated very severe impairment.<BR/>Record review of Resident #52 face sheet revealed a [AGE] year old male resident with an admission date of 08/19/2020 with the following diagnosis: benign prostatic hyperplasia (age-related prostate gland enlargement that can cause urination difficulty), hyperlipidemia (too many lipids (fats) in the blood), neuromuscular dysfunction of bladder (lacks bladder control due to brain or spinal nerve problems), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath).<BR/>Record review of Resident #52's annual MDS dated [DATE] under section C revealed Resident #52's BIMS (Brief Interview for Mental Status) of 9, which indicated the resident was moderately impaired. Resident #52 was at risk for pressure ulcers and developing pressure ulcers and it indicated that the resident does have a stage 2 pressure ulcer. The MDS indicated that pressure ulcer/injury care of application of non-surgical dressings and application of ointments/medications. <BR/>Record review of Resident #52's physician orders dated 03/23/2022 and start date of 03/23/2022 indicated: Stage II PI to Coccyx; Cleans with NS or wound cleanser, pat dry, collagen and foam dressing and prn until healed as needed for Wound Healing. <BR/>Record review of Resident #52's care plan indicated in part: (1.) My skin is fragile, and I am at risk for skin injury--new or worsening skin condition. Stage II Coccyx. Date Initiated: 02/02/2022 . I will have intact skin, free of redness, blisters, or discoloration by/through review date . Date Initiated: 08/20/2020. Keep clean & dry and apply skin barrier cream as indicated.<BR/>Record review of Resident #78's face sheet revealed a [AGE] year old male resident with an admission date of 05/23/2017 and a previous admission date of 07/23/2015 with the following diagnosis: non-Hodgkin lymphoma lymph nodes of multiple sites (cancer that starts in the lymphatic system), congestive heart failure, hypertension (high blood pressure), alcohol dependence, hyperlipidemia (too many lipids (fats) in the blood). <BR/>Record review of Resident #78's annual MDS dated [DATE], under section C- Cognitive Patterns indicated that Resident #78 had a BIMs (Brief Interview for Mental Status) of 15, which indicates intact cognition. It also indicated that Resident #78 is at risk for developing pressure ulcers/injuries. <BR/>Record review of Resident #78's physician orders dated on 03/12/2022 and start date of 03/13/2022 indicated: Cleanse wound to left forehead with NS/wound cleanser, pat dry and LOTA until healed. If area is bleeding, cover with non-adherent dressing until controlled. every day shift for Wound Healing. <BR/>Record review of Resident #78's physician orders dated on 03/12/2022 and start date of 03/13/2022 indicated: Cleanse wound to left [NAME] with NS/Wound Cleanser, pat dry, LOTA until healed. If area is bleeding, cover with non-adherent dressing until healed. every day shift for Wound Healing.<BR/>Observation and interview on 03/23/2022 at 07:34 AM, LVN A conducted a glucose check on Resident #79. LVN A took a blue carrying caddy into the Resident's room with necessary glucose materials and set it on the Resident's table where his belongings were located. LVN A did not clean the table or provide a barrier before placing the caddy on the table. LVN A conducted the glucose check then proceeded to leave the room with the caddy to acquire insulin for the Resident#79. LVN A took the caddy and set it on another medication cart, then took the same caddy and put it on the nurses' station. LVN A then came back to Resident #79's room to administer insulin and set the same caddy back on top of the Resident's table. LVN A did not clean the medication cart, nurses' station, or the bottom of the caddy. LVN A stated, she did not clean the caddy and that leaves the potential of passing an infection if not cleaned properly.<BR/>During an interview with the DON on 03/23/2022 at 9:11 AM,. the DON stated that if a carrying caddy was used, there should be a barrier between the caddy and the resident's table, or the caddy needs to be cleaned upon leaving the room to prevent the spread of infection.<BR/>During an observation and interview of wound care of Resident #52's pressure ulcer to center coccyx, stage 2, with RN B on 03/23/22 at 9:59 am. RN B conducted wound care on Resident #52 back lower buttock area. RN B gathered supplies to conduct wound care on Resident #52 and did not wash her hands or use hand sanitizer prior to gathering supplies. RN B cleaned the bedside table with a disinfectant wipe, placed a barrier on the bedside table and then placed her supplies on the barrier of the bedside table. RN B then washed her hands, put on clean gloves. RN B removed Resident #52's brief and turned Resident #52 to the right side. RN B stopped and laid Resident #52 on his back and then raised Resident#52's bed. RN B stated that the bed was too low. RN B removed old gloves and replaced with a new pair of gloves. RN B raised bed and then turned Resident #52 to the right side to remove the old foam bandage. Observed that old bandage was dated 3/22/22 and initialed. RN B did not use hand sanitizer or wash hands prior to replacing gloves from removing the old bandage and cleaning the wound. RN B used the 4 X 4 gauze that was soaked with wound wash to begin cleaning the wound. RN B stated that she did not remember seeing an order to dress the wound. RN B stopped the wound care and placed a clean brief on Resident #52 without dressing the wound. RN B removed old gloves and RN B washed her hands after cleaning the wound. RN B immediately reached out to the Nurse Practitioner using the computer for orders to dress the wound. RN B stated that it could take a couple of hours to get orders placed to be able to dress the wound. <BR/>During an observation of wound care of Resident #78 wound to left [NAME] and left side forehead, with RN B on 03/23/22 at 10:43 am. RN B conducted wound care on Resident #78 left side forehead. RN B gathered supplies to conduct wound care on Resident #78 and did not wash her hands or use hand sanitizer prior to gathering supplies to conduct wound care. RN B wiped off the bedside table with a disinfectant wipe and placed wax paper on the bedside table for a barrier. RN B placed all supplies on the barrier on the bedside table. RN B washed her hands and placed on clean gloves. RN B used 4 x 4 gauze that was soaked with wound wash to clean Resident #78 wound on left side of forehead. RN B used dry gauze to pat dry the wound. RN B left the wound open to air as instructed by orders. RN B removed dirty gloves and disposed in the designated trash. RN B washed hands and removed trash from Resident #78 room. <BR/>Interview with RN B (wound care nurse) on 03/23/2022 at 11:12 am. RN B stated that today was her first day in doing the wound care position and she was nervous. RN B stated that she does realize that she should have washed her hands prior to gathering her supplies and during the wound care procedure but was not thinking about it. RN B stated that when she had to stop the wound care because of the bed and then because of the orders threw off the procedure and stated she lost track. She stated that she has been trained in hand washing throughout school and often in the facility. RN B stated that the negative potential outcome for the resident was the spread of infection to the residents. <BR/>Interview with (Intern DON) on 03/24/2022 8:10 am DON stated that RN B should have known better because she used to be a DON in another facility, and she should have known to wash her hands. DON stated that she does understand that the RN B has not been in the position of wound care nurse for very long, but she should already know to wash her hands and that she will do an in-service with her. DON stated that RN B has been trained through school and the facility do skills checks for hand washing monthly and the staff have in-services as well. DON stated that it was the responsibility of herself and the administrator to make sure that the skills checks are completed and up to date. DON stated that the potential negative outcome for the resident's would be that by not washing hands it could possibly cause infection and spread from resident to resident. <BR/>Interview with Administrator on 03/24/2022 8:42 am, Administrator stated that she does expect that a nurse should know to wash her hands prior to gathering supplies and treating wounds. Administrator stated that the facility has been in the middle of hiring new people to fill the positions that have been empty, and the wound care nurse position is one of those positions. Administrator states that it was nursing 101 to automatically know to wash your hands. Administrator stated that the staff members were trained and do have skills checks and matter of fact the facility just conducted a skill check on 03/ 10/2022 for hand washing. Administrator stated that the facility provides reliase which is a computer-based training provided monthly and the facility also provides monthly revolving schedule for different kinds of checks such as handwashing. Administrator stated that it was the responsibility of her and the DON but mainly the DON to make sure that these trainings were completed and up to date. Administrator stated that the facility also makes sure to conduct a skill check upon hire to make sure that the staff member does know how to do what they are asked. Administrator stated that the potential negative outcome for the residents would be the transfer of infection. Administrator stated that if she had been treating and infected wound, she could have transferred that infection to another resident. <BR/>Record Review of the facility provided policy titled; Infection Control dated July 2014 revealed.<BR/>2) C. Establish guidelines for implementing Isolation precautions, including Standard and Transmission-Based Precautions. <BR/>4) All personnel will be trained on out infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.<BR/>Record Review of the facility provided policy titled; Infection Control & Prevention no date labeled, revealed:<BR/>Skill: Hand-Hygiene:<BR/>Purpose: To prevent cross contamination and the spread of infection. <BR/>Guidelines and Precautions: <BR/>1. <BR/>Handwashing is the single most important method in the prevention and control of infection. <BR/>2. <BR/>Handwashing should be done at the following times:<BR/>B). Before and after caring for each resident. <BR/>C). Before applying gloves and after removing gloves. <BR/>E). After contact with blood, body fluids, and contaminated items. <BR/>F). Whenever hands are obviously soiled. <BR/>Record Review of the facility skills checks provided titled; SVH COVID Contact & Documentation Tracker no date labeled revealed:<BR/>1. <BR/>On 11/23/2021-Hand Hygiene skill performed.<BR/>2. <BR/>On 03/10/2022- Hand Hygiene skill performed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident had the right to be free from misappropriation of property for 1 of 5 resident (Resident #1) reviewed for misappropriation of property. <BR/>The facility failed to prevent the misappropriation of Resident #1's Norco medication.<BR/>This failure could place residents at risk for not receiving prescribed medications.<BR/>Findings included: <BR/>Record review of Resident #1's undated face sheet, indicated the resident was admitted to the facility on [DATE]. His diagnosis includes unspecified dementia, Psychotic disorder with delusions, Heart failure, Hypertension, Lack of coordination, History of healed traumatic fracture. <BR/>Record review of a Resident #1's quarterly MDS dated [DATE] indicated a BIMS of 3 indicating a severe cognitive impairment. <BR/>Record review of Resident #1's orders revealed an active order for Acetaminophen ordered on 8/28/23; Assess level of pain every shift on 0-10 scale; Hydrocodone-Acetaminophen 7.5-3.25 ordered on 2/4/21.<BR/>A record review of the pharmacy shipment summary for Resident #1 revealed the facility received an order on 7/8/22 at 4:13 p.m. for Hydrocodone-ACET 7.5-325 MG (Norco) tablet quantity of 15. <BR/>During an interview on 3/30/23 11:01 a.m. the DON stated she became aware of the 15 missing Norco pills on 3/29/23 at approximately 8:30 a.m. when LVN A called her and reported that Resident #1's card of 15 Norco pills was not in the medication cart. The DON stated LVN A started her shift on 3/29/23 at 6 a.m. and it was during a medication cart count with LVN C that LVN A questioned what happened to Resident #1's card of 15 count Norco. The DON stated LVN A stated LVN C had no idea about the missing medication for Resident #1. The DON stated the med count sheet that accounted for the 15 count Norco was also missing. The DON stated LVN A should have immediately notified her (DON) of the suspected missing medication and should not have allowed LVN C to go home, nor should LVN A have signed for the cart. The DON stated LVN C signed onto the medication cart on 3/28/23 at 6 p.m. when she came onto her shift and took responsibility of the cart from LVN B whose shift ended on 3/28/23 at 6 p.m. The DON stated per facility policy LVN A was trained to immediately notify the DON of any suspected medications and to make sure the previous LVN (LVN C) did not leave the facility until she (DON) showed up to investigate. The DON stated LVN A called LVN D who overseas pharmacy/medication services in the facility. The DON stated LVN A also contacted LVN B to see if the medications were in the cart when she signed onto and off the cart on 3/28/23 and LVN B confirmed the medication was accounted for during LVN B's count with LVN C. The DON stated that LVN A stated that LVN B confirmed the controlled medication count with LVN C and then handed responsibility of the cart and medications to LVN C. The DON stated that both LVN A and LVN B were drug tested by the facility and both LVN A and LVN B were negative for all substances. The DON stated she has attempted to contact LVN C numerous times and either LVN C stated that she was on the way to the facility or refused to answer or return calls and texts from her. The DON stated LVN C had not had a drug test yet because LVN C had not come to the facility as requested. The DON stated that Resident #1's Norco was PRN and Resident #1 rarely asked for pain medication. The DON stated the facility was still investigating the missing medications for Resident #1. The DON stated that she and LVN D both counted all medications on the carts and found no discrepancies with missing medications or on any other medication cart in the building. The DON stated the LVN medication cart contained the PRN pain medications for residents and the CNAs/Medication Aides did not have access or the keys to the LVN PRN medication cart. <BR/>During an interview on 3/30/23 1:17 p.m. LVN A stated her assigned shift is 6 a.m. to 6 p.m. and she was the one who identified that Resident #1's hydrocodone blister pack of 15 tablets was missing from the cart on 3/29/23. LVN A stated she had not worked on 3/27/23 or 3/28/23 but the last time she worked on 3/26/23 the blister pack was in the medication cart. LVN A stated when shift change occurs, the oncoming and off going nurse have to count the PRN narcotics in the lock box and on 3/29/23 she noticed that Resident #1 was missing 15 tablets of Norco's. LVN A stated she counted with LVN C on 3/29/23 at 6 a.m. and there is a binder with count sheets for each resident's narcotic for each blister pack. LVN A stated that because she has worked at the facility for a long time, she had counted the controlled substances in the cart numerous times she has remembered the order of the sheets and count for Resident #1's Norco. LVN A stated that the count for Resident #1's Norco rarely changed because Resident #1 rarely takes a pain pill. LVN A stated she has remembered the order of the sheets and count. LVN A stated the order of the count of PRN narcotics in the book go in the order of 8, 15, 30 and Resident #1 has a blister pack of Norco with 8 tablets left and another blister pack for 15 tablets. LVN A stated the 8-tablet count sheet was in the book and the 8-tablet blister pack was in the cart. LVN A stated the 15-tablet count sheet, and the 15-tablet blister pack were both missing. LVN A stated she asked LVN C what happened to the 15-count sheet and blister pack of Resident #1's Norco and LVN C told her she did not know about the 15-tablet blister pack and that when she signed onto the cart at 6 p.m. on 3/28/23 there was no 15-tablet blister pack. LVN A stated the 15-tablet count sheet and blister pack had been in the cart for several months and she thought that it was discontinued and pulled from the cart on her days off but that the PRN order was still in the computer. LVN A stated she called LVN B to see if she knew what happened to the 15 Norco and LVN B stated they were in the cart when she ended her shift at 6 p.m. on 3/28/23. LVN A stated she then texted the Pharmacy LVN at 6:34 a.m. and asked about it and the Pharmacy LVN stated she did not pull the medication from the cart. LVN A stated she did not suspect they were taken and thought that someone must have pulled and discontinued the medication when she did the count, so she told LVN C to go home and she (LVN A) signed onto the cart taking accountability of it. LVN A stated she did not immediately report to the DON as required because she did not initially think there was a missing medication issue. LVN A stated without the narcotic count sheet for Resident #1 and the medication not being in the cart, that no one would have realized the medication was supposed to be in the cart. LVN A stated she only realized the medication and count sheet were missing because the count had been the same on the PRN narcotics for several months. LVN A stated if she would have suspected a medication error or missing medication she would have immediately reported to the DON as required by policy and training. LVN A stated she was written up by the facility for not immediately reporting the suspected missing medication to the DON, and allowing LVN C to leave without having the missing medication investigated by the DON. <BR/>LVN A stated, I have been trained on med counts and to report immediately to the DON. But I didn't want to think someone took them. I thought maybe they had been removed from the cart between my days off. If medications that are controlled are removed from the cart meaning discontinued, there is nowhere I would know to look for that information and would find out by speaking to people about it. <BR/>During a phone interview on 3/30/23 at 1:39 p.m. LVN B stated she worked on 3/28/23 from 6 a.m. to 6 p.m. and she took responsibility of the cart at 6 a.m. Resident #1's 8 count of Norco's were in the medication cart. LVN B stated at 6 p.m. on 3/28/23 she did a medication count with LVN C and Resident #1's 15 count of Norco were in the cart and the med count sheet was in the book. LVN B stated in the book of med count sheets, she remembers that the count goes in order of 8, 15, 30. LVN B stated that Resident #1 has the 8 count and 15 count of Norco with different strengths based on the level of pain and they are separate sheets and separate blister packs for the 8 count and the 15 count. LVN B stated that the order of the med count sheets correlates with the order of the blister packs in the cart and when a med count is done, they look in the book and see an 8-count left and confirm that it is in the cart. LVN B stated the next sheet shows 15 remaining pills in the blister pack and it is confirmed that is what is locked in the cart. LVN B stated that the next medication is a 30 count and again it is confirmed that there are 30 pills left in the blister pack in the medication cart. LVN B stated that because she has counted and verified that the medications were in the count, she has remembered the order of which comes first, 8, then 15, then 30. LVN B stated LVN A called her on 3/29/23 and asked if she had pulled Resident #1's 15 count tablets of hydrocodone from the cart and put in the disposable medication box, and LVN B stated she did not. LVN B stated, I would not accept count if there was a question about a medication that had previously been in the cart. LVN B stated she would probably call the Pharmacy nurse first and then the DON and would not sign onto the medication cart book because she did not want to be responsible or sign onto ownership for the cart if there was a question about missing medications. <BR/>During an interview on 3/30/23 at 2:10 p.m. the DON stated LVN A should not have signed onto the cart because even if she suspected something was missing, she was trained to report to the DON. call her. The DON stated LVN A is to notify her immediately and should not sign onto a medication cart if she had any suspicion that there was a medication missing. The DON stated if LVNA A had reasonable suspicion that something was wrong, or something was missing she should have immediately called her, not signed onto the cart, and told LVN C to stay until she arrived. The DON stated she would have immediately come to the facility to investigate and would have called the police to determine if the missing medication was on site, or in any staff vehicle in the parking lot. <BR/>During an interview on 3/30/23 at 2:56 p.m. LVN C stated she had worked for three weeks at the facility but has been a nurse for over 10 years. LVN C stated she and LVN A were counting medications on 3/29/23 at 6 a.m. when her shift ended and LVN A was starting her shift. LVN C stated a medication cart count is performed on all of the controlled substances in the nurse medication cart and that includes the PRN controlled substances. LVN C stated during the count, LVN A asked her where Resident #1's count sheet for Norco was and where the blister pack of 15 pills went. LVN C stated she told LVN A she did not know about the missing medication for Resident #1. LVN C stated she did not know she was not supposed to leave when there was a medication count discrepancy and did not know she was supposed to notify the DON immediately. LVN C stated she did not notify the DON and she left the facility at approximately 6:30 a.m. that morning. LVN C stated she was not aware of the policy and did not have training on what to do when there was a medication count issue. LVN C stated she did not take the missing Norco and that today the facility conducted a drug test on her prior to this interview and she has no concerns regarding the drug test results. LVN C stated she did not take any medications from the facility, and she did not take any of Resident #1's PRN Norco. <BR/>During an interview on 3/30/23 at 3:45 p.m. the DON stated they suspended LVN A, LVN B, and LVN C until they complete their investigation. The DON stated LVN A and LVN B had clear drug tests in all areas tested. The DON stated the areas tested included: Marijuana; Opiate-Morphine; Amphetamine; Barbiturates; Methadone; Tricyclic; Propoxyphene; Cocaine; Methamphetamine; Phencyclidine; Benzodiazepine; Ecstasy; Oxycodone; Alcohol The DON stated LVN C tested positive for 5 areas that included Amphetamine; Methadone; Methamphetamine; Benzodiazepine and Oxycodone. and the facility is sending the testing kit and results to an independent lab to confirm what substances LVN C was positive for and what medications LVN C is prescribed. The DON stated that per facility policy and HIPAA the facility cannot ask LVN C what medications she takes or if they would interfere with a drug test. <BR/>During an interview on 3/30/23 at 4:17 p.m. with Resident #1; was observed in his wheelchair in C hall in the common areas. Resident #1 did not respond to verbal prompts by investigator and did not acknowledge the investigator during an attempt to interview. <BR/>During an interview on 3/31/23 at 8:51 a.m. the DON stated Resident #1's scheduled pain medications are in a different medication cart and administered by the medication aides. The DON stated PRN pain medications are stored in the nurse medication cart and only the nurse assigned to the cart at that time have the keys to it. <BR/>During an interview on 3/31/23 at 11:05 a.m. The Pharmacy nurse stated LVN C started work at the facility on 3/14/23 and would have been assigned to another nurse for training that included medication carts and administering and documenting medications and PRN pain medications. The Pharmacy nurse stated when there is a concern or suspicion of missing medications, the nurse who identified the issue must notify the DON immediately. The Pharmacy nurse stated after the DON is notified, the DON would notify her as well and an investigation would be conducted. The Pharmacy nurse stated she was notified of Resident #1's suspected missing Norco controlled sheet and the blister pack of 15 pills. The Pharmacy nurse stated all nurses and medication aides are trained on medication diversion, counting controlled substances and to immediately report any suspicion of error to the DON. <BR/>During a phone interview on 3/31/23 at 10:41 a.m. with LVN C; stated that she has been a nurse for 19 years and has been trained on how to administer and document PRN medications. The LVN C stated that she has been trained to first review the order in the computer to verify if there is an active order, then to document on the narcotic count sheet and pull the narcotic from the blister pack. The LVN C stated that there is a pain scale that she has to enter in the medication administration record in the computer. The LVN C stated that she does not know what happened to Resident #1's missing Norco pills from the medication cart. <BR/>Record Review of the facility's Loss or Theft of Medications; revised on 5/1/22 reflected, for Suspected Diversion: The employee discovering an alleged diversion will report immediately to the nursing supervisor/Director of Nurses. The DON will direct an investigation including full accounting of controlled substances. <BR/>Record Review of the facility's Resident Abuse Policy, revised July 2018; revealed: <BR/>Policy statement: It is the responsibility of our team members, community consultants, attending physicians, family members, visitors etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to community management. <BR/>-Team member shall report any suspected abuse or incidents of abuse to the community designated abuse coordinator promptly. The Administrator and Director of Nurses services shall be notified immediately and if incidents occur or are discovered after hours, the Administrator and Director of Nurses shall be called at home or be paged and notified of such incident. <BR/>-Investigating Incidents of Theft and/or Misappropriation of Resident Property: <BR/>-Policy statement: All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated. Misappropriation of resident property is defined as the pattern or deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. <BR/>-<BR/>Record Review of the facility's Medication: Controlled Drugs policy, implemented on 3/15/19 revealed: <BR/>-Compliance Guidelines: To provide guidance on the process where Controlled drugs are inventoried and administered as required by state and federal agencies. <BR/>When administering a controlled medication, identify the medication in the resident eMar, review the control sheet and write in the remaining doses on the sheet. Administer the medication and sign the eMar once administered. <BR/>-Reconcile the declining inventory record at the beginning and end of each shift. Reconciliation shall be performed by a physical count of the remaining medication and a visual of the card/bottle contents by two persons who are legally authorized to administer medications. <BR/>In case of a discrepancy: <BR/>-Report any discrepancy in the count to the DON at the time it identified. <BR/>-Nurse and med-aides are not to leave the community until a member of the clinical management team comes in to investigate and rectify/correct the count.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for residents who consumed food orally from 1 of 1 facility kitchen in that:<BR/>1)Food was not stored properly in the refrigerator and in the pantry.<BR/>2)Food were past the manufacturer's Use by dates and were stored with current foods (juice concentrates)<BR/>These failures could place residents at risk of foodborne illness. <BR/>The findings included:<BR/>The following kitchen observations were made beginning on 3/22/22 at 9:22 AM and concluding at 10:10 AM:<BR/>In the pantry, one 7lb can of pork and beans, one 7lb can of grape jelly and one 7lb can of dice pears were stored on the floor. One box of parboiled rice was wide open and not sealed.<BR/>On a food storage shelf by the refrigerator, there were six large containers of Prune Juice concentrate that were labeled Used by 3/8/22. <BR/>In the walk-in refrigerator, one container of Homestyle Coleslaw was not sealed properly and was open to air. One container labeled 10 Beef Patties was undated in the refrigerator. <BR/>Interview and observation on 3/22/22 at 9:50 AM with the Dietary Manager, she was asked who was responsible for monitoring to ensure that these foods were within the manufacturer's Use by date. Dietary Manager stated all dietary staff was responsible for expired items in the kitchen. <BR/>Interview on 3/23/22 at 2:17 PM with Dietary Manager stated, she normally checked for food items on the floor, expired items, undated items, and opened food containers in the morning. Dietary Manager stated the cooks should also be checking for these items. Dietary Manager stated she last did a complete kitchen check on 03/20/22 and everything was in order. Dietary Manager stated she didn't have time to check the kitchen yesterday morning and was surprised to see cans on the floor and opened food containers. Dietary Manager stated staff get trained at least monthly regarding proper food storage. Dietary Manager stated she did not know how these food items were missed and she believed it was an accident. Dietary Manager stated the residents were at risk for getting sick due to the improper storage of food items.<BR/>Record review of the facility policy and procedure titled, Food Storage, dated 2018 reflected the following:<BR/>Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all foods will be stored according to the state, federal and US Food Codes and HACCP guidelines.<BR/>Procedure: <BR/>1. Dry Storage Rooms <BR/>d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. <BR/>h. Store all items at least 6 above the floor .<BR/>2. Refrigerators<BR/>d. Date, label, and tightly seal all refrigerated food using clean, nonabsorbent, covered containers that are approved for food storage

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, in that 1 of 29 residents (Resident #9) continued to receive psychotropic medications PRN for more than 14 days without a physician addressing the continued use of the medication:<BR/>- Resident #9 continued to have a PRN order for Lorazepam concentrate 2mg/ml after 14 days without an evaluation by the physician for continued treatment.<BR/>This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions. <BR/>The findings include:<BR/>Record review of Resident #9's face sheet, dated 05/17/23, revealed an [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include Parkinson's (a progressive nervous system disease), dementia (progressive loss of intellectual functioning), atrial fibrillation (irregular or rapid heartbeat that causes poor blood flow),major depressive disorder and Alzheimer's (progressive disease that destroys memory and other mental functions)<BR/>Record review of Resident #9's quarterly MDS, dated [DATE], revealed Section N - Medication Section N0410 - Medications Received: B - Antianxiety - Given 7 out of 7 days. <BR/>Record review of Resident #09's physician order summary dated 05/17/23 revealed an order start date 11/25/22 with an indefinite end date for Lorazepam Concentrate 2 MG/ML Give 0.5 ml by mouth every 2 hours as needed for Anxiety/Agitation <BR/>Record review of Resident #1's MAR for the past 90 days revealed Lorazepam 1mg give 1 tablet by mouth every 4 hrs. as needed for anxiety was administered on 04/24/23 <BR/>Record review of the pharmacy consultant book dated March 2023 revealed Resident #9 was receiving hospice, comfort, or palliative care services and had an active order for Lorazepam PRN. The Pharmacy Consultant Recommended the following on 03/02/23:<BR/>Even with hospice status, these orders would require 14 day stop date or indication of specific duration of therapy. There was no additional notes that indicate the response from the attending physician. <BR/>Record review of the pharmacy consultant book dated February 2023 revealed the Pharmacy Consultant Recommended the following on 02/02/23:<BR/>Even with hospice status, these orders would require 14 day stop date or indication of specific duration of therapy. There was no additional notes that indicate the response from the attending physician. <BR/>Record review of the pharmacy consultant book dated January 2023 revealed that Resident #9 was receiving hospice, comfort, or palliative care services and had an active order for Lorazepam PRN. The Pharmacy Consultant Recommended the following on 01/05/23:<BR/>Even with hospice status, these orders would require 14 day stop date or indication of specific duration of therapy. There was a handwritten note that indicated, recommendation declined per Attending Physician A and that the order would remain the same. No reason indicated as to why. <BR/>The Pharmacy Consultant had an order for Haldol (PRN w/o a stop date) and recommended that the medication be discontinued, or a stop date be added. The rationale for this recommendation indicated the following:<BR/> CMS requires that PRN orders for antipsychotic drugs be limited to 14 days. A new order should not be written without the prescriber directly examining the resident and assessing the residence condition and progress to determine if the PRN antipsychotic is still needed. Report of the residence condition from facility staff to the prescriber does not meet the criteria for an evaluation.<BR/>Record review of Resident #09's progress notes dated 05/10/23 at 12:06 PM, 6:07 PM; 05/03/23 at 11:52 AM, 11:32 AM; 05/01/23 11:06 AM, 3:06 PM; 03/25/23 8:21 AM; 11:22 AM revealed the following:<BR/>Note Text : LORazepam Concentrate 2 MG/ML<BR/>Give 1 ml by mouth every 2 hours as needed for Anxiety/Agitation PATIENT WILL REMAIN ON LORAZEPAM WHILE ON ACTIVE HOSPICE<BR/>CARE<BR/>PRN Administration was: Effective<BR/>Author: RN A, RN Nursing - Nursing [e-SIGNED]<BR/>Record review of Resident #09's progress notes revealed the following progress notes on dated 04/24/23 8:21 AM, 1:33 PM; revealed the following:<BR/>Note Text : LORazepam Concentrate 2 MG/ML<BR/>Give 0.75 ml by mouth every 2 hours as needed for Anxiety/Agitation PATIENT WILL REMAIN ON LORAZEPAM WHILE ON ACTIVE<BR/>HOSPICE CARE<BR/>PRN Administration was: Effective<BR/>Author: RN B, RN Nursing - Nursing [e-SIGNED]<BR/>An interview and observation was conducted on 05/19/23 at 11:06 AM, and the ADON said the nurses were responsible for documenting psychotropic medications. She said monitoring psychotropic medications was important because people could have side effects that come with taking psychotropic medications. She said it could create long-term neurological issues. She said she was not familiar with the PRN 14-day stop date rule. The ADON reviewed Resident #9's orders and acknowledged the order had no stop date and read indefinite. When asked what the purpose of the 14-day stop date was, she responded, I don't know the exact answer, but I can get the information She said she knew the DON had said 14 days and could not exceed that amount for psychotropic medications. She stated she was new to the facility. She said indefinite means anytime and forever. She said if the pharmacist or the doctor recommended that there should have been a stop date, then the facility should have taken that recommendation. <BR/>An interview was conducted on 05/19/23 at 11:55 AM, the Pharmacy nurse said the physician was responsible for ensuring the order was just for 14 days for PRN antipsychotics. The facility does not want them to be on the medications indefinitely. She said antipsychotics could have adverse side effects. She said she was unaware any residents were on PRN medications without a 14-day stop date. She said she had been trained on the expectation that PRN antipsychotics should have a 14-day stop date. She said the nurses at the facility were also aware that if they get an order, there should be a 14-day stop date. When asked specifically about Resident #9 being on hospice and the doctor not wanting to change it, she said he said hewould not change it because he was on hospice, and that was one of the hospice meds. The surveyor requested documentation supporting the doctor's refusal to add the 14-day stop date. No additional information provided.<BR/>An interview was conducted on 05/19/23 at 12:52 PM, the ADM said she was aware of 14 day stop date but was not aware that there were residents in the facility that was on PRN medications without a 14-day stop date. She said the DON and the nurse obtaining the order were responsible for ensuring that the PRN Antipsychotic had a 14-day stop date. She said she was unaware of any residents receiving PRN antipsychotics without the 14-day stop date. When asked about the potential negative outcome, she said those medications could have different side effects. She said she had been trained in general about PRN antipsychotic standards. She said her expectation was for there to be a 14-day stop date on all PRN antipsychotics. She said if the doctor chose not to change, she would call the medical director to see if he could prescribe something else or make it routine. <BR/>On 05/22/23 at 10:29 AM surveyor attempted to contact Attending Physician A he did not answer a message was left with the surveyor's contact information. <BR/>An interview was conducted on 05/22/23 at 10:36 AM, the Medical Director said it was important to have the 14-day stop date because research had shown that psychotropic medications contribute to increased death in elderly patients. He said he was unaware of any residents on PRN psychotropics without a 14-day stop date. He said even if the resident was a hospice resident and they had a PRN antipsychotic, they should have still had a 14-day stop date. He said hospice companies generally would not want to pay for anything outside of that. He said there would be no exception to the 14-day stop date for PRN antipsychotic medications.<BR/>On 05/23/23 at 11:04 AM surveyor attempted to contact Attending Physician A. He did not answer. A message was left with the surveyor's contact information. <BR/>An interview was conducted on 05/23/23 at 11:06 AM, the Pharmacy Consultant said he was familiar with PRN psychotropics having a 14-day stop date. He said this was important because there are a lot of times when residents do not need those medications after that time period and could experience side effects. He said if the resident does not have the 14-day stop date, then there should still be a stop date with specifications as to why they are exceeding the 14-day stop date. He said he was not at his computer at the time of the phone interview, so he could not speak specifically on the residents in question, but that he has brought to facility staff attention when he does catch PRN psychotropics without a 14-day stop date. He said when he had done this in the past, the staff addressed it immediately. <BR/>An interview was conducted on 05/23/23 at 02:48 PM, Attending Physician B was unaware any residents were on PRN medication with no 14-day stop date. She said if there were any, she did not order it. She said Resident #9 was on hospice, which would be a hospice issue. She said she provided basic needs but that she was not the person responsible for comfort medications. She said she was unsure of who his hospice doctor was. When asked if, in her experience, if there was an exception made for residents on hospice concerning PRN psychotropic medications, she said she was unsure, but she graduated in 1997. She said they do not receive updates, texts, or emails on any new regulations. She said she would think in a hospice situation that, they would not worry about the potential negative outcomes, such as addiction or abuse, because the resident was dying. She said she was not familiar with strict regulations for hospice patients.<BR/>An interview was conducted on 05/24/23 at 03:33 PM, and RN A said she was aware of the 14-day stop date for PRN psychotropic medications. She said the 14-day stop date was important because psychotropic medications' effects on the elderly could be detrimental. She said it was her understanding when a person was in hospice, this was not the case because the focus was keeping the resident comfortable. She said each time there was a progress note in the electronic medical record regarding the PRN Lorazepam, the PRN medication was administered. She said she has not spoken with the hospice doctor. When asked why medication administration was not on the MAR, she said it should have been. She said once the medication was checked on the MAR, which was what generated the progress note. She said she was unaware of why it would not appear on the MAR.<BR/>On 05/26/23 09:54 AM surveyor attempted to contact Attending Physician A. He did not answer. A message was left with the surveyor's contact information.<BR/>Record Review of the Pharmacy Consultant book included the following document: Quality improvement: Consultant Pharmacist Summary dated 03/01/23-03/31/23 signed by the Pharmacy Consultant on 03/22/23 revealed the following:<BR/>Psychotropic Drugs<BR/>(d) documentation is appropriate for PRN non-antipsychotic psychotropic drug used greater than 14 days: No irregularities observed.<BR/>(e) PRN antipsychotic drug use does not continue beyond 14 days without prescriber assessment and new order: No irregularities observed.<BR/>Record Review of the Pharmacy Consultant book included the following document: Quality improvement: Consultant Pharmacist Summary dated 02/01/23-02/28/23 signed by the Pharmacy Consultant on 02/26/23 revealed the following:<BR/>Psychotropic Drugs<BR/>(d) documentation is appropriate for PRN non-antipsychotic psychotropic drug used greater than 14 days: No irregularities observed.<BR/>(e) PRN antipsychotic drug use does not continue beyond 14 days without prescriber assessment and new order: No irregularities observed.<BR/>Record Review of the Texas Health and Human Services document titled Quality Monitoring Program Limiting the use of PRN Psychotropic Medications dated June 2018 revealed the following:<BR/>PRN use of psychotropic is limited to 14 days. The psychotropic orders may be extended beyond 14 days if the prescribing practitioner: believes it is appropriate to extend the order, and provides a specific duration of use (this could be indicated by a stop date listed on the MAR), and documents clinical rationale for the extension.<BR/>There are no exclusions for PRN psychotropic orders once the resident is admitted to a nursing facility.<BR/>Inform all prescribing practitioners including Hospice care agencies that new orders for PRN and psychotropic medications must comply with CMS requirements.<BR/>Record Review of facility policy, Psychotropic Medications & Gradual Dose Reduction revised January 2023<BR/> STANDARDS <BR/>The community is expected to make every effort to comply with state and federal regulations related to the use of psychotropic medications in the community to include diagnosis, targeted behavior or clinical indications for use, prescriber's specified dosage frequency and duration of therapy, consent must be received and noted in the medical record for any use of psychotropic medications. Additionally, the prescriber must provide specific rational for use, clinical indications for use, risks and/or benefits of therapy and informed consent as per defined content in the Texas 3713 form for all antipsychotic or neuroleptic drug therapy. <BR/>o <BR/>o The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. <BR/>PHARMACIST and/or CONSULTING PHARMACIST <BR/>1. Monitors psychotropic drug use in the community to ensure that medications are not used in excessive doses or for excessive duration. <BR/>2. Notifies the physician and the nursing management team if whenever a psychotropic medication is past due for review. <BR/>Record review of the facility's policy titled Pharmacy Services: Provision of Medications and Biologicals with a revised date of November 2023 revealed the following:<BR/>Compliance Guidelines<BR/>The community is responsible for the timely acquisition and administration of medications and biologicals. A drug, whether prescribed on a routine, emergency, or as-needed basis, must be provided in a timely manner.<BR/> Pharmacist service consultation <BR/> Pharmacist and consultant reports <BR/>The consultant pharmacist submits a monthly report to the director of nursing that identifies the existence of problems, issues, or irregularities with recordkeeping and the acquisition and dispensing of medications. <BR/>Within three (3) business days of conducting a drug regimen review, the pharmacist will provide a summary report to the attending physician and the community's director of nursing who (a) documents no irregularity was identified, or (b) reports any irregularities. The pharmacist and community agree on a procedure to apply when an attending physician does not respond to such report or fails to document the basis for his/her disagreement with such report.<BR/>The report also suggests changes to resident drug regimens and updates the community of the latest regulatory news (e.g., medications approved or not approved for certain diagnoses, restrictions, or warnings on use). <BR/>The director of nursing advises the attending physician of any suggested drug regime changes. <BR/>Neither the director of nursing nor the attending physician is required to agree with or implement the consultant pharmacist's recommendations. Unless state law requires an explanation of acceptance or rejection, neither the director of nursing nor physician is required to provide a rationale for not implementing the recommendations. <BR/>However, there will be documentation that the director of nursing and attending physician reviewed the report and acted.<BR/>Repeated or frequent rejections of the consultant pharmacist's recommendations indicate that there should be a review the community's drug management program.<BR/>

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for residents who consumed food orally from 1 of 1 facility kitchen in that:<BR/>1)Food was not stored properly in the refrigerator and in the pantry.<BR/>2)Food were past the manufacturer's Use by dates and were stored with current foods (juice concentrates)<BR/>These failures could place residents at risk of foodborne illness. <BR/>The findings included:<BR/>The following kitchen observations were made beginning on 3/22/22 at 9:22 AM and concluding at 10:10 AM:<BR/>In the pantry, one 7lb can of pork and beans, one 7lb can of grape jelly and one 7lb can of dice pears were stored on the floor. One box of parboiled rice was wide open and not sealed.<BR/>On a food storage shelf by the refrigerator, there were six large containers of Prune Juice concentrate that were labeled Used by 3/8/22. <BR/>In the walk-in refrigerator, one container of Homestyle Coleslaw was not sealed properly and was open to air. One container labeled 10 Beef Patties was undated in the refrigerator. <BR/>Interview and observation on 3/22/22 at 9:50 AM with the Dietary Manager, she was asked who was responsible for monitoring to ensure that these foods were within the manufacturer's Use by date. Dietary Manager stated all dietary staff was responsible for expired items in the kitchen. <BR/>Interview on 3/23/22 at 2:17 PM with Dietary Manager stated, she normally checked for food items on the floor, expired items, undated items, and opened food containers in the morning. Dietary Manager stated the cooks should also be checking for these items. Dietary Manager stated she last did a complete kitchen check on 03/20/22 and everything was in order. Dietary Manager stated she didn't have time to check the kitchen yesterday morning and was surprised to see cans on the floor and opened food containers. Dietary Manager stated staff get trained at least monthly regarding proper food storage. Dietary Manager stated she did not know how these food items were missed and she believed it was an accident. Dietary Manager stated the residents were at risk for getting sick due to the improper storage of food items.<BR/>Record review of the facility policy and procedure titled, Food Storage, dated 2018 reflected the following:<BR/>Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all foods will be stored according to the state, federal and US Food Codes and HACCP guidelines.<BR/>Procedure: <BR/>1. Dry Storage Rooms <BR/>d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. <BR/>h. Store all items at least 6 above the floor .<BR/>2. Refrigerators<BR/>d. Date, label, and tightly seal all refrigerated food using clean, nonabsorbent, covered containers that are approved for food storage