THE VILLAGES OF DALLAS

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Residents #1, #2, and #3) of 9 residents reviewed for call lights in reach. <BR/>Resident #1's call pad was on the floor, under his bed, and not within reach, while he was in bed. <BR/>Resident #2's call button was on the floor, under his bed, and not within reach, while he was in bed. <BR/>Resident #3's call button was clipped to his pillow, and not within reach, while he was in his wheelchair at the foot of his bed. <BR/>These failures could place residents at risk of not having their needs and preferences met and a decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet, 06/14/2024, reflected he was, and [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included acute cystitis without hematuria (bladder infection), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), lack of coordination, and dysphasia (speaks slowly with great difficulty). <BR/>Record review of Resident #1s MDS Assessment, dated 05/28/2024, revealed Resident #1's BIMS was 3, which indicated severe cognitive impairment. He was dependent for toileting, showers, dressing, personal hygiene and eating. He required extensive assistance in transferring and bed mobility. <BR/>Record review of Resident #1's Comprehensive Care Plan, dated 06/10/2024, revealed, Focus: At risk for a communication problem r/t Hearing Impairment, Dementia. Interventions: Anticipate and meet needs. Focus: ADL Self Care Performance Deficit r/t weakness and confusion. Intervention: Encourage to use bell to call for assistance. Focus: At risk for falls r/t weakness, dementia, bowel/bladder incontinence. Intervention: Be sure the call light is within reach and encourage to use it to call for assistance as needed. <BR/>Record review of Resident #2's Face Sheet, 06/14/2024, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of prostate (cancerous tumor), type 2 diabetes (problem in the way the body regulates and uses sugar as fuel), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and hypertension (pressure in blood vessels is too high). <BR/>Record review of Resident #2s MDS Assessment, dated 06/14/2024, revealed no record of Resident #2's BIMS. His cognitive skills were severely impaired, He had an indwelling catheter and was always incontinent of bladder and frequently incontinent of bowel. <BR/>Record review of Resident #2's Comprehensive Care Plan, dated 06/10/2024, revealed, Focus: ADL Self Care Performance Deficit r/t bed bound, seizures, stroke, brain tumor, dementia. At risk for falls r/t history of recent falls,<BR/>seizures, stroke, dementia, history of brain tumor. Intervention: Be sure the call light is within reach and encourage to use it to call for assistance as needed. Bed in lowest position.<BR/>Record review of Resident #3's Face Sheet, 06/14/2024, reflected he was an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included lack of coordination, and dysphasia (speaks slowly with great difficulty), muscle wasting and atrophy (thinning of muscle mass), chronic kidney disease (kidneys cannot filter blood the way they should), and unsteadiness on feet. <BR/>Record review of Resident #3s MDS Assessment, dated 06/08/2024, revealed Resident #3's BIMS was 10, which indicated a mild cognitive impairment. He was totally dependent for toileting, showers, dressing and personal hygiene. He was dependent for sit to stand and bed to chair transfers. <BR/>Record review of Resident #3's Comprehensive Care Plan, dated 06/06/2024, revealed, Focus: At risk for falls r/t weakness, dementia. Interventions: Be sure the call light is within reach and encourage to use it to call for assistance as needed. Keep needed items, water, etc. in reach.<BR/>An observation on 06/14/2024 at 9:16 AM revealed Resident #1's call pad on the floor under his bed. Resident #1's roommate, Resident #2's call button was on the floor, under the bed and against the wall. Resident #2 was sleeping. <BR/>In an interview on 06/14/2024 at 9:18 AM, Resident #1 said he did use his call light and it was usually on his bed beside him but could not find it at the moment. He stated he needed assistance to get out of bed and did use the call light to call for assistant when he needed it. <BR/>An observation and interview on 06/14/2024 at 9:33 AM revealed Resident #3's call button clipped to the pillow at the head of his bed. The button was under the pillow. Resident #3 was in his wheelchair at the foot of his bed. Resident #3 said he was cold and wanted a blanket. When asked if he used his call light, he said he did but could not find it. <BR/>In an interview on 06/14/2024 at 9:36 AM, the Administrator in Training (AIT) said call lights should be place so residents could reach them. He said residents had a right to use call lights to ensure they can call for assistance when they needed it. <BR/>In an interview on 06/14/2024 at 9:42 AM, LVN A stated Resident #1 could not get out of bed on his own and needed the call pad to call for assistance as needed. He said Resident #2 was recently admitted to the facility and should have the call button within his reach at all times. He stated Resident #3 required total assistance and should also have his call light accessible to him at all times. He said residents had a right to be able to call for assistance when they needed it. He said if residents did not have access to their call lights, they could try to get up and fall. <BR/>In an interview on 06/14/2024 at 9:56 AM, CNA B stated all residents should have access to their call light. She stated she checked for call lights when she did rounds but may have forgotten to place some. She said she had not noticed that Reisidents #1, #2, and #3's call lights were not wihtin thier reach. She said all staff were responsible to ensure call lights were answered and placed in reach of residents. She said if the call lights were not in reach, residents could try to get up and fall resulting in an injury. <BR/>In an interview on 06/14/2024 at 10:41 AM, ADON C stated residents had a right to have call lights in their reach. She stated they need to be able to call for assistance when they require it. She said when resident was not able to call for assistance they often try to meet their own needs and they could fall and hurt themselves. She stated all staff were responsible to ensure call lights were within reach of each resident. She said nurse managers monitor this by rounding. <BR/>In an interview on 06/14/2024 at 12:43 PM, the DON stated all staff should ensure call lights were placed in reach of residents. She stated not doing this was a safety concern as resident could get up to help themselves and fall. She said she expected staff to watch for any safety issues when they are rounding throughout the day. <BR/>In an interview on 06/14/2024 at 1:10 PM, ADON D stated call lights should be accessible to all residents no matter their ability to use them or not. He said it was a resident right to be able to call for assistance as needed. <BR/>In an interview on 06/14/2024 at 2:24 PM, the administrator stated he expected all staff to follow the facility policies. He said resident had a right to have their call lights accessible to them to ensure their needs were met. <BR/>Record review of the facility's policy titled, Call Light/Bell dated 05/2020, reflected, . 5. Leave the resident comfortable. Place the call device within resident's reach before leaving room. If the call light/bell is defective, immediately report this information to the unit supervisor. <BR/>Record review of the facility's policy titled, Safety/Resident revised 07/2013, reflected, .1. Place call light within reach of the resident. 7.Conduct room checks routinely by staff members to promote quality of life and ensure safety of residents residing in the facility. Room checks include but not limited to resident observation (wearing appropriate clothing, oral hygiene, assistive devices, etc.) and bedside observation (call lights within reach, no unauthorized medications, ointments, lotions at bedside, infection control, etc.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 5 residents (Resident #1) reviewed for care plans.<BR/>The facility failed to ensure Resident #1's care plan was updated to reflect the resident's recent fall on 03/08/2025.<BR/>This failure could place residents at risk of not receiving appropriate care to meet their current needs. <BR/>Findings included: <BR/>Record review of a facility undated face sheet for Resident #1, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included: vascular dementia (a condition caused by problems with blood flow to the brain, damaging blood vessels, leading to memory, thinking, and behavioral difficulties), other lack of coordination (jerky, unsteady movements and difficulty with balance and coordination), and muscle weakness (decreased ability of muscles to contract and generate force).<BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected the resident had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #1's Quarterly MDS reflected she was dependent in the following areas: eating, oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene. Resident #1's MDS Section J1800 reflected that Resident #1 has had falls since admission/entry or reentry or the prior assessment with no injuries. <BR/>Record review of Resident #1's undated Care Plan revealed Resident #1 was care planned for risks of falls, dx of dementia and had impaired cognition. Resident #1's care plan did not reflect she had a fall on 3/8/2025. <BR/>Record review of Resident #1's progress notes did not reveal an entry by RN A related to Resident #1 being found on the floor on 03/08/2025. <BR/>Record review of Resident #1's progress notes dated 03/08/2025 (LATE ENTRY) entered by the ADON not until 03/13/2025 revealed, Received report from the CNA of this resident being on the floor, laying on her fall mat after falling out of bed. Bed in low position with floor mat in place. Per the resident roommate, this resident crawled out of bed and no injury or complaints of pain voiced. Intervention: place a scoop mattress on resident bed. MD notified of this incident.<BR/>Record review of the facility's incident log, dated 03/13/2025, reflected [Resident #1] had a fall on 3/08/2025. <BR/>Record review of Resident #1's EMR revealed RN A failed to complete a Fall Assessment on 03/08/2025. <BR/>Record review of Resident #1's EMR revealed the ADON completed a Fall Evaluation (with an effective date of 03/08/2025) five days later on 03/13/2025.<BR/>Attempted to interview Resident #1 on 03/13/2025 at 1:45pm but was not successful due to her being hospitalized and diagnosed with acute metabolic encephalopathy (a change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness) and a suspected UTI (an infection in any part of the urinary system). <BR/>Attempted to interview Resident #1's FM on 03/14/2025 at 11:05 am. Unable to leave a message as the voicemail was full.<BR/>During an interview with RN B on 03/14/2025 at 10:35 am, she stated you are required to document no matter if the resident was observed on the mat, or if a fall was witnessed. RN B stated the staff member that assessed the resident was the one that needed to enter documentation into the EMR and complete any assessments and reports.<BR/>During an interview with the ADON on 03/14/2025 at 11:40 am, he stated Resident #1's care plan should had been updated to reflect her most recent fall. The ADON stated the incident occurred on Saturday (3/8/2025) but he did not learn of it until Monday (3/10/2025). The ADON stated himself and the DON reached out to RN A on Tuesday (3/11/2025). The ADON stated he entered a Progress Note and created an Incident Report on Wednesday (3/13/2025) because RN A had not completed these tasks. The ADON stated if a resident's care plan was not updated then the resident may have not received the most efficient care.<BR/>During an interview with the ADM on 03/14/2025 at 12:10 pm, he stated staff must make notifications and enter documentation. The ADM stated the assessment and documentation should had been completed timely. The ADM stated a resident's care plan should be updated after each fall. The ADM stated if a resident's care was not updated after a fall the resident would potentially not be receiving the highest level of care.<BR/>A record review of the facility's Care Planning policy, with a reviewed date of July 2020, reflected Procedures: .<BR/>9. The resident's plan of care - focus, goals, and interventions - are communicated and implemented by the members of the health care continuum accordingly.<BR/>10. The resident's plan of care is reviewed and revised on an ongoing basis, quarterly at a minimum and/or as needed with changes in condition.<BR/>A record review of the facility's Fall Management System policy, with a revision/reviewed date of January 2022, reflected Policy: It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.<BR/>3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record.<BR/>6. Resident's care plan will be updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents' environment remained as free of accident hazards as is possible; and residents received adequate supervision and assistance devices to prevent accidents, for one 1 of 5 residents (Resident #1) reviewed for accident hazards. <BR/>The facility failed to ensure Resident #1's fall mat was on the floor, next to her bed on 03/08/2025. This was evident by the photo taken on 03/08/2025 and submitted by FM B which showed Resident #1 laying on the bare floor away from her bed with her fall mat observed underneath her bed.<BR/>This failure could place the resident at risk of injuries from falls and a decreased quality of care.<BR/>Findings included:<BR/>Record review of a facility undated face sheet for Resident #1, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included: vascular dementia (a condition caused by problems with blood flow to the brain, damaging blood vessels, leading to memory, thinking, and behavioral difficulties), other lack of coordination (jerky, unsteady movements and difficulty with balance and coordination), and muscle weakness (decreased ability of muscles to contract and generate force).<BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected the resident had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #1's Quarterly MDS reflected she was dependent in the following areas: eating, oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene. Resident #1's MDS Section J1800 reflected that Resident #1 has had falls since admission/entry or reentry or the prior assessment with no injuries. <BR/>Record review of Resident #1's undated Care Plan revealed the following:<BR/>Focus: At risk for falls r/t decreased mobility, impaired cognition. Goal: Will not sustain serious injury through the review date. Interventions: Anticipate and meet needs. Be sure the call light is within reach and encourage to use it to call for assistance as needed. Keep needed items, water, etc., in reach.<BR/>Focus: Has had an actual fall no injury r/t: Poor balance & Poor cognition. 01/14/25 Fall, no injury. 02/27/25 Fall, no injury. Goal: Will resume usual activities without further incident through the review date. Interventions: 1/14/25 Bed in lowest position. 2/27/25 Fall mat on floor. Continue interventions on the at-risk plan. Staff will make frequent bed checks.<BR/>Record review of Resident #1's progress notes did not reveal an entry by RN A related to Resident #1 being found on the floor on 03/08/2025. <BR/>Record review of Resident #1's Order Summary dated 03/13/2025, reflected [Resident #1] was to have a floor mat on both sides of her bed with the bed set at its lowest setting was ordered on 12/20/2024 and no start or end date noted.<BR/>Record review of the facility's incident log, dated 03/13/2025, reflected [Resident #1] had a fall on 3/08/2025. <BR/>Record review of the facility's incident report, dated 3/13/2025, under Nursing Description reflected, Received report from the CNA of this [Resident #1] resident being on the floor, laying on her fall mat after falling out of bed. Bed in low position with floor mat in place.<BR/>Record review of the photo provided by FM B showed Resident #1 lying on the hardwood floor with her fall mat underneath her bed. <BR/>During an interview on 03/13/2025 at 9:01 am, FM B stated she arrived at the facility on Saturday (03/08/2025) at 9:35 am. FM B stated as she walked past Resident #1's room, she saw her lying on the floor. FM B stated Resident #1 was positioned on her right side away from her bed and her fall mat was underneath her bed. FM B stated she walked to the dining room and informed a CNA that Resident #1 was on the floor. FM B stated she then walked back to visit her own family member.<BR/>During an interview with CNA A on 03/13/2025 at 1:55 pm, she stated RN A requested her help to transfer Resident #1 from the floor. CNA A stated after RN A assessed Resident #1, they placed her in bed and changed her. CNA A stated she could not remember the exact time they picked Resident #1 up off the floor, but it could not have been more than 15 minutes that she had been on the floor. CNA A stated Resident #1 wiggled herself out of the bed. CNA A stated 10 minutes later, Resident #1 had wiggled out of the bed again. CNA A stated the first time, Resident #1 was on the floormat. CNA A stated the second time Resident #1 was halfway off the fall mat. CNA A stated due to not being able to use restraints, they brought Resident #1 to the nurse's station. CNA A stated Resident #1 had a fall mat on both sides of the bed. CNA A stated when Resident #1 was not in bed, they folded the fall mats up and placed them in the corner. CNA A stated when Resident #1 was in the bed, the fall mats were placed on the floor. CNA A stated Resident #1 was unable to walk nor transfer herself.<BR/>During an interview with the ADON on 03/13/2025 at 2:25 pm, he stated himself and the DON called RN A and asked her if she knew how long Resident #1 had been on the floor and RN A stated, No, but it was not a long time because she had taken the roommate's vital signs around 9:20 am and then went to chart. The ADON stated RN A said she returned to the room around 9:30 am to see if the roommate was dressed for dialysis and that was when she observed Resident #1 laying on her fall mat. The ADON stated the incident was categorized as a fall with no injuries. <BR/>During an interview with RN A on 03/14/2025 at 11:10 am, she stated she saw Resident #1 on the fall mat and immediately reached out to CNA A for assistance. RN A stated each time she went to check on Resident #1, she was back on the fall mat again. RN A stated she and CNA A assisted Resident #1 back in bed each time. RN A stated she changed Resident #1's diaper herself to make sure that was not why Resident #1 kept having the behavior. Resident #1 stated she continued to check on Resident #1 and administered her medications. RN A stated to the best of her knowledge that was what happened. RN A stated Resident #1 had not sustained any injuries. RN A stated Resident #1 was on the fall mat both times. RN A stated she assessed Resident #1 each time but failed to complete any assessments or enter any documentation into the EMR due to there being no injuries. RN A stated when she saw Resident #1 on the floor again she was confused as to why Resident #1 kept doing it. RN A stated per policy, whenever a resident was found on the floor, they would be assessed. RN A stated the nurse was required to complete all appropriate assessments that needed to be done. RN A stated she did not do any of these things because Resident #1 was on the fall mat with no injuries.<BR/>During an interview with the ADON on 03/14/2025 at 11:40 am, he stated due to Resident #1 not being in her bed and observed on her fall mat, the incident would be categorized as an unwitnessed fall. The ADON stated RN A had not charted anything. The ADON stated RN A informed him and the DON that she had not believed it was a fall because Resident #1 was on the fall mat. The ADON stated regardless, if it was a fall or not, the DON informed RN A even if she thought it was a behavior, the least she could had done was documented it as a behavior. The ADON stated the incident occurred on Saturday (3/8/2025) but he did not learn of it until Monday (3/10/2025). The ADON stated he entered a Progress Note and created an Incident Report on Wednesday (3/13/2025) because RN A had not completed these tasks. The ADON stated the Care Plan should be updated to reflect all falls to ensure residents received the most effective care. The ADON stated the Charge Nurse said she completed an assessment including a pain assessment but failed to document anything.<BR/>During an interview with the ADM on 03/14/2025 at 12:10 pm, he stated Resident #1 had not sustained any injuries and was okay. The ADM stated Resident #1 used a wheelchair and was unable to get up on her own. The ADM stated they preferred fall mats to be off the floor if the resident was not in bed to prevent a tripping hazard. The ADM stated no one was perfect, and they try their best to find the best fit for each resident. The ADM stated staff should assess to ensure it was safe to transfer the resident to bed from the floor pending the nurse's discretion. The ADM stated an assessment and documentation should had been completed timely. The ADM stated he expected all staff to follow the facility's policies.<BR/>A record review of the facility's Fall Management System policy, with a revision/reviewed date of January 2022, reflected Policy: It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.<BR/>3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record.<BR/>c. A Fall Risk Evaluation will be completed post fall incident.<BR/>A record review of the facility's Significant Change of Condition, Response policy, with a revision/reviewed date of December 2023, reflected It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care.<BR/>Procedure<BR/>1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): .<BR/>-Change in behavior or increased problems that may cause injuries or incidents to self or others .<BR/>-Fall or other related incident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown and infection for one (Resident #45) of four residents reviewed for pressure ulcers (open wound on the skin caused by prolonged pressure to bony prominences). <BR/>The facility failed to ensure that LVN A cleaned Resident #45's wound to right 5th toe from inside to outside on 02/05/2025.<BR/>This failure could place the residents with pressure ulcers at risk for worsening of existing pressure ulcers and infection.<BR/>Findings included: <BR/>Record review of Resident #45's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with sepsis (infection of the blood stream) and muscle weakness.<BR/>Record review of Resident #45's Comprehensive MDS Assessment, dated 11/01/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 02. Comprehensive MDS Assessment indicated the resident had a pressure ulcer over a bony prominence.<BR/>Record review of Resident #45's Comprehensive Care Plan, dated 01/13/2025, reflected the resident had a pressure ulcer to right foot related to decreased mobility and one of the interventions was administer treatments as ordered.<BR/>Record review of Resident #45's Physician Order, dated 01/17/2025, reflected Right foot (5th toe)- cleanse with NS/wound cleanser, pat dry, apply collagen (wound care product that support the wound's healing process) and cover with a dry dressing.<BR/>Observation on 02/05/2025 at 9:59 AM revealed LVN A and the ADON were about to do Resident #45's wound care to the fifth toe of the right foot. LVN A sanitized her hand, put on a pair of gloves, and prepared the things needed for wound care. She prepared some gauze, some normal saline bullets, collagen wound dressing, a 2 by 2 dressing, and a plastic bag. While LVN A was preparing the things needed for wound care, the ADON washed his hands, put on a pair of gloves, and sanitized the resident's table. After the ADON sanitized the overbed table, LVN A placed the things to be used for wound care on the resident's overbed table. Both staff removed their gloves, washed their hands, and put on gowns and gloves. The ADON positioned and stabilized the resident's right leg under a blanket to raise it. LVN A removed the old dressing and threw it on the plastic bag. It was observed that the resident's wound was covered by a small piece of collagen dressing and the skin surrounding the wound was dry and scaly. LVN A removed her gloves, washed her hands, and put on a new pair of gloves. She took some gauzes and poured normal saline on them. She started to clean the skin surrounding skin of the wound by wiping it in circular motion. She did it two times. With the same gauze used to clean the surrounding skin, she cleaned the wound, and at the same time tried to remove the collagen that was on the wound. She removed her gloves, washed her hands, and put on a pair of gloves. She dried the wound with some gauze from outside to inside. After drying the wound, she put the collagen dressing, and covered the wound with a 2 by 2 dressing. The ADON removed the blanket from under the resident's right leg and lowered it to the bed. Both staff removed their gowns and gloves and washed their hands.<BR/>In an interview with LVN A on 02/05/2025 at 10:20 AM, LVN A stated Resident #45's wound had a small opening that was why the collagen was sticking on the wound. She said she cleaned around the wound first before cleaning the wound. When asked again, she replied again that she started cleaning the surrounding skin of the wound and then moved to the wound. She said her understanding was that the wound must be cleaned from clean to dirty and for her the surrounding skin was cleaner than the wound. When asked if it was possible that whatever germs the gauze got from the surrounding skin were introduced to the wound, she replied yes. When asked if she was supposed to change the gauze when cleaning the wound, she said yes.<BR/>In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated she was made aware by LVN A about the findings during wound care. She said she told LVN A that wound should be cleaned from the least contaminated area, meaning the wound itself to the most contaminated area, which was the surrounding skin. She said the wound could be infected if the contaminants from the surrounding skin were introduced to the wound bed. She said in cleaning the wound, the gauze should be discarded after every stroke. She said the expectation was for the wound to be cleaned the right way. She said she already did a one-on-one in-service with LVN A about wound care, and she was enrolled to a wound care training the following month.<BR/>In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated the purpose of wound care was to remove debris, bacteria, and exudate in the wound to reduce the risk of infection. He said in wound cleaning, the staff start at the center of the wound going outward, ensuring not to spread the bacteria from the outer area back into the wound. He said a new piece of gauze must be used for each stroke to avoid contamination. He said the expectation was the wound would be cleaned from inside to outside and the gauze be changed with every stroke. He said they would conduct an in-service about wound care.<BR/>In an interview with the Administrator on 02/06/2025 at 10:07 AM, the Administrator stated the expectation was for the staff do the right procedure in cleaning the wound to prevent infection. He said he would collaborate with the DON on how to deal with the issue.<BR/>Record review of facility policy Wound Care Policy/Procedure - Nursing Clinical revised 05/2007 revealed Procedure for Clean Dressing Technique . Wash from the center of the wound to the periphery. Always wash from the area of least contamination to the area of most contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #42) of three residents observed for Incontinent Care.<BR/>The facility failed to ensure that CNA D did not wipe Resident #42's perineal (area between the legs) area from back to front while providing incontinent care on 02/05/2025. <BR/>This failure could place the residents at risk of cross-contamination and development of urinary tract infections.<BR/>Findings included:<BR/>Review of Resident #42's Face Sheet, dated 02/05/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with acute kidney failure.<BR/>Review of Resident #42's Comprehensive MDS Assessment, dated 01/22/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated Resident #42 was always incontinent for bladder and bowel.<BR/>Review of Resident #42's Comprehensive Care Plan, dated 01/27/2025, reflected the resident had bowel/bladder incontinence r/t: impaired mobility and one of the interventions was check as required for incontinence, wash, rinse, and dry perineum.<BR/>Observation on 02/05/2025 at 9:02 AM revealed CNA D was about to transfer Resident #42 to her wheelchair through sit-to-stand. She said before she transfered the resident to her wheelchair, the resident would go to the restroom first for a bowel movement. She assisted the resident to a sitting position at the side of the resident's bed, put the sit-to-stand sling around the resident's torso, secured the sling to the sit-to-stand machine, and raised the resident to a standing position. CNA D rolled the resident to the restroom, pulled down the brief, and lowered the resident to the toilet seat. CNA D removed the sling and said she would wait for the resident. While she was waiting for the resident to be done, she removed her gloves, washed her hands, pulled a pair of gloves from the left pocket of her scrub top, and put on the gloves. She prepared some wipes on the sink covered with paper towels. When the resident was done with the <BR/>bowel movement, CNA D put back the sling and raised the resident. She cleaned the bottom of the resident. After cleaning the resident's bottom, she removed her gloves, and put on a new pair of gloves. CNA D then cleaned the perineal area from back to front. She did it three times. After cleaning the perineal area, she pulled the resident's brief and pants back up, rolled the sit-to-stand machine out of the restroom, and lowered the resident to her wheelchair.<BR/>Observation and interview with CNA D on 02/05/2025 at 9:29 AM revealed CNA D demonstrated the manner she cleaned Resident #42's perineal area. She said she started on the sides and then the middle. When asked how she cleaned the middle of the perineal area, she demonstrated wiping the middle from back to front. She said it was because of the position of the resident that was why she cleaned the resident's perineal area that way. She said she still should had cleaned the resident's front part from front to back regardless of the position of the resident. She said the wiping should always be from front to back to prevent urinary tract infection. She said she should be mindful of how she does incontinent care because the resident would be at risk for infection.<BR/>In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated the cleaning the perineal area should be from front to back to prevent cross contamination and probable infection. She said the procedure did not change with regards to the position of the resident. She said cleaning the perineal area was front to back whether the resident was in the bed, sitting in the toilet seat, sitting in a commode, or standing up. She said the gloves should not be placed in their pockets because, basically, we did not know how dirty their pockets were and then they would use the gloves from the pockets to clean the residents. She said the expectation was for the staff to focus on the prevention of infection and not their convenience. She said she would do an in-service about incontinent care and said the expectation was for them to practice the right procedure of incontinent care. <BR/>In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated the proper way of cleaning the resident's perineal area would be always front to back to avoid transfer of germs from the bottom to the front part of the resident. He said the purpose of which was to prevent infection. He said the expectation was for the staff to do incontinent care the right way which was cleaning the front part from front to back. He said they would do an in-service pertaining to incontinent care focusing on proper cleaning of the front part of the residents.<BR/>In an interview with the Administrator on 02/06/2025 at 10:07 AM, the Administrator stated improper incontinent care could cause infection and the expectation was for the staff to do the right procedure. He said he would collaborate with the DON on how to deal with the issue.<BR/>Record review of facility policy, Perineal Care Policy/Procedure - Nursing Clinical revised 07/2021 revealed Policy . 3. Prevent irritation or infection . Procedures . NOTE: The basic infection control-concept for pericare is to wash from the cleanest area to the dirtiest area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #59) of five residents was provided medications and pharmaceutical services, including the accurate administering of all drugs, to meet their needs.<BR/>The facility failed to ensure MA did not leave Resident #59's medications inside the resident's room and failed to monitor the administration of the medications on 02/04/2025. <BR/>This failure could place the residents at risk of chocking or not receiving medications as ordered by the physician.<BR/>Findings included: <BR/>Record review of Resident #59's Face Sheet, dated 02/05/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure), gastro-esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach), cerebral infarction (insufficient oxygen in the brain causing stroke).<BR/>Record review of Resident #59's Quarterly MDS Assessment, dated 12/16/2024, reflected resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment also indicated the resident had cerebral infarction, hypertension, and gastro-esophageal reflux disease.<BR/>Record review of Resident #59's Comprehensive Care Plan, dated 11/07/2024, reflected the resident had gastro-esophageal reflux disease, cerebral vascular disease, and hypertension and the interventions for the three medical issues were to give medications as ordered.<BR/>Review of Resident #59's Clinical Assessment on 02/04/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage her own medications.<BR/>Review of Resident #59's Physician Order, dated 04/04/2023, reflected Aspirin EC Tablet Delayed Release 81 MG (Aspirin). Give 1 tablet by mouth one time a day for CVA (cerebrovascular accident: stroke).<BR/>Review of Resident #59's Physician Order, dated 04/04/2023, reflected Famotidine Oral Tablet 20 MG (Famotidine) Give 1 tablet by Mouth one time a day for GERD (gastro-esophageal reflux disease: stomach acid repeatedly flows back into the tube connecting your mouth and stomach).<BR/>Review of Resident #59's Physician Order, dated 04/04/2023, reflected Nifedipine ER Oral Tablet Extended Release 24 Hour 30 MG (Nifedipine) Give 1 tablet by mouth one time a day for HTN DO NOT CRUSH Hold for SBP&lt;110 DBP&lt;60 HR&lt;60,<BR/>Observation on 02/04/2025 at 10:38 AM revealed MA was observed exiting Resident #59's room and closing the door.<BR/>Observation and interview with Resident #59 on 02/04/2025 at 10:40 AM revealed the resident was sitting on a chair beside her bed. In front of the resident was her overbed table with a small plastic cup on top of it. Inside the plastic cup was a white, round pill. The resident she was going to take the medication in a minute. She said she already taken two out of three pills that was left by the staff. She said the staff would leave her medications with her and she would take. She said she told her what the medications were, but she could not remember them and all she could remember was how many.<BR/>In an interview with the MA on 02/04/2025 at 10:48 AM, the MA stated she did leave Resident #59's medication with her because the resident wanted to take the medication every five minutes. She said should have returned to the room and checked on the resident or stayed with the resident until the resident had taken all the medications. She said the pills should not be left with the resident because the resident might not take them, throw them, or choke while taking them and no one would know. She said she left three pills with the resident, her aspirin, famotidine, and her blood pressure medication.<BR/>In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated staff should never leave the medications with the resident for the residents to take later. She said the staff must wait for the residents to be done with their medications before leaving the room. She said the resident might choke while taking the medications and no one would know. She said the resident might not take the medications or hide the pills to avoid taking them. She said the residents could also hoard the medications and take them altogether that could cause an overdose. The DON said the expectation was for the staff not to leave the room until the residents were done taking the medications or if the residents were still not ready to take the medication, just take the medications with them and come back later. She said she would do an in-service pertaining to not leaving the medications with a resident.<BR/>In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated medications were not left with the residents. He said the staff administering the medications should stay with the resident until the resident was done taking the medications. He said the resident might not take them or someone else might, like another resident or a visitor. He said the resident might aspirate while taking the medications and nobody was with him. He said he would coordinate with the DON to do an in-service about not leaving the medications with the residents.<BR/>In an interview with the Administrator on 02/026/2025 at 10:07 AM, the Administrator stated staff should not leave medications unattended because of the risk of the resident not taking them or the pills not taken on time. He said he would coordinate with the DON on how to go forward to prevent untoward outcomes of leaving the medications with a resident.<BR/>Record review of facility policy, Medication Administration Policy/Procedure - Nursing Services revised 07/2020 revealed POLICY: It is the policy of this facility that medications shall be administered as prescribed by the attending physician . PROCEDURES . 4. Identification of the resident must be made prior to administering medication to the resident . 5. Medications may not be set up in advance and scheduled medications must be administered within facility time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #42, Resident #45, and Resident #58) of eight residents reviewed for Infection Control. <BR/>1. <BR/>The facility failed to ensure CNA B performed hand hygiene, changed her gloves, and did not put the gloves on her pocket while providing incontinent care to Resident #58 on 02/04/2025.<BR/>2. <BR/>The facility failed to ensure CNA B and CNA C changed their gloves and performed hand hygiene while providing incontinent care to Resident #45 on 02/04/2025.<BR/>3. <BR/>The facility failed to ensure CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #42 on 02/05/2025.<BR/>These failures could place residents at risk of cross-contamination and development of infections.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #58's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with urinary tract infection.<BR/>Record review of Resident #58's Quarterly MDS Assessment, dated 10/28/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated the resident was always incontinent for bowel and bladder.<BR/>Record review of Resident #58's Comprehensive Care Plan, dated 01/29/2025, reflected the resident had bowel/bladder incontinence and one of the interventions was to provide pericare after each incontinent episode.<BR/>Observation on 02/04/2025 at 9:46 AM revealed CNA B was about to do Resident #58's incontinent care. CNA B washed her hands and put on a pair of gloves. She prepared some wipes, a brief, and a plastic bag and put them on the resident's overbed table. She lowered the head of the bed and raised the bed. She unfastened the brief and pushed it between the resident's thighs. She removed her gloves, threw them on the plastic bag placed on the overbed table, and put on a new pair of gloves that she took from the left pocket of her scrub suit's top. She did not sanitize her hands before pulling the gloves from her pocket. She pulled some wipes and cleaned the resident perineal area (area between the thighs) using the front to back technique. She did it three times. After cleaning the perineal area, she assisted the resident to roll towards the left side and cleaned the resident's bottom. After cleaning the resident's bottom, CNA B took the new brief from the overbed table, put it under the resident, and fixed it. She did not change her gloves after cleaning the bottom of the resident and before touching the new brief. After fixing the brief, CNA B assisted the resident to roll back and fastened the brief on both sides. CNA B took off her gloves, threw them in the trash bag, and washed her hands.<BR/>2. <BR/>Record review of Resident #45's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and need for assistance with personal care.<BR/>Record review of Resident #45's Comprehensive MDS Assessment, dated 11/01/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 02. Comprehensive MDS Assessment indicated the resident was always incontinent for bowel and bladder.<BR/>Record review of Resident #45's Comprehensive Care Plan, dated 01/13/2025, reflected the resident had bowel/bladder incontinence and one of the interventions was provide pericare (cleaning the private areas of the resident) after each incontinent episode.<BR/>Observation on 02/04/2025 at 1:22 PM revealed CNA B and CNA C were about to do Resident #45's incontinent care. Both staff washed their hands and put on a pair of gloves. CNA B went to the resident's left side, while CNA C went to the resident's right side. CNA B unfastened the brief and pushed it between the resident's thighs. CNA B removed her gloves, pulled some gloves from her scrub suits' left pocket, and put on the gloves. CNA B pulled some wipes placed on the resident's side and cleaned the resident's perineal area. CNA B removed her gloves, pulled some gloves from her left pocket, and put on the gloves. After CNA B cleaned the perineal area, both CNAs assisted the resident to roll to his right side and CNA B cleaned the resident's bottom. After cleaning the resident's bottom, CNA B pulled the brief and threw it on the trash can. After CNA B threw the soiled brief, it was observed that the resident was still having a bowel movement. CNA B continued to clean the resident's bottom and placed the used wipes on the padding. After cleaning the resident's bottom, again, CNA B removed her gloves, went to the bathroom, took a box of gloves, placed some gloves in her pocket, and put on a pair of gloves. CNA B instructed CNA C to get the resident's brief on top of the resident's drawer. CNA C gave the brief to CNA B. CNA B placed a new padding on top of the rolled soiled padding, put the new brief on top of the new padding, and fixed them. Both CNAs rolled the resident to the other side. CNA C took the soiled padding with soiled wipes in it, put it on a plastic bag, and helped in fixing the brief. They rolled back the resident and fastened the brief. CNA C did not change her gloves after putting the soiled padding on a plastic bag.<BR/>In an interview with CNA B on 02/04/2025 at 1:42 PM, CNA B stated she did change her gloves when she did Resident #58 and Resident # 45's incontinent care but did not sanitize in between changing of gloves. She said hand hygiene should be done after removing the gloves to make sure the hands were not soiled before touching the new gloves. She said gloves should also be changed before touching the new brief to prevent the new brief from being soiled. She said gloves should not be placed in the pockets because she used her pockets for something else, like for her cellphone, her car keys, and others. She said she would be mindful next time not to put the gloves in her pocket, to change gloves after cleaning the residents' bottom, and to do hand hygiene when she changed her gloves. She said not sanitizing the hands when the gloves were changed and not changing the gloves could cause infection. She said putting the gloves in the packet could also indirectly cause infection.<BR/>In an interview with CNA C on 02/06/2025 at 9:47 AM, CNA C stated she realized she did not change her gloves after pulling the soiled padding that had soiled wipes in it. She said she should have changed her gloves, sanitized her hands, and put on a new pair of gloves. She said her gloves were basically soiled when she assisted in fixing the brief. She said not changing the gloves could cause infection like urinary tract infection.<BR/>3. <BR/>Review of Resident #42's Face Sheet, dated 02/05/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with acute kidney failure.<BR/>Review of Resident #42's Comprehensive MDS Assessment, dated 01/22/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated Resident #42 was always incontinent for bladder and bowel.<BR/>Review of Resident #42's Comprehensive Care Plan, dated 01/27/2025, reflected the resident had bowel/bladder incontinence r/t: impaired mobility and one of the interventions was check as required for incontinence, wash, rinse, and dry perineum.<BR/>Observation on 02/05/2025 at 9:02 AM revealed CNA D was about to transfer Resident #42's to her wheelchair through sit-to-stand. She said before she transfered the resident to her wheelchair, the resident would go to the restroom first for a bowel movement. She assisted the resident to a sitting position at the side of the resident's bed, put the sit-to-stand sling around the resident's torso, secured the sling to the sit-to-stand machine, and raised the resident to a standing position. CNA D rolled the resident to the restroom, pulled down the brief, and lowered the resident to the toilet seat. CNA D removed the sling and said she would wait for the resident. While she was waiting for the resident to be done, she removed her gloves, washed her hands, and put on a pair gloves. She put some paper towel on the sink and put some wipes and a brief on the paper towels. When the resident was done with the bowel movement, CNA D put back the sling around the resident, hooked it to the sit-to-stand machine, and raised the resident. She cleaned the bottom of the resident first. After cleaning the resident's bottom, she removed her gloves and put on a new pair of gloves. She did not sanitize her hands when she changed her gloves. CNA D then cleaned the perineal area. After cleaning the perineal area, she pulled the resident's brief and pants back up, rolled the sit-to-stand machine out of the restroom, and lowered the resident to her wheelchair. She did not change her gloves after cleaning the resident's perineal area and before pulling up the brief.<BR/>In an interview with CNA D on 02/05/2025 at 9:29 AM revealed CNA D stated hands should be washed or sanitized when changing the gloves. She said gloves should be clean when touching the brief to prevent infection. She said the gloves should be changed after she cleaned the resident's perineal area and before touching the brief because the gloves that she used to clean the resident's perineal area were already soiled. She said she would be mindful the next time she does incontinent care to wash her hands and change her gloves during incontinent care. She said she had trainings for pericare but did not know why she forgot to wash her hands and change her gloves.<BR/>In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and any kind of infection. She said the expectation was for the staff to sanitize their hands in between changing of gloves and change their gloves after touching anything soiled. She said, another expectation was for the staff to get their gloves from the boxes and not put them in their pockets. She said the pockets might be dirty that would render the gloves also dirty. She said she would do and in-service about hand hygiene, incontinent care, and not putting the gloves in their pockets. She said she would personally monitor the staff doing direct care. <BR/>In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated putting the gloves in the pocket was a bad habit. He said the gloves, when placed in the pockets, could be considered soiled because the dirt from the pockets might cling to the gloves. He said hands should be sanitized every time the gloves were removed, and gloves should be changed after touching something soiled to prevent cross contamination and development of infection. He said they would he would remind the staff to change their gloves from dirty to clen, sanitize in between changing of gloves, and not to put their gloves in their pockets. He said they would also do an in-service about hand hygiene, pericare, and not to put the gloves in the pockets of their scrub suits.<BR/>In an interview with the Administrator on 02/026/2025 at 10:07 AM, the Administrator stated the staff should change their gloves and sanitize their hands to prevent infection. He said they should not put the gloves in their pockets. He said the expectation was for the staff to follow the policy and procedures pertaining to incontinent care and infection control. He said he would coordinate with the DON on how to handle the issue about infection control and hand hygiene.<BR/>Record review of facility policy, Perineal Care Policy/Procedure - Nursing Clinical revised 07/2021 revealed Policy . 3. Prevent irritation or infection.<BR/>Record review of facility policy, Hand Hygiene Infection Prevention and Control Program 2009 revealed Policy: This facility considers hand hygiene the primary means to prevent the spread of infections . 4. Use an alcohol-based hand rub . f. Before donning sterile gloves . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . k. After handling used dressings, contaminated equipment, etc. m. After removing gloves . Applying and removing gloves . 1. Perform hand hygiene before and after applying non-sterile gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Residents #1, #2, and #3) of 9 residents reviewed for call lights in reach. <BR/>Resident #1's call pad was on the floor, under his bed, and not within reach, while he was in bed. <BR/>Resident #2's call button was on the floor, under his bed, and not within reach, while he was in bed. <BR/>Resident #3's call button was clipped to his pillow, and not within reach, while he was in his wheelchair at the foot of his bed. <BR/>These failures could place residents at risk of not having their needs and preferences met and a decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet, 06/14/2024, reflected he was, and [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included acute cystitis without hematuria (bladder infection), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), lack of coordination, and dysphasia (speaks slowly with great difficulty). <BR/>Record review of Resident #1s MDS Assessment, dated 05/28/2024, revealed Resident #1's BIMS was 3, which indicated severe cognitive impairment. He was dependent for toileting, showers, dressing, personal hygiene and eating. He required extensive assistance in transferring and bed mobility. <BR/>Record review of Resident #1's Comprehensive Care Plan, dated 06/10/2024, revealed, Focus: At risk for a communication problem r/t Hearing Impairment, Dementia. Interventions: Anticipate and meet needs. Focus: ADL Self Care Performance Deficit r/t weakness and confusion. Intervention: Encourage to use bell to call for assistance. Focus: At risk for falls r/t weakness, dementia, bowel/bladder incontinence. Intervention: Be sure the call light is within reach and encourage to use it to call for assistance as needed. <BR/>Record review of Resident #2's Face Sheet, 06/14/2024, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of prostate (cancerous tumor), type 2 diabetes (problem in the way the body regulates and uses sugar as fuel), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and hypertension (pressure in blood vessels is too high). <BR/>Record review of Resident #2s MDS Assessment, dated 06/14/2024, revealed no record of Resident #2's BIMS. His cognitive skills were severely impaired, He had an indwelling catheter and was always incontinent of bladder and frequently incontinent of bowel. <BR/>Record review of Resident #2's Comprehensive Care Plan, dated 06/10/2024, revealed, Focus: ADL Self Care Performance Deficit r/t bed bound, seizures, stroke, brain tumor, dementia. At risk for falls r/t history of recent falls,<BR/>seizures, stroke, dementia, history of brain tumor. Intervention: Be sure the call light is within reach and encourage to use it to call for assistance as needed. Bed in lowest position.<BR/>Record review of Resident #3's Face Sheet, 06/14/2024, reflected he was an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included lack of coordination, and dysphasia (speaks slowly with great difficulty), muscle wasting and atrophy (thinning of muscle mass), chronic kidney disease (kidneys cannot filter blood the way they should), and unsteadiness on feet. <BR/>Record review of Resident #3s MDS Assessment, dated 06/08/2024, revealed Resident #3's BIMS was 10, which indicated a mild cognitive impairment. He was totally dependent for toileting, showers, dressing and personal hygiene. He was dependent for sit to stand and bed to chair transfers. <BR/>Record review of Resident #3's Comprehensive Care Plan, dated 06/06/2024, revealed, Focus: At risk for falls r/t weakness, dementia. Interventions: Be sure the call light is within reach and encourage to use it to call for assistance as needed. Keep needed items, water, etc. in reach.<BR/>An observation on 06/14/2024 at 9:16 AM revealed Resident #1's call pad on the floor under his bed. Resident #1's roommate, Resident #2's call button was on the floor, under the bed and against the wall. Resident #2 was sleeping. <BR/>In an interview on 06/14/2024 at 9:18 AM, Resident #1 said he did use his call light and it was usually on his bed beside him but could not find it at the moment. He stated he needed assistance to get out of bed and did use the call light to call for assistant when he needed it. <BR/>An observation and interview on 06/14/2024 at 9:33 AM revealed Resident #3's call button clipped to the pillow at the head of his bed. The button was under the pillow. Resident #3 was in his wheelchair at the foot of his bed. Resident #3 said he was cold and wanted a blanket. When asked if he used his call light, he said he did but could not find it. <BR/>In an interview on 06/14/2024 at 9:36 AM, the Administrator in Training (AIT) said call lights should be place so residents could reach them. He said residents had a right to use call lights to ensure they can call for assistance when they needed it. <BR/>In an interview on 06/14/2024 at 9:42 AM, LVN A stated Resident #1 could not get out of bed on his own and needed the call pad to call for assistance as needed. He said Resident #2 was recently admitted to the facility and should have the call button within his reach at all times. He stated Resident #3 required total assistance and should also have his call light accessible to him at all times. He said residents had a right to be able to call for assistance when they needed it. He said if residents did not have access to their call lights, they could try to get up and fall. <BR/>In an interview on 06/14/2024 at 9:56 AM, CNA B stated all residents should have access to their call light. She stated she checked for call lights when she did rounds but may have forgotten to place some. She said she had not noticed that Reisidents #1, #2, and #3's call lights were not wihtin thier reach. She said all staff were responsible to ensure call lights were answered and placed in reach of residents. She said if the call lights were not in reach, residents could try to get up and fall resulting in an injury. <BR/>In an interview on 06/14/2024 at 10:41 AM, ADON C stated residents had a right to have call lights in their reach. She stated they need to be able to call for assistance when they require it. She said when resident was not able to call for assistance they often try to meet their own needs and they could fall and hurt themselves. She stated all staff were responsible to ensure call lights were within reach of each resident. She said nurse managers monitor this by rounding. <BR/>In an interview on 06/14/2024 at 12:43 PM, the DON stated all staff should ensure call lights were placed in reach of residents. She stated not doing this was a safety concern as resident could get up to help themselves and fall. She said she expected staff to watch for any safety issues when they are rounding throughout the day. <BR/>In an interview on 06/14/2024 at 1:10 PM, ADON D stated call lights should be accessible to all residents no matter their ability to use them or not. He said it was a resident right to be able to call for assistance as needed. <BR/>In an interview on 06/14/2024 at 2:24 PM, the administrator stated he expected all staff to follow the facility policies. He said resident had a right to have their call lights accessible to them to ensure their needs were met. <BR/>Record review of the facility's policy titled, Call Light/Bell dated 05/2020, reflected, . 5. Leave the resident comfortable. Place the call device within resident's reach before leaving room. If the call light/bell is defective, immediately report this information to the unit supervisor. <BR/>Record review of the facility's policy titled, Safety/Resident revised 07/2013, reflected, .1. Place call light within reach of the resident. 7.Conduct room checks routinely by staff members to promote quality of life and ensure safety of residents residing in the facility. Room checks include but not limited to resident observation (wearing appropriate clothing, oral hygiene, assistive devices, etc.) and bedside observation (call lights within reach, no unauthorized medications, ointments, lotions at bedside, infection control, etc.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 6 (room [ROOM NUMBER], #2, #3, #4, #5, and #6) of 10 resident rooms reviewed for cleanliness and sanitization.<BR/>The facility failed to ensure that Resident Rooms #1, #2, #3, #4, #5, and #6 were thoroughly cleaned and sanitized.<BR/>This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. <BR/>Findings included:<BR/>An observation on 09/24/24 at 12:57 PM of Resident room [ROOM NUMBER] reflected the bathroom floor had built up dirt particles along the walls. The base that the toilet sat on, had thick brownish stains along the front and sides. The air condition unit in the resident's room had dirt stains along the top of the unit and thick black dirt between the vents. The mini fridge in the room had a thick orange stain along the inside bottom. <BR/>An observation on 09/24/24 at 12:59 PM of Resident room [ROOM NUMBER] reflected the base that the toilet sat on, had thick brownish stains along the front and sides. The air condition unit in the resident's room had dirt stains along the top of the unit and thick black dirt between the vents. The mini fridge in the room had a thick white dust along the top.<BR/>An observation on 09/24/24 at 01:01 PM of Resident room [ROOM NUMBER] reflected the bathroom floor had built up dirt particles along the walls. The base that the toilet sat on, had thick brownish stains along the front and sides. The air condition unit in the resident's room had dirt stains along the top of the unit and thick black dirt between the vents. <BR/>An observation on 09/24/24 at 01:03 PM of Resident room [ROOM NUMBER] reflected the bathroom floor had built up dirt particles along the walls. The base that the toilet sat on, had thick brownish stains along the front and sides. The air condition unit in the resident's room had dirt stains along the top of the unit and thick black dirt between the vents.<BR/>An observation on 09/24/24 at 01:05 PM of Resident room [ROOM NUMBER] reflected the air condition unit had dirt stains along the top of the unit and thick black dirt between the vents.<BR/>An observation on 09/24/24 at 01:07 PM of Resident room [ROOM NUMBER] reflected the air condition unit had dirt stains along the top of the unit and thick black dirt between the vents. The mini fridge in the room had a brownish stain along the inside bottom. <BR/>In an interview on 09/25/24 at 09:41 AM, Housekeeping S stated she had been at the facility for 3 years. She stated they are supposed to clean all parts of the room, including the bathrooms and the air condition unit. She stated they are also supposed to dust, mop, and empty trash. She was shown pictures of the concerns observed in the resident rooms and she stated they were supposed to clean the air condition units, but she stated they did not have a good brush to clean the vents. She stated she tried cleaning the base of the toilets, but it was rust. She stated the risk to the residents was that the concerns observed was a hazard and could cause breathing issues.<BR/>In an interview on 09/25/24 at 10:22 AM, the Housekeeping Supervisor stated she had been at the facility for 12 years and in her current position for 4 years. She stated housekeeping staff was supposed to clean bathrooms, floor, windowsills, air condition units. She stated the filter was cleaned once a week at the beginning of the month. She stated housekeeping did not clean out the mini fridges in the resident rooms unless they are very dirty. She stated the family member, or the CNAs clean the mini fridges out. She was shown pictures of the concerns observed in the resident rooms and she stated that there was no excuse and she had completed in services on 09/18/24 about properly deep cleaning the rooms. She stated the resident rooms are scheduled to be deep cleaned once a week. She stated the concerns observed could cause health problems for the resident.<BR/>In an interview on 09/25/24 at 10:35 AM, the Administrator stated he had spoken with the housekeeping supervisor about the concerns observed in the resident rooms. He was also shown pictures of the concerns observed. He stated housekeeping was to clean all the areas of concern, including cleaning the inside of the resident's mini fridge. He stated the housekeeping supervisor takes her role very seriously and she will ensure that the concerns were corrected. He stated the concerns observed in the resident rooms could cause health problems for the resident.<BR/>Review of the facility's policy on Cleaning and Disinfection of Environmental Surfaces (08/2019) reflected Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard.<BR/>Review of the facility's policy on Environmental Services (November 2021) revealed To provide a clean, attractive, and safe environment for residents, visitors, and staff. <BR/> High Dust Wall Articles:<BR/>Damp Dust the Doors and Wall the tops of items along the resident's room and restroom walls (door frames, picture frames, clocks, over bed lighting, door closures, etc.) that are at or above your shoulder height.<BR/>Clean and Disinfect the Room Furnishings:<BR/>A.<BR/>Clean all furnishings in the resident's room including the bed rails, IV poles, doorknobs, wheelchairs, walkers, and all other high contact surfaces.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents' environment remained as free of accident hazards as is possible; and residents received adequate supervision and assistance devices to prevent accidents, for one 1 of 5 residents (Resident #1) reviewed for accident hazards. <BR/>The facility failed to ensure Resident #1's fall mat was on the floor, next to her bed on 03/08/2025. This was evident by the photo taken on 03/08/2025 and submitted by FM B which showed Resident #1 laying on the bare floor away from her bed with her fall mat observed underneath her bed.<BR/>This failure could place the resident at risk of injuries from falls and a decreased quality of care.<BR/>Findings included:<BR/>Record review of a facility undated face sheet for Resident #1, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included: vascular dementia (a condition caused by problems with blood flow to the brain, damaging blood vessels, leading to memory, thinking, and behavioral difficulties), other lack of coordination (jerky, unsteady movements and difficulty with balance and coordination), and muscle weakness (decreased ability of muscles to contract and generate force).<BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected the resident had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #1's Quarterly MDS reflected she was dependent in the following areas: eating, oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene. Resident #1's MDS Section J1800 reflected that Resident #1 has had falls since admission/entry or reentry or the prior assessment with no injuries. <BR/>Record review of Resident #1's undated Care Plan revealed the following:<BR/>Focus: At risk for falls r/t decreased mobility, impaired cognition. Goal: Will not sustain serious injury through the review date. Interventions: Anticipate and meet needs. Be sure the call light is within reach and encourage to use it to call for assistance as needed. Keep needed items, water, etc., in reach.<BR/>Focus: Has had an actual fall no injury r/t: Poor balance & Poor cognition. 01/14/25 Fall, no injury. 02/27/25 Fall, no injury. Goal: Will resume usual activities without further incident through the review date. Interventions: 1/14/25 Bed in lowest position. 2/27/25 Fall mat on floor. Continue interventions on the at-risk plan. Staff will make frequent bed checks.<BR/>Record review of Resident #1's progress notes did not reveal an entry by RN A related to Resident #1 being found on the floor on 03/08/2025. <BR/>Record review of Resident #1's Order Summary dated 03/13/2025, reflected [Resident #1] was to have a floor mat on both sides of her bed with the bed set at its lowest setting was ordered on 12/20/2024 and no start or end date noted.<BR/>Record review of the facility's incident log, dated 03/13/2025, reflected [Resident #1] had a fall on 3/08/2025. <BR/>Record review of the facility's incident report, dated 3/13/2025, under Nursing Description reflected, Received report from the CNA of this [Resident #1] resident being on the floor, laying on her fall mat after falling out of bed. Bed in low position with floor mat in place.<BR/>Record review of the photo provided by FM B showed Resident #1 lying on the hardwood floor with her fall mat underneath her bed. <BR/>During an interview on 03/13/2025 at 9:01 am, FM B stated she arrived at the facility on Saturday (03/08/2025) at 9:35 am. FM B stated as she walked past Resident #1's room, she saw her lying on the floor. FM B stated Resident #1 was positioned on her right side away from her bed and her fall mat was underneath her bed. FM B stated she walked to the dining room and informed a CNA that Resident #1 was on the floor. FM B stated she then walked back to visit her own family member.<BR/>During an interview with CNA A on 03/13/2025 at 1:55 pm, she stated RN A requested her help to transfer Resident #1 from the floor. CNA A stated after RN A assessed Resident #1, they placed her in bed and changed her. CNA A stated she could not remember the exact time they picked Resident #1 up off the floor, but it could not have been more than 15 minutes that she had been on the floor. CNA A stated Resident #1 wiggled herself out of the bed. CNA A stated 10 minutes later, Resident #1 had wiggled out of the bed again. CNA A stated the first time, Resident #1 was on the floormat. CNA A stated the second time Resident #1 was halfway off the fall mat. CNA A stated due to not being able to use restraints, they brought Resident #1 to the nurse's station. CNA A stated Resident #1 had a fall mat on both sides of the bed. CNA A stated when Resident #1 was not in bed, they folded the fall mats up and placed them in the corner. CNA A stated when Resident #1 was in the bed, the fall mats were placed on the floor. CNA A stated Resident #1 was unable to walk nor transfer herself.<BR/>During an interview with the ADON on 03/13/2025 at 2:25 pm, he stated himself and the DON called RN A and asked her if she knew how long Resident #1 had been on the floor and RN A stated, No, but it was not a long time because she had taken the roommate's vital signs around 9:20 am and then went to chart. The ADON stated RN A said she returned to the room around 9:30 am to see if the roommate was dressed for dialysis and that was when she observed Resident #1 laying on her fall mat. The ADON stated the incident was categorized as a fall with no injuries. <BR/>During an interview with RN A on 03/14/2025 at 11:10 am, she stated she saw Resident #1 on the fall mat and immediately reached out to CNA A for assistance. RN A stated each time she went to check on Resident #1, she was back on the fall mat again. RN A stated she and CNA A assisted Resident #1 back in bed each time. RN A stated she changed Resident #1's diaper herself to make sure that was not why Resident #1 kept having the behavior. Resident #1 stated she continued to check on Resident #1 and administered her medications. RN A stated to the best of her knowledge that was what happened. RN A stated Resident #1 had not sustained any injuries. RN A stated Resident #1 was on the fall mat both times. RN A stated she assessed Resident #1 each time but failed to complete any assessments or enter any documentation into the EMR due to there being no injuries. RN A stated when she saw Resident #1 on the floor again she was confused as to why Resident #1 kept doing it. RN A stated per policy, whenever a resident was found on the floor, they would be assessed. RN A stated the nurse was required to complete all appropriate assessments that needed to be done. RN A stated she did not do any of these things because Resident #1 was on the fall mat with no injuries.<BR/>During an interview with the ADON on 03/14/2025 at 11:40 am, he stated due to Resident #1 not being in her bed and observed on her fall mat, the incident would be categorized as an unwitnessed fall. The ADON stated RN A had not charted anything. The ADON stated RN A informed him and the DON that she had not believed it was a fall because Resident #1 was on the fall mat. The ADON stated regardless, if it was a fall or not, the DON informed RN A even if she thought it was a behavior, the least she could had done was documented it as a behavior. The ADON stated the incident occurred on Saturday (3/8/2025) but he did not learn of it until Monday (3/10/2025). The ADON stated he entered a Progress Note and created an Incident Report on Wednesday (3/13/2025) because RN A had not completed these tasks. The ADON stated the Care Plan should be updated to reflect all falls to ensure residents received the most effective care. The ADON stated the Charge Nurse said she completed an assessment including a pain assessment but failed to document anything.<BR/>During an interview with the ADM on 03/14/2025 at 12:10 pm, he stated Resident #1 had not sustained any injuries and was okay. The ADM stated Resident #1 used a wheelchair and was unable to get up on her own. The ADM stated they preferred fall mats to be off the floor if the resident was not in bed to prevent a tripping hazard. The ADM stated no one was perfect, and they try their best to find the best fit for each resident. The ADM stated staff should assess to ensure it was safe to transfer the resident to bed from the floor pending the nurse's discretion. The ADM stated an assessment and documentation should had been completed timely. The ADM stated he expected all staff to follow the facility's policies.<BR/>A record review of the facility's Fall Management System policy, with a revision/reviewed date of January 2022, reflected Policy: It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.<BR/>3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record.<BR/>c. A Fall Risk Evaluation will be completed post fall incident.<BR/>A record review of the facility's Significant Change of Condition, Response policy, with a revision/reviewed date of December 2023, reflected It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care.<BR/>Procedure<BR/>1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): .<BR/>-Change in behavior or increased problems that may cause injuries or incidents to self or others .<BR/>-Fall or other related incident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #59) of five residents was provided medications and pharmaceutical services, including the accurate administering of all drugs, to meet their needs.<BR/>The facility failed to ensure MA did not leave Resident #59's medications inside the resident's room and failed to monitor the administration of the medications on 02/04/2025. <BR/>This failure could place the residents at risk of chocking or not receiving medications as ordered by the physician.<BR/>Findings included: <BR/>Record review of Resident #59's Face Sheet, dated 02/05/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure), gastro-esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach), cerebral infarction (insufficient oxygen in the brain causing stroke).<BR/>Record review of Resident #59's Quarterly MDS Assessment, dated 12/16/2024, reflected resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment also indicated the resident had cerebral infarction, hypertension, and gastro-esophageal reflux disease.<BR/>Record review of Resident #59's Comprehensive Care Plan, dated 11/07/2024, reflected the resident had gastro-esophageal reflux disease, cerebral vascular disease, and hypertension and the interventions for the three medical issues were to give medications as ordered.<BR/>Review of Resident #59's Clinical Assessment on 02/04/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage her own medications.<BR/>Review of Resident #59's Physician Order, dated 04/04/2023, reflected Aspirin EC Tablet Delayed Release 81 MG (Aspirin). Give 1 tablet by mouth one time a day for CVA (cerebrovascular accident: stroke).<BR/>Review of Resident #59's Physician Order, dated 04/04/2023, reflected Famotidine Oral Tablet 20 MG (Famotidine) Give 1 tablet by Mouth one time a day for GERD (gastro-esophageal reflux disease: stomach acid repeatedly flows back into the tube connecting your mouth and stomach).<BR/>Review of Resident #59's Physician Order, dated 04/04/2023, reflected Nifedipine ER Oral Tablet Extended Release 24 Hour 30 MG (Nifedipine) Give 1 tablet by mouth one time a day for HTN DO NOT CRUSH Hold for SBP&lt;110 DBP&lt;60 HR&lt;60,<BR/>Observation on 02/04/2025 at 10:38 AM revealed MA was observed exiting Resident #59's room and closing the door.<BR/>Observation and interview with Resident #59 on 02/04/2025 at 10:40 AM revealed the resident was sitting on a chair beside her bed. In front of the resident was her overbed table with a small plastic cup on top of it. Inside the plastic cup was a white, round pill. The resident she was going to take the medication in a minute. She said she already taken two out of three pills that was left by the staff. She said the staff would leave her medications with her and she would take. She said she told her what the medications were, but she could not remember them and all she could remember was how many.<BR/>In an interview with the MA on 02/04/2025 at 10:48 AM, the MA stated she did leave Resident #59's medication with her because the resident wanted to take the medication every five minutes. She said should have returned to the room and checked on the resident or stayed with the resident until the resident had taken all the medications. She said the pills should not be left with the resident because the resident might not take them, throw them, or choke while taking them and no one would know. She said she left three pills with the resident, her aspirin, famotidine, and her blood pressure medication.<BR/>In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated staff should never leave the medications with the resident for the residents to take later. She said the staff must wait for the residents to be done with their medications before leaving the room. She said the resident might choke while taking the medications and no one would know. She said the resident might not take the medications or hide the pills to avoid taking them. She said the residents could also hoard the medications and take them altogether that could cause an overdose. The DON said the expectation was for the staff not to leave the room until the residents were done taking the medications or if the residents were still not ready to take the medication, just take the medications with them and come back later. She said she would do an in-service pertaining to not leaving the medications with a resident.<BR/>In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated medications were not left with the residents. He said the staff administering the medications should stay with the resident until the resident was done taking the medications. He said the resident might not take them or someone else might, like another resident or a visitor. He said the resident might aspirate while taking the medications and nobody was with him. He said he would coordinate with the DON to do an in-service about not leaving the medications with the residents.<BR/>In an interview with the Administrator on 02/026/2025 at 10:07 AM, the Administrator stated staff should not leave medications unattended because of the risk of the resident not taking them or the pills not taken on time. He said he would coordinate with the DON on how to go forward to prevent untoward outcomes of leaving the medications with a resident.<BR/>Record review of facility policy, Medication Administration Policy/Procedure - Nursing Services revised 07/2020 revealed POLICY: It is the policy of this facility that medications shall be administered as prescribed by the attending physician . PROCEDURES . 4. Identification of the resident must be made prior to administering medication to the resident . 5. Medications may not be set up in advance and scheduled medications must be administered within facility time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #42, Resident #45, and Resident #58) of eight residents reviewed for Infection Control. <BR/>1. <BR/>The facility failed to ensure CNA B performed hand hygiene, changed her gloves, and did not put the gloves on her pocket while providing incontinent care to Resident #58 on 02/04/2025.<BR/>2. <BR/>The facility failed to ensure CNA B and CNA C changed their gloves and performed hand hygiene while providing incontinent care to Resident #45 on 02/04/2025.<BR/>3. <BR/>The facility failed to ensure CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #42 on 02/05/2025.<BR/>These failures could place residents at risk of cross-contamination and development of infections.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #58's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with urinary tract infection.<BR/>Record review of Resident #58's Quarterly MDS Assessment, dated 10/28/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated the resident was always incontinent for bowel and bladder.<BR/>Record review of Resident #58's Comprehensive Care Plan, dated 01/29/2025, reflected the resident had bowel/bladder incontinence and one of the interventions was to provide pericare after each incontinent episode.<BR/>Observation on 02/04/2025 at 9:46 AM revealed CNA B was about to do Resident #58's incontinent care. CNA B washed her hands and put on a pair of gloves. She prepared some wipes, a brief, and a plastic bag and put them on the resident's overbed table. She lowered the head of the bed and raised the bed. She unfastened the brief and pushed it between the resident's thighs. She removed her gloves, threw them on the plastic bag placed on the overbed table, and put on a new pair of gloves that she took from the left pocket of her scrub suit's top. She did not sanitize her hands before pulling the gloves from her pocket. She pulled some wipes and cleaned the resident perineal area (area between the thighs) using the front to back technique. She did it three times. After cleaning the perineal area, she assisted the resident to roll towards the left side and cleaned the resident's bottom. After cleaning the resident's bottom, CNA B took the new brief from the overbed table, put it under the resident, and fixed it. She did not change her gloves after cleaning the bottom of the resident and before touching the new brief. After fixing the brief, CNA B assisted the resident to roll back and fastened the brief on both sides. CNA B took off her gloves, threw them in the trash bag, and washed her hands.<BR/>2. <BR/>Record review of Resident #45's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and need for assistance with personal care.<BR/>Record review of Resident #45's Comprehensive MDS Assessment, dated 11/01/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 02. Comprehensive MDS Assessment indicated the resident was always incontinent for bowel and bladder.<BR/>Record review of Resident #45's Comprehensive Care Plan, dated 01/13/2025, reflected the resident had bowel/bladder incontinence and one of the interventions was provide pericare (cleaning the private areas of the resident) after each incontinent episode.<BR/>Observation on 02/04/2025 at 1:22 PM revealed CNA B and CNA C were about to do Resident #45's incontinent care. Both staff washed their hands and put on a pair of gloves. CNA B went to the resident's left side, while CNA C went to the resident's right side. CNA B unfastened the brief and pushed it between the resident's thighs. CNA B removed her gloves, pulled some gloves from her scrub suits' left pocket, and put on the gloves. CNA B pulled some wipes placed on the resident's side and cleaned the resident's perineal area. CNA B removed her gloves, pulled some gloves from her left pocket, and put on the gloves. After CNA B cleaned the perineal area, both CNAs assisted the resident to roll to his right side and CNA B cleaned the resident's bottom. After cleaning the resident's bottom, CNA B pulled the brief and threw it on the trash can. After CNA B threw the soiled brief, it was observed that the resident was still having a bowel movement. CNA B continued to clean the resident's bottom and placed the used wipes on the padding. After cleaning the resident's bottom, again, CNA B removed her gloves, went to the bathroom, took a box of gloves, placed some gloves in her pocket, and put on a pair of gloves. CNA B instructed CNA C to get the resident's brief on top of the resident's drawer. CNA C gave the brief to CNA B. CNA B placed a new padding on top of the rolled soiled padding, put the new brief on top of the new padding, and fixed them. Both CNAs rolled the resident to the other side. CNA C took the soiled padding with soiled wipes in it, put it on a plastic bag, and helped in fixing the brief. They rolled back the resident and fastened the brief. CNA C did not change her gloves after putting the soiled padding on a plastic bag.<BR/>In an interview with CNA B on 02/04/2025 at 1:42 PM, CNA B stated she did change her gloves when she did Resident #58 and Resident # 45's incontinent care but did not sanitize in between changing of gloves. She said hand hygiene should be done after removing the gloves to make sure the hands were not soiled before touching the new gloves. She said gloves should also be changed before touching the new brief to prevent the new brief from being soiled. She said gloves should not be placed in the pockets because she used her pockets for something else, like for her cellphone, her car keys, and others. She said she would be mindful next time not to put the gloves in her pocket, to change gloves after cleaning the residents' bottom, and to do hand hygiene when she changed her gloves. She said not sanitizing the hands when the gloves were changed and not changing the gloves could cause infection. She said putting the gloves in the packet could also indirectly cause infection.<BR/>In an interview with CNA C on 02/06/2025 at 9:47 AM, CNA C stated she realized she did not change her gloves after pulling the soiled padding that had soiled wipes in it. She said she should have changed her gloves, sanitized her hands, and put on a new pair of gloves. She said her gloves were basically soiled when she assisted in fixing the brief. She said not changing the gloves could cause infection like urinary tract infection.<BR/>3. <BR/>Review of Resident #42's Face Sheet, dated 02/05/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with acute kidney failure.<BR/>Review of Resident #42's Comprehensive MDS Assessment, dated 01/22/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated Resident #42 was always incontinent for bladder and bowel.<BR/>Review of Resident #42's Comprehensive Care Plan, dated 01/27/2025, reflected the resident had bowel/bladder incontinence r/t: impaired mobility and one of the interventions was check as required for incontinence, wash, rinse, and dry perineum.<BR/>Observation on 02/05/2025 at 9:02 AM revealed CNA D was about to transfer Resident #42's to her wheelchair through sit-to-stand. She said before she transfered the resident to her wheelchair, the resident would go to the restroom first for a bowel movement. She assisted the resident to a sitting position at the side of the resident's bed, put the sit-to-stand sling around the resident's torso, secured the sling to the sit-to-stand machine, and raised the resident to a standing position. CNA D rolled the resident to the restroom, pulled down the brief, and lowered the resident to the toilet seat. CNA D removed the sling and said she would wait for the resident. While she was waiting for the resident to be done, she removed her gloves, washed her hands, and put on a pair gloves. She put some paper towel on the sink and put some wipes and a brief on the paper towels. When the resident was done with the bowel movement, CNA D put back the sling around the resident, hooked it to the sit-to-stand machine, and raised the resident. She cleaned the bottom of the resident first. After cleaning the resident's bottom, she removed her gloves and put on a new pair of gloves. She did not sanitize her hands when she changed her gloves. CNA D then cleaned the perineal area. After cleaning the perineal area, she pulled the resident's brief and pants back up, rolled the sit-to-stand machine out of the restroom, and lowered the resident to her wheelchair. She did not change her gloves after cleaning the resident's perineal area and before pulling up the brief.<BR/>In an interview with CNA D on 02/05/2025 at 9:29 AM revealed CNA D stated hands should be washed or sanitized when changing the gloves. She said gloves should be clean when touching the brief to prevent infection. She said the gloves should be changed after she cleaned the resident's perineal area and before touching the brief because the gloves that she used to clean the resident's perineal area were already soiled. She said she would be mindful the next time she does incontinent care to wash her hands and change her gloves during incontinent care. She said she had trainings for pericare but did not know why she forgot to wash her hands and change her gloves.<BR/>In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and any kind of infection. She said the expectation was for the staff to sanitize their hands in between changing of gloves and change their gloves after touching anything soiled. She said, another expectation was for the staff to get their gloves from the boxes and not put them in their pockets. She said the pockets might be dirty that would render the gloves also dirty. She said she would do and in-service about hand hygiene, incontinent care, and not putting the gloves in their pockets. She said she would personally monitor the staff doing direct care. <BR/>In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated putting the gloves in the pocket was a bad habit. He said the gloves, when placed in the pockets, could be considered soiled because the dirt from the pockets might cling to the gloves. He said hands should be sanitized every time the gloves were removed, and gloves should be changed after touching something soiled to prevent cross contamination and development of infection. He said they would he would remind the staff to change their gloves from dirty to clen, sanitize in between changing of gloves, and not to put their gloves in their pockets. He said they would also do an in-service about hand hygiene, pericare, and not to put the gloves in the pockets of their scrub suits.<BR/>In an interview with the Administrator on 02/026/2025 at 10:07 AM, the Administrator stated the staff should change their gloves and sanitize their hands to prevent infection. He said they should not put the gloves in their pockets. He said the expectation was for the staff to follow the policy and procedures pertaining to incontinent care and infection control. He said he would coordinate with the DON on how to handle the issue about infection control and hand hygiene.<BR/>Record review of facility policy, Perineal Care Policy/Procedure - Nursing Clinical revised 07/2021 revealed Policy . 3. Prevent irritation or infection.<BR/>Record review of facility policy, Hand Hygiene Infection Prevention and Control Program 2009 revealed Policy: This facility considers hand hygiene the primary means to prevent the spread of infections . 4. Use an alcohol-based hand rub . f. Before donning sterile gloves . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . k. After handling used dressings, contaminated equipment, etc. m. After removing gloves . Applying and removing gloves . 1. Perform hand hygiene before and after applying non-sterile gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Residents #1, #2, and #3) of 9 residents reviewed for call lights in reach. <BR/>Resident #1's call pad was on the floor, under his bed, and not within reach, while he was in bed. <BR/>Resident #2's call button was on the floor, under his bed, and not within reach, while he was in bed. <BR/>Resident #3's call button was clipped to his pillow, and not within reach, while he was in his wheelchair at the foot of his bed. <BR/>These failures could place residents at risk of not having their needs and preferences met and a decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet, 06/14/2024, reflected he was, and [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included acute cystitis without hematuria (bladder infection), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), lack of coordination, and dysphasia (speaks slowly with great difficulty). <BR/>Record review of Resident #1s MDS Assessment, dated 05/28/2024, revealed Resident #1's BIMS was 3, which indicated severe cognitive impairment. He was dependent for toileting, showers, dressing, personal hygiene and eating. He required extensive assistance in transferring and bed mobility. <BR/>Record review of Resident #1's Comprehensive Care Plan, dated 06/10/2024, revealed, Focus: At risk for a communication problem r/t Hearing Impairment, Dementia. Interventions: Anticipate and meet needs. Focus: ADL Self Care Performance Deficit r/t weakness and confusion. Intervention: Encourage to use bell to call for assistance. Focus: At risk for falls r/t weakness, dementia, bowel/bladder incontinence. Intervention: Be sure the call light is within reach and encourage to use it to call for assistance as needed. <BR/>Record review of Resident #2's Face Sheet, 06/14/2024, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of prostate (cancerous tumor), type 2 diabetes (problem in the way the body regulates and uses sugar as fuel), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and hypertension (pressure in blood vessels is too high). <BR/>Record review of Resident #2s MDS Assessment, dated 06/14/2024, revealed no record of Resident #2's BIMS. His cognitive skills were severely impaired, He had an indwelling catheter and was always incontinent of bladder and frequently incontinent of bowel. <BR/>Record review of Resident #2's Comprehensive Care Plan, dated 06/10/2024, revealed, Focus: ADL Self Care Performance Deficit r/t bed bound, seizures, stroke, brain tumor, dementia. At risk for falls r/t history of recent falls,<BR/>seizures, stroke, dementia, history of brain tumor. Intervention: Be sure the call light is within reach and encourage to use it to call for assistance as needed. Bed in lowest position.<BR/>Record review of Resident #3's Face Sheet, 06/14/2024, reflected he was an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included lack of coordination, and dysphasia (speaks slowly with great difficulty), muscle wasting and atrophy (thinning of muscle mass), chronic kidney disease (kidneys cannot filter blood the way they should), and unsteadiness on feet. <BR/>Record review of Resident #3s MDS Assessment, dated 06/08/2024, revealed Resident #3's BIMS was 10, which indicated a mild cognitive impairment. He was totally dependent for toileting, showers, dressing and personal hygiene. He was dependent for sit to stand and bed to chair transfers. <BR/>Record review of Resident #3's Comprehensive Care Plan, dated 06/06/2024, revealed, Focus: At risk for falls r/t weakness, dementia. Interventions: Be sure the call light is within reach and encourage to use it to call for assistance as needed. Keep needed items, water, etc. in reach.<BR/>An observation on 06/14/2024 at 9:16 AM revealed Resident #1's call pad on the floor under his bed. Resident #1's roommate, Resident #2's call button was on the floor, under the bed and against the wall. Resident #2 was sleeping. <BR/>In an interview on 06/14/2024 at 9:18 AM, Resident #1 said he did use his call light and it was usually on his bed beside him but could not find it at the moment. He stated he needed assistance to get out of bed and did use the call light to call for assistant when he needed it. <BR/>An observation and interview on 06/14/2024 at 9:33 AM revealed Resident #3's call button clipped to the pillow at the head of his bed. The button was under the pillow. Resident #3 was in his wheelchair at the foot of his bed. Resident #3 said he was cold and wanted a blanket. When asked if he used his call light, he said he did but could not find it. <BR/>In an interview on 06/14/2024 at 9:36 AM, the Administrator in Training (AIT) said call lights should be place so residents could reach them. He said residents had a right to use call lights to ensure they can call for assistance when they needed it. <BR/>In an interview on 06/14/2024 at 9:42 AM, LVN A stated Resident #1 could not get out of bed on his own and needed the call pad to call for assistance as needed. He said Resident #2 was recently admitted to the facility and should have the call button within his reach at all times. He stated Resident #3 required total assistance and should also have his call light accessible to him at all times. He said residents had a right to be able to call for assistance when they needed it. He said if residents did not have access to their call lights, they could try to get up and fall. <BR/>In an interview on 06/14/2024 at 9:56 AM, CNA B stated all residents should have access to their call light. She stated she checked for call lights when she did rounds but may have forgotten to place some. She said she had not noticed that Reisidents #1, #2, and #3's call lights were not wihtin thier reach. She said all staff were responsible to ensure call lights were answered and placed in reach of residents. She said if the call lights were not in reach, residents could try to get up and fall resulting in an injury. <BR/>In an interview on 06/14/2024 at 10:41 AM, ADON C stated residents had a right to have call lights in their reach. She stated they need to be able to call for assistance when they require it. She said when resident was not able to call for assistance they often try to meet their own needs and they could fall and hurt themselves. She stated all staff were responsible to ensure call lights were within reach of each resident. She said nurse managers monitor this by rounding. <BR/>In an interview on 06/14/2024 at 12:43 PM, the DON stated all staff should ensure call lights were placed in reach of residents. She stated not doing this was a safety concern as resident could get up to help themselves and fall. She said she expected staff to watch for any safety issues when they are rounding throughout the day. <BR/>In an interview on 06/14/2024 at 1:10 PM, ADON D stated call lights should be accessible to all residents no matter their ability to use them or not. He said it was a resident right to be able to call for assistance as needed. <BR/>In an interview on 06/14/2024 at 2:24 PM, the administrator stated he expected all staff to follow the facility policies. He said resident had a right to have their call lights accessible to them to ensure their needs were met. <BR/>Record review of the facility's policy titled, Call Light/Bell dated 05/2020, reflected, . 5. Leave the resident comfortable. Place the call device within resident's reach before leaving room. If the call light/bell is defective, immediately report this information to the unit supervisor. <BR/>Record review of the facility's policy titled, Safety/Resident revised 07/2013, reflected, .1. Place call light within reach of the resident. 7.Conduct room checks routinely by staff members to promote quality of life and ensure safety of residents residing in the facility. Room checks include but not limited to resident observation (wearing appropriate clothing, oral hygiene, assistive devices, etc.) and bedside observation (call lights within reach, no unauthorized medications, ointments, lotions at bedside, infection control, etc.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents' environment remained as free of accident hazards as is possible; and residents received adequate supervision and assistance devices to prevent accidents, for one 1 of 5 residents (Resident #1) reviewed for accident hazards. <BR/>The facility failed to ensure Resident #1's fall mat was on the floor, next to her bed on 03/08/2025. This was evident by the photo taken on 03/08/2025 and submitted by FM B which showed Resident #1 laying on the bare floor away from her bed with her fall mat observed underneath her bed.<BR/>This failure could place the resident at risk of injuries from falls and a decreased quality of care.<BR/>Findings included:<BR/>Record review of a facility undated face sheet for Resident #1, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included: vascular dementia (a condition caused by problems with blood flow to the brain, damaging blood vessels, leading to memory, thinking, and behavioral difficulties), other lack of coordination (jerky, unsteady movements and difficulty with balance and coordination), and muscle weakness (decreased ability of muscles to contract and generate force).<BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected the resident had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #1's Quarterly MDS reflected she was dependent in the following areas: eating, oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene. Resident #1's MDS Section J1800 reflected that Resident #1 has had falls since admission/entry or reentry or the prior assessment with no injuries. <BR/>Record review of Resident #1's undated Care Plan revealed the following:<BR/>Focus: At risk for falls r/t decreased mobility, impaired cognition. Goal: Will not sustain serious injury through the review date. Interventions: Anticipate and meet needs. Be sure the call light is within reach and encourage to use it to call for assistance as needed. Keep needed items, water, etc., in reach.<BR/>Focus: Has had an actual fall no injury r/t: Poor balance & Poor cognition. 01/14/25 Fall, no injury. 02/27/25 Fall, no injury. Goal: Will resume usual activities without further incident through the review date. Interventions: 1/14/25 Bed in lowest position. 2/27/25 Fall mat on floor. Continue interventions on the at-risk plan. Staff will make frequent bed checks.<BR/>Record review of Resident #1's progress notes did not reveal an entry by RN A related to Resident #1 being found on the floor on 03/08/2025. <BR/>Record review of Resident #1's Order Summary dated 03/13/2025, reflected [Resident #1] was to have a floor mat on both sides of her bed with the bed set at its lowest setting was ordered on 12/20/2024 and no start or end date noted.<BR/>Record review of the facility's incident log, dated 03/13/2025, reflected [Resident #1] had a fall on 3/08/2025. <BR/>Record review of the facility's incident report, dated 3/13/2025, under Nursing Description reflected, Received report from the CNA of this [Resident #1] resident being on the floor, laying on her fall mat after falling out of bed. Bed in low position with floor mat in place.<BR/>Record review of the photo provided by FM B showed Resident #1 lying on the hardwood floor with her fall mat underneath her bed. <BR/>During an interview on 03/13/2025 at 9:01 am, FM B stated she arrived at the facility on Saturday (03/08/2025) at 9:35 am. FM B stated as she walked past Resident #1's room, she saw her lying on the floor. FM B stated Resident #1 was positioned on her right side away from her bed and her fall mat was underneath her bed. FM B stated she walked to the dining room and informed a CNA that Resident #1 was on the floor. FM B stated she then walked back to visit her own family member.<BR/>During an interview with CNA A on 03/13/2025 at 1:55 pm, she stated RN A requested her help to transfer Resident #1 from the floor. CNA A stated after RN A assessed Resident #1, they placed her in bed and changed her. CNA A stated she could not remember the exact time they picked Resident #1 up off the floor, but it could not have been more than 15 minutes that she had been on the floor. CNA A stated Resident #1 wiggled herself out of the bed. CNA A stated 10 minutes later, Resident #1 had wiggled out of the bed again. CNA A stated the first time, Resident #1 was on the floormat. CNA A stated the second time Resident #1 was halfway off the fall mat. CNA A stated due to not being able to use restraints, they brought Resident #1 to the nurse's station. CNA A stated Resident #1 had a fall mat on both sides of the bed. CNA A stated when Resident #1 was not in bed, they folded the fall mats up and placed them in the corner. CNA A stated when Resident #1 was in the bed, the fall mats were placed on the floor. CNA A stated Resident #1 was unable to walk nor transfer herself.<BR/>During an interview with the ADON on 03/13/2025 at 2:25 pm, he stated himself and the DON called RN A and asked her if she knew how long Resident #1 had been on the floor and RN A stated, No, but it was not a long time because she had taken the roommate's vital signs around 9:20 am and then went to chart. The ADON stated RN A said she returned to the room around 9:30 am to see if the roommate was dressed for dialysis and that was when she observed Resident #1 laying on her fall mat. The ADON stated the incident was categorized as a fall with no injuries. <BR/>During an interview with RN A on 03/14/2025 at 11:10 am, she stated she saw Resident #1 on the fall mat and immediately reached out to CNA A for assistance. RN A stated each time she went to check on Resident #1, she was back on the fall mat again. RN A stated she and CNA A assisted Resident #1 back in bed each time. RN A stated she changed Resident #1's diaper herself to make sure that was not why Resident #1 kept having the behavior. Resident #1 stated she continued to check on Resident #1 and administered her medications. RN A stated to the best of her knowledge that was what happened. RN A stated Resident #1 had not sustained any injuries. RN A stated Resident #1 was on the fall mat both times. RN A stated she assessed Resident #1 each time but failed to complete any assessments or enter any documentation into the EMR due to there being no injuries. RN A stated when she saw Resident #1 on the floor again she was confused as to why Resident #1 kept doing it. RN A stated per policy, whenever a resident was found on the floor, they would be assessed. RN A stated the nurse was required to complete all appropriate assessments that needed to be done. RN A stated she did not do any of these things because Resident #1 was on the fall mat with no injuries.<BR/>During an interview with the ADON on 03/14/2025 at 11:40 am, he stated due to Resident #1 not being in her bed and observed on her fall mat, the incident would be categorized as an unwitnessed fall. The ADON stated RN A had not charted anything. The ADON stated RN A informed him and the DON that she had not believed it was a fall because Resident #1 was on the fall mat. The ADON stated regardless, if it was a fall or not, the DON informed RN A even if she thought it was a behavior, the least she could had done was documented it as a behavior. The ADON stated the incident occurred on Saturday (3/8/2025) but he did not learn of it until Monday (3/10/2025). The ADON stated he entered a Progress Note and created an Incident Report on Wednesday (3/13/2025) because RN A had not completed these tasks. The ADON stated the Care Plan should be updated to reflect all falls to ensure residents received the most effective care. The ADON stated the Charge Nurse said she completed an assessment including a pain assessment but failed to document anything.<BR/>During an interview with the ADM on 03/14/2025 at 12:10 pm, he stated Resident #1 had not sustained any injuries and was okay. The ADM stated Resident #1 used a wheelchair and was unable to get up on her own. The ADM stated they preferred fall mats to be off the floor if the resident was not in bed to prevent a tripping hazard. The ADM stated no one was perfect, and they try their best to find the best fit for each resident. The ADM stated staff should assess to ensure it was safe to transfer the resident to bed from the floor pending the nurse's discretion. The ADM stated an assessment and documentation should had been completed timely. The ADM stated he expected all staff to follow the facility's policies.<BR/>A record review of the facility's Fall Management System policy, with a revision/reviewed date of January 2022, reflected Policy: It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.<BR/>3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record.<BR/>c. A Fall Risk Evaluation will be completed post fall incident.<BR/>A record review of the facility's Significant Change of Condition, Response policy, with a revision/reviewed date of December 2023, reflected It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care.<BR/>Procedure<BR/>1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): .<BR/>-Change in behavior or increased problems that may cause injuries or incidents to self or others .<BR/>-Fall or other related incident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' right to be free from abuse for one (Resident #1) of eight residents reviewed for abuse. <BR/>-The facility failed to have interventions in place to prevent Resident #1 from being abused by Resident #2, who had a history of being aggressive with no interventions care planned until 06/06/24, after the incident. On 06/05/24 Resident #1 wandered into Resident #2's room where he was physically attacked and sustained a serious injury. <BR/>The non-compliance was identified as past non-compliance (PNC). The IJ began on 06/05/24 and ended on 06/06/24. The facility had corrected the non-compliance before the state's investigation began. <BR/>These failures could place all residents at risk for abuse that could lead to serious injury, harm, impairment, or death. <BR/>Findings included: <BR/>1.<BR/>Record review of Resident #1's face sheet, dated 06/10/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: dementia (loss of memory and thinking), traumatic brain injury, dysphasia (difficulty speaking), unsteadiness on feet, and age-related physical debility (weakness caused by age). <BR/>Record review of Resident #1's quarterly MDS assessment, dated 03/0724, reflected his BIMS score was 03, which indicated severe cognitive impairment. <BR/>Record review of Resident #1's care plan, revised 01/30/24, reflected the resident was at risk for impaired thought processes r/t traumatic brain injury with cognitive deficit, new facility, and seizure disorder, with interventions that included communication (identifying self at each interaction, face when speaking, reduce distractions, use simple directives, and provide necessary cues-stop and return if agitated). <BR/>Record review of Resident #1's hospital records, dated 06/05/24, reflected the following: [Resident #1] is a [AGE] year-old male who presents s/p being pushes at his nursing facility in which patient hit his head. Patient has a history of prior head trauma for which he underwent craniectomy and cranioplasty. His [family] was at bedside to help provide history. [Family] reports that he is more confused than usual because he cannot remember his birthdate. On exam, he is able to tell us the date and month of his birthday but mixes up the year. [Resident #1] denied pain and had no obvious signs of trauma. Further review reflected results from a CT scan completed on 06/05/24 with findings of an epidural hematoma (bleed between skull and brain matter and postsurgical changes of right frontal craniotomy (surgical opening of skull) and left pterional craniectomy (brain surgery). <BR/>Record review of Resident #1's progress note, dated 06/05/24 by LVN A, reflected the following: At about 6:00pm, this writer heard a sound of a fall in the hallway. Upon getting there, found [Resident #1] on the floor lying on his back unconscious with [Resident #2] standing over him. The [Resident #2] said 'I pushed him because I don't want him coming in my room'. Head to toe assessment was done. [Resident #1] was unconscious, no visible injuries was noted unable to follow commands. Respiration even labored, unable to move extremities. EMS was called. [Resident #1] regained consciousness at about 6:15PM before 911 arrival . [Resident #1] then was transported to [local hospital] for treatment and evaluation. NP on-call, DON, ADON, Administrator and family notified.<BR/>2.<BR/>Record review of Resident #2's face sheet, dated 06/10/2024, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: dementia (loss of memory and thinking), cerebral infarction (stroke), congestive heart failure (weakened heart condition that cause a buildup of fluid in the body), chronic kidney disease, and embolism of pulmonary (blood clot in lungs). <BR/>Record review of Resident 2's PPS MDS assessment, dated 05/07/24, reflected his BIMS score was 13, which indicated cognition was intact. <BR/>Record review of Resident #2's care plan, revised 06/06/24, reflected the resident had the potential to demonstrate physical behaviors r/t dementia, poor impulse control with intervention which included: monitor/document/report to MD of danger to self or others., psychiatric consult as indicated, and transfer to hospital for evaluation and treatment for other medical conditions. Further review reflected there were no interventions in place to address Resident #2's aggressive behaviors prior to 06/06/24. <BR/>Record review of Resident #2's progress note, dated 12/21/23 by LVN A, reflected the following: [Resident #2] tried to exit the facility twice through the back gate and also through the fence by the dining area. After being stopped twice, he became upset and frustrated. This [nurse] redirected [Resident #2] back to his room. Un [sic] getting there, [Resident #2] saw [Resident #3] and kicked him and [Resident #3] yelled out saying 'He kicked me' and Thia [sic] writer went into the room and removed the attack resident from [Resident #2] room, assessed [Resident #3] from head to toe no injuries and no bruises noted .<BR/>Record review of Resident #2's EHR reflected the resident was assessed by psychologist on 09/30/23, when he first admitted to the nursing facility, to address adjustment to facility, memory loss and appetite disturbance for an estimated frequency/duration of 4 times a month for 3 months. Further review reflected Resident #2 was evaluated again on 1/10/24 to address mood and aggressive behaviors. Resident #2 was discharged from psychological services in 03/2024.<BR/>In an interview on 06/07/24 at 9:45 AM with the DON and the Administrator, the DON stated she worked at the facility for 8 years. She stated during dinnertime on 06/05/24 it was reported that the CNAs were assisting residents with eating and LVN A had Resident #1 close to her as he was known to wander; however, she turned to get Resident #1 some water and he wandered into Resident #2's room. The DON stated LVN A heard commotion coming from the room and found Resident #1 on the floor. The DON stated the incident was unwitnessed and she could not state if Resident #1 was pushed to the floor or fell on his own. She stated Resident #2 was alert enough to make some decisions, but he had impulsive thinking. The DON stated Resident #2 would get upset around the 1st of the month because he would get confused and think he needed to leave the facility to go pay his bills, he also thought people were trying to take his money which was why he did not like anyone in his room. The DON stated both Resident #1 and Resident #2 resided on the facility's secured unit for behaviors related to dementia. The Administrator stated he worked at the facility for 1.5 years. He stated the plan was to discharge Resident #2 and there was a discharge meeting with the family scheduled. He stated Resident #2's family agreed to provide 1:1 monitoring of the resident until the facility could find placement. The Administrator stated the facility did not have residents who had aggressive behaviors in general, but any resident who exhibited any type of behaviors, it was related to dementia, and they resided on the facility's secured unit.<BR/>An attempted interview on 06/07/24 with Resident #1 was unsuccessful due to him being in the local hospital and unable to communicate for an interview. Resident #1 was expected to be discharged from the local hospital and return to the nursing facility on 06/10/24; however, he did not arrive by time of Investigator's exit on 06/10/24. <BR/>An attempted interview on 06/07/24 with Resident #2 was unsuccessful due to him being in the community with family and not responding to phone call. Resident #2 was discharged from the nursing facility on the evening of 06/07/24 and unable to be observed/interviewed when Investigator returned to the facility on [DATE]. <BR/>In an interview on 06/07/24 at 1:21 PM., LVN A stated she worked at the facility for almost 5 years. She stated she worked on 06/05/24 when Resident #2 attacked Resident #1. LVN A stated the incident happened during dinnertime when the aides were busy assisting other residents. She stated Resident #1 had finished his meal and she had him near the nurses' station to monitor him closely due to wandering behavior. LVN A stated she turned to get Resident #1 some water when he got up and wandered into Resident #2's room. LVN A stated she heard commotion coming from the room and when she rushed there, she found Resident #1 unconscious on the floor with Resident #2 standing over him. She stated Resident #2 did not like anyone in his room and he informed her that he pushed Resident #1 down for coming in . LVN A stated Resident #2 would sometimes become verbally aggressive towards other residents for going into his room, but she had never seen him get physically aggressive. LVN A stated the other residents did not report or appear to be afraid of Resident #2. <BR/>In an interview on 06/07/24 at 1:48 PM, the SSD stated she was in the process of finding placement for Resident #2 to be discharged . She stated she had sent out referrals to different facilities and the family agreed with the discharge. The SSD stated the family felt an assisted living environment would be more appropriate for Resident #2 because it would provide more space and privacy. The SSD stated Resident #2 had not exhibited aggressive behaviors prior to the incident to her knowledge; however, the facility still thought it was best to discharge him for the safety of everyone. <BR/>In an interview on 06/07/24 at 1:55 PM, CNA C stated she worked at the facility for 30 years on 2nd shift, 2:00 PM-10:00 PM. CNA C stated she worked on 06/05/24 during the incident between Resident #1 and Resident #2. She stated she was assisting other residents with dinner and did not witness the incident; however, LVN A informed her of what happened. CNA C stated Resident #1 always wandered into Resident #2's room because it used to be his room and he would get confused due to dementia and think that was still his room. She stated the staff would always redirect Resident #1 to his room. CNA C stated Resident #2 would get upset when other residents went into his room, but she had never seen him become physically aggressive. <BR/>In an interview on 06/07/24 at 2:12 PM, CNA B stated she worked at the facility for 7 months on 2nd shift, 2:00 PM-10:00 PM. CNA B stated she worked on 06/05/24 during the incident between Resident #1 and Resident #2. She stated she was assisting other residents with dinner when she heard a noise and the LVN A yelled for her to come in Resident #2's room to help. CNA B stated when she got in the room, she saw Resident #1 on the floor, and he was unresponsive. She stated Resident #2 was known to have a bad temper and would curse and get upset if a resident went into his room; however, she never observed him become physically aggressive towards anyone. She stated Resident #2 was mostly quiet and stayed to himself in the room. CNA B stated Resident #2's family stayed at the facility with him to help with his behaviors. She stated Resident #1 previously stayed in the room but was moved for Resident #2's family to stay there, and that was why Resident #1 would get confused and wander back into that room. <BR/>In an interview on 06/07/24 at 3:05 PM, Resident #2's family member stated the facility notified her that Resident #2 had pushed Resident #1 down for entering his room. The family member stated Resident #2 was not usually physically aggressive and knew better then to put his hands on anyone. She stated Resident #2's friend began residing at the facility with him in 12/2023 after Resident #2 attempted to elope from the facility. She stated that was the facility's way of managing Resident #2's behaviors. She stated the facility was not good at implementing interventions and she expressed concerns about Resident #2' care plan to the ombudsman . The family member stated the facility wanted to discharge Resident #2 back in 01/2024 for behaviors but the ombudsman was able to stop it due to the care plan not properly addressing all of Resident #2's needs. <BR/>In an interview on 06/10/24 at 8:45 AM, the Administrator stated Resident #2 had been discharged to one of the company's assisted living facilities. He also stated the hospital reported that Resident #1 was stable and expected to be discharged back to the facility on this date. The Administrator stated although Resident #2's care plan did not reflect interventions to address his aggressive behaviors, the facility had interventions in place that included psychological services, training staff on dementia related behaviors and abuse/neglect, and staff knowing to closely monitor redirect all resident away from Resident #2's room. <BR/>In an interview on 06/10/24 at 09:52 AM, Resident #1's family member stated she visited the resident on 06/05/24, prior to the incident and he did not seem like himself as he was not talking as much. The family stated later after she had left the facility, she received a call informing her that Resident #1 had been taken to the emergency room after being pushed down by another resident and hitting his head. The family member stated Resident #1 had a previous brain injury and testing showed the recent incident caused further injury. The family member stated she did not have any concerns for abuse or neglect prior to the incident; however, now had concerns about there being enough staff to properly monitor residents to prevent incidents like that from occurring again. She stated Resident #1 often wandered into Resident #2's room because that used to be his room until they moved him. She stated Resident #1 had good rapport with his new roommate and family, and there had been no issues between them. <BR/>In an interview on 06/10/24 at 4:35 PM with the Administrator and the DON, the DON stated the staff were trained on behaviors related to dementia and knew to monitor for signs and redirect residents when wandering, especially into Resident #2's room. The DON stated Resident #2 was also seeing a psychologist for his behaviors. The DON stated those interventions should have been on Resident #2's care plan; however, she believed that they were care planned back in 12/2023 because she was very thorough and normally care planned any changes immediately. The DON stated she and the MDS Coordinator were very experienced with care planning, and both understood the importance of keeping it updated; however, this was an oversight. The DON stated she may have accidentally erased previous interventions for behaviors when she updated the care plan after the incident occurred on 06/05/24. The DON stated the risk of not having interventions in place to address aggressive behaviors could result in a negative outcome for residents. The Administrator stated his expectation was that care plans addressed all needs for the residents and was updated whenever there was change in condition/behavior to provide staff with interventions on how to provide appropriate care. The Administrator stated the risk of not updating care plans could be not catching something regarding the care of residents. He stated the facility now ensures that all changes in condition/behaviors are captured during daily morning meetings, and the DON and MDS Coordinator work together to make sure everything is addressed. He stated he is also becoming more involved in the care planning process to verify that care plans are updated per policy. <BR/>The non-compliance was identified as past non-compliance (PNC). The IJ began on 06/05/24 and ended on 06/06/24. The facility had corrected the non-compliance before the state's investigation began. <BR/>The facility took the following actions to correct the non-compliance prior to the survey:<BR/>Record review of in-service titled Dealing with difficult behaviors/Abuse, Neglect & Exploitation, dated 06/06/24, reflected all staff were educated by the DON on how to identify and report abuse/neglect and protocols for dealing with behaviors. <BR/>Record review of Residents #1, #2, #3, #4, #5, #6, #7, and #8'S EHR revealed their care plans were updated and had interventions to address all care needs. <BR/>Record review of incident/accident reports, from 05/07/24-06/07/24, reflected no other resident-to-resident incidents regarding abuse. <BR/>Interviews were conducted on 06/10/24-06/07/24 with DON, ADON, MDS Coordinator, and staff who worked with residents on secured unit with behaviors: LVN A (1st shift), CNA B (2nd shift), CNA C (2nd shift), and LVN D (1st shift), CNA E (1st shift), CNA L (2nd shift). All staff were able to provide competency regarding in-service over abuse/neglect and dealing with difficult behaviors. All staff were able to provide examples of abuse/neglect, appropriate interventions, and when and who to report it to. All staff were also able to provide appropriate interventions and protocols to manage aggressive behaviors and behaviors related to dementia. Staff stated they were made aware of any changes in condition or new behaviors by the charge nurses, DON, and also by access to care plans. <BR/>Record review of the facility's policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment: Freedom from abuse, neglect, exploitation, revised 12/2023, reflected in part the following:<BR/>Policy: It is the policy of this facility that each resident has the right to be free from abuse, neglect misappropriation of resident property, exploitation, and mistreatment <BR/>Procedure:<BR/>1. In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will:<BR/> a. Ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injury of unknown origin and misappropriation of resident property, are reported immediately <BR/>2.Ensure that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injury of unknown origin and misappropriation of resident property, are reported to:<BR/> a. The Administrator of the facility<BR/> b. The State Survey Agency<BR/> c. Adult Protective Services<BR/>3. Ensure that, after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident(s).<BR/>4. Ensure that the results of all investigations are reported within 5 working days of the incident.<BR/>5. Ensure that if the alleged violation is verified, appropriate corrective action is taken.<BR/> .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 2 (Resident #1and Resident #2) of 8 residents reviewed for care plans.<BR/>- The facility failed to document measurable objectives, interventions, or timeframes to address Resident #1's wandering behavior r/t diagnosis of dementia. On 06/05/24 Resident #1 wandered into Resident #2's room and was physically attacked and sustained a serious injury. <BR/>-The facility failed to document measurable objectives, interventions, or timeframes to address Resident #2's aggressive behaviors after he exhibited combative behaviors in 12/2023. Interventions were not documented on Resident #2's care plan until after an incident occurred on 06/05/24 where he was physically aggressive with Resident #1 and caused serious injury.<BR/>The non-compliance was identified as past non-compliance (PNC). The IJ began on 06/05/24 and ended on 06/06/24. The facility had corrected the non-compliance before the state's investigation began. <BR/>This failure could place all residents at risk of not receiving appropriate care and services to meet their needs. <BR/>Findings included: <BR/>1.<BR/>Record review of Resident #1's face sheet, dated 06/10/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: dementia (loss of memory and thinking), traumatic brain injury, dysphasia (difficulty speaking), unsteadiness on feet, and age-related physical debility (weakness caused by age). <BR/>Record review of Resident #1's quarterly MDS assessment, dated 03/0724, reflected his BIMS score was 03, which indicated severe cognitive impairment. <BR/>Record review of Resident #1's care plan, revised 01/30/24, reflected the resident was at risk for impaired thought processes r/t traumatic brain injury with cognitive deficit, new facility, and seizure disorder, with interventions that included communication (identifying self at each interaction, face when speaking, reduce distractions, use simple directives, and provide necessary cues-stop and return if agitated). Further review of the care plan revealed Resident #1 did not have interventions in place to address his wandering behavior. <BR/>Record review of Resident #1's hospital records, dated 06/05/24, reflected the following: [Resident #1] is a [AGE] year-old male who presents s/p being pushes at his nursing facility in which patient hit his head. Patient has a history of prior head trauma for which he underwent craniectomy and cranioplasty. His [family] was at bedside to help provide history. [Family] reports that he is more confused than usual because he cannot remember his birthdate. On exam, he is able to tell us the date and month of his birthday but mixes up the year. [Resident #1] denied pain and had no obvious signs of trauma. Further review reflected results from a CT scan completed on 06/05/24 with findings of an epidural hematoma (bleed between skull and brain matter and postsurgical changes of right frontal craniotomy (surgical opening of skull) and left pterional craniectomy (brain surgery). <BR/>Record review of Resident #1's progress note, dated 06/05/24 by LVN A, reflected the following: At about 6:00pm, this writer heard a sound of a fall in the hallway. Upon getting there, found [Resident #1] on the floor lying on his back unconscious with [Resident #2] standing over him. The [Resident #2] said 'I pushed him because I don't want him coming in my room'. Head to toe assessment was done. [Resident #1] was unconscious, no visible injuries were noted unable to follow commands. Respiration even labored, unable to move extremities. EMS was called. [Resident #1] regained consciousness at about 6:15PM before 911 arrival . [Resident #1] then was transported to [local hospital] for treatment and evaluation. NP on-call, DON, ADON, Administrator and family notified.<BR/>2.<BR/>Record review of Resident #2's face sheet, dated 06/10/2024, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: dementia (loss of memory and thinking), cerebral infarction (stroke), congestive heart failure (weakened heart condition that cause a buildup of fluid in the body), chronic kidney disease, and embolism of pulmonary (blood clot in lungs). <BR/>Record review of Resident 2's PPS MDS assessment, dated 05/0724, reflected his BIMS score was 13, which indicated cognition was intact. <BR/>Record review of Resident #2's care plan, revised 06/06/24, reflected the resident had the potential to demonstrate physical behaviors r/t dementia, poor impulse control with intervention which included: monitor/document/report to MD of danger to self or others., psychiatric consult as indicated, and transfer to hospital for evaluation and treatment for other medical conditions. Further review reflected there were no interventions in place to address Resident #2's aggressive behaviors prior to 06/06/24. <BR/>Record review of Resident #2's progress note, dated 12/21/23 by LVN A, reflected the following: [Resident #2] tried to exit the facility twice through the back gate and also through the fence by the dining area. After being stopped twice, he became upset and frustrated. This [nurse] redirected [Resident #2] back to his room. Un [sic] getting there, [Resident #2] saw [Resident #3] and kicked him and [Resident #3] yelled out saying 'He kicked me' and Thia [sic] writer went into the room and removed the attack resident from [Resident #2] room, assessed [Resident #3] from head to toe no injuries and no bruises noted .<BR/>Record review of Resident #2's EHR reflected the resident was assessed by psychologist on 09/30/23, when he first admitted to the nursing facility, to address adjustment to facility, memory loss and appetite disturbance for an estimated frequency/duration of 4 times a month for 3 months. Further review reflected Resident #2 was evaluated again on 1/10/24 to address mood and aggressive behaviors. Resident #2 was discharged from psychological services in 03/2024.<BR/>In an interview on 06/07/24 at 9:45 AM with the DON and the Administrator, the DON stated she worked at the facility for 8 years. She stated during dinnertime on 06/05/24 it was reported that the CNAs were assisting residents with eating and LVN A had Resident #1 close to her as he was known to wander; however, she turned to get Resident #1 some water and he wandered into Resident #2's room. The DON stated LVN A heard commotion coming from the room and found Resident #1 on the floor. The DON stated the incident was unwitnessed and she could not state if Resident #1 was pushed to the floor or fell on his own. She stated Resident #2 was alert enough to make some decisions, but he had impulsive thinking. The DON stated Resident #2 would get upset around the 1st of the month because he would get confused and think he needed to leave the facility to go pay his bills, he also thought people were trying to take his money which was why he did not like anyone in his room. The DON stated both Resident #1 and Resident #2 resided on the facility's secured unit for behaviors related to dementia. The Administrator stated he worked at the facility for 1.5 years. He stated the plan was to discharge Resident #2 and there was a discharge meeting with the family scheduled. He stated Resident #2's family agreed to provide 1:1 monitoring of the resident until the facility could find placement. The Administrator stated the facility did not have residents who had aggressive behaviors in general, but any resident who exhibited any type of behaviors, it was related to dementia, and they resided on the facility's secured unit.<BR/>An attempted interview on 06/07/24 with Resident #1 was unsuccessful due to him being in the local hospital and unable to communicate for an interview. Resident #1 was expected to be discharged from the local hospital and return to the nursing facility on 06/10/24; however, he did not arrive by time of Investigator's exit on 06/10/24. <BR/>An attempted interview on 06/07/24 with Resident #2 was unsuccessful due to him being in the community with family and not responding to phone call. Resident #2 was discharged from the nursing facility on the evening of 06/07/24 and unable to be observed/interviewed when Investigator returned to the facility on [DATE]. <BR/>In an interview on 06/07/24 at 1:21 PM. LVN A stated she worked at the facility for almost 5 years. She stated she worked on 06/05/24 when Resident #2 attacked Resident #1. LVN A stated the incident happened during dinnertime when the aides were busy assisting other residents. She stated Resident #1 had finished his meal and she had him near the nurses' station to monitor him closely due to wandering behavior. LVN A stated she turned to get Resident #1 some water when he got up and wandered into Resident #2's room LVN A stated she heard commotion coming from the room and when she rushed there, she found Resident #1 unconscious on the floor with Resident #2 standing over him. She stated Resident #2 did not like anyone in his room and he informed her that he pushed Resident #1 down for coming in. LVN A stated Resident #2 would sometimes become verbally aggressive towards other residents for going into his room, but she had never seen him get physically aggressive. LVN A stated the other residents did not report or appear to be afraid of Resident #2. <BR/>In an interview on 06/07/24 at 1:55 PM, CNA C stated she worked at the facility for 30 years on 2nd shift, 2:00 PM-10:00 PM. CNA C stated she worked on 06/05/24 during the incident between Resident #1 and Resident #2. She stated she was assisting other residents with dinner and did not witness the incident; however, LVN A informed her of what happened. CNA C stated Resident #1 always wandered into Resident #2's room because it used to be his room and he would get confused due to dementia and think that was still his room. She stated the staff would always redirect Resident #1 to his room. CNA C stated Resident #2 would get upset when other residents went into his room, but she had never seen him become physically aggressive. <BR/>In an interview on 06/07/24 at 2:12 PM, CNA B stated she worked at the facility for 7 months on 2nd shift, 2:00 PM-10:00 PM. CNA B stated she worked on 06/05/24 during the incident between Resident #1 and Resident #2. She stated she was assisting other residents with dinner when she heard a noise and the LVN A yelled for her to come in Resident #2's room to help. CNA B stated when she got in the room, she saw Resident #1 on the floor, and he was unresponsive. She stated Resident #2 was known to have a bad temper and would curse and get upset if a resident went into his room; however, she never observed him become physically aggressive towards anyone. She stated Resident #2 was mostly quiet and stayed to himself in the room. CNA B stated Resident #2's family stayed at the facility with him to help with his behaviors. She stated Resident #1 previously stayed in the room but was moved for Resident #2's family to stay there, and that is why Resident #1 would get confused and wander back into that room. <BR/>In an interview on 06/07/24 at 3:05 PM, Resident #2's family member stated the facility notified her that Resident #2 had pushed Resident #1 down for entering his room. The family member stated Resident #2 was not usually physically aggressive and knew better then to put his hands on anyone. She stated Resident #2's friend began residing at the facility with him in 12/2023 after Resident #2 attempted to elope from the facility. She stated that was the facility's way of managing Resident #2's behaviors. She stated the facility was not good at implementing interventions and she expressed concerns about Resident #2' care plan to the ombudsman/ The family member stated the facility wanted to discharge Resident #2 back in 01/2024 for behaviors but the ombudsman was able to stop it due to the care plan not properly addressing all of Resident #2's needs. <BR/>In an interview on 06/10/24 at 8:45 AM, the Administrator stated Resident #2 had been discharged to one of the company's assisted living facilities. He also stated the hospital reported that Resident #1 was stable and expected to be discharged back to the facility on this date. The Administrator stated although Resident #2's care plan did not reflect interventions to address his aggressive behaviors, the facility had interventions in place that included psychological services, training staff on dementia related behaviors and abuse/neglect, and staff knowing to closely monitor redirect all resident away from Resident #2's room. The Administrator stated staff also knew to monitor and redirect Resident #1 from wandering into rooms. <BR/>In an interview on 06/10/24 at 09:52 AM, Resident #1's family member stated she visited the resident on 06/05/24, prior to the incident and he did not seem like himself as he was not talking as much. The family stated later after she had left the facility, she received a call informing her that Resident #1 had been taken to the emergency room after being pushed down by another resident and hitting his head. The family member stated Resident #1 had a previous brain injury and testing showed the recent incident caused further injury. The family member stated she did not have any concerns for abuse or neglect prior to the incident; however, now had concerns about there being enough staff to properly monitor residents to prevent incidents like that from occurring again. She stated Resident #1 often wandered into Resident #2's room because that used to be his room until they moved him. She stated Resident #1 had good rapport with his new roommate and family, and there had been no issues between them. <BR/>In an interview on 06/10/24 at 11:50 AM, the MDS Coordinato r revealed she worked at the facility for one year. She stated it was her responsibility to initiate care plans when a resident admitted and to update them as needed; however, the DON also assisted with the task due to the large number of residents. She stated care plans needed to be updated at least quarterly and if there was a significant change in a resident's condition/behaviors. The MDS Coordinator stated any changes in condition/behaviors had to be addressed on the care plan immediately after the first occurrence. She stated any changes or issues with the residents were discussed during morning meeting every day, that was when she received knowledge of any changes that needed to be updated on the care plans. The MDS Coordinator stated she could not recall receiving reports that Resident #2 exhibited any aggressive behaviors and did not update his care plan to reflect so. The MDS Coordinator stated the DON would sometimes be aware of changes in condition that she was not aware of, and the DON would update the care plan herself. The MDS Coordinator stated the importance of a care plan was for nursing staff to know how to provide proper care to each individual resident. She stated the risk of not updating care plans as needed could be improper care being provided to the residents, and in Resident #2's case, his aggressive behaviors were not being addresses and placed other residents in danger. <BR/>In an interview on 06/10/24 at 4:35 PM with the Administrator and the DON, the DON stated the staff were trained on behaviors related to dementia and knew to monitor for signs and redirect residents when wandering, especially into Resident #2's room. The DON stated Resident #2 was also seeing a psychologist for his behaviors. The DON stated those interventions should have been on Resident #2's care plan; however, she believed that they were care planned back in 12/2023 because she was very thorough and normally care planned any changes immediately. The DON stated she and the MDS Coordinator were very experienced with care planning, and both understood the importance of keeping it updated; however, this was an oversight. The DON stated she may have accidentally erased previous interventions for behaviors when she updated the care plan after the incident occurred on 06/05/24. The DON stated the risk of not having interventions in place to address aggressive behaviors could result in a negative outcome for residents. The Administrator stated his expectation was that care plans addressed all needs for the residents and was updated whenever there was change in condition/behavior to provide staff with interventions on how to provide appropriate care. The Administrator stated the risk of not updating care plans could be not catching something regarding the care of residents. He stated the facility now ensures that all changes in condition/behaviors are captured during daily morning meetings, and the DON and MDS Coordinator work together to make sure everything is addressed. He stated he is also becoming more involved in the care planning process to verify that care plans are updated per policy. <BR/>The non-compliance was identified as past non-compliance (PNC). The IJ began on 06/05/24 and ended on 06/06/24. The facility had corrected the non-compliance before the state's investigation began. <BR/>The facility took the following actions to correct the non-compliance prior to the survey : <BR/>Record review of Residents #1, #2, #3, #4, #5, #6, #7, and #8'S EHR revealed their care plans were updated and had interventions to address all care needs. <BR/>Interviews on 06/10/24 at 12:30 PM were conducted with the DON and MDS Coordinator revealed they conveyed the understanding that care plans had to be developed at the time of a residents' admission, then updated quarterly and when there was a significant change in a resident's condition and/or behavior. <BR/>Review of the facility's policy titled Nursing Administration: Care Planning, revised 07/2020, revealed in part the following:<BR/>Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. <BR/>Procedures: <BR/> .<BR/>9. The resident's plan of care-focus, goals, and interventions-are communicated and implemented by the members of the health care continuum accordingly. <BR/>10. The residents' plan of care is reviewed and revised on an ongoing basis, quarterly at a minimum and/or as needed with changes in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents' environment remained as free of accident hazards as is possible; and residents received adequate supervision and assistance devices to prevent accidents, for one 1 of 5 residents (Resident #1) reviewed for accident hazards. <BR/>The facility failed to ensure Resident #1's fall mat was on the floor, next to her bed on 03/08/2025. This was evident by the photo taken on 03/08/2025 and submitted by FM B which showed Resident #1 laying on the bare floor away from her bed with her fall mat observed underneath her bed.<BR/>This failure could place the resident at risk of injuries from falls and a decreased quality of care.<BR/>Findings included:<BR/>Record review of a facility undated face sheet for Resident #1, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included: vascular dementia (a condition caused by problems with blood flow to the brain, damaging blood vessels, leading to memory, thinking, and behavioral difficulties), other lack of coordination (jerky, unsteady movements and difficulty with balance and coordination), and muscle weakness (decreased ability of muscles to contract and generate force).<BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected the resident had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #1's Quarterly MDS reflected she was dependent in the following areas: eating, oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene. Resident #1's MDS Section J1800 reflected that Resident #1 has had falls since admission/entry or reentry or the prior assessment with no injuries. <BR/>Record review of Resident #1's undated Care Plan revealed the following:<BR/>Focus: At risk for falls r/t decreased mobility, impaired cognition. Goal: Will not sustain serious injury through the review date. Interventions: Anticipate and meet needs. Be sure the call light is within reach and encourage to use it to call for assistance as needed. Keep needed items, water, etc., in reach.<BR/>Focus: Has had an actual fall no injury r/t: Poor balance & Poor cognition. 01/14/25 Fall, no injury. 02/27/25 Fall, no injury. Goal: Will resume usual activities without further incident through the review date. Interventions: 1/14/25 Bed in lowest position. 2/27/25 Fall mat on floor. Continue interventions on the at-risk plan. Staff will make frequent bed checks.<BR/>Record review of Resident #1's progress notes did not reveal an entry by RN A related to Resident #1 being found on the floor on 03/08/2025. <BR/>Record review of Resident #1's Order Summary dated 03/13/2025, reflected [Resident #1] was to have a floor mat on both sides of her bed with the bed set at its lowest setting was ordered on 12/20/2024 and no start or end date noted.<BR/>Record review of the facility's incident log, dated 03/13/2025, reflected [Resident #1] had a fall on 3/08/2025. <BR/>Record review of the facility's incident report, dated 3/13/2025, under Nursing Description reflected, Received report from the CNA of this [Resident #1] resident being on the floor, laying on her fall mat after falling out of bed. Bed in low position with floor mat in place.<BR/>Record review of the photo provided by FM B showed Resident #1 lying on the hardwood floor with her fall mat underneath her bed. <BR/>During an interview on 03/13/2025 at 9:01 am, FM B stated she arrived at the facility on Saturday (03/08/2025) at 9:35 am. FM B stated as she walked past Resident #1's room, she saw her lying on the floor. FM B stated Resident #1 was positioned on her right side away from her bed and her fall mat was underneath her bed. FM B stated she walked to the dining room and informed a CNA that Resident #1 was on the floor. FM B stated she then walked back to visit her own family member.<BR/>During an interview with CNA A on 03/13/2025 at 1:55 pm, she stated RN A requested her help to transfer Resident #1 from the floor. CNA A stated after RN A assessed Resident #1, they placed her in bed and changed her. CNA A stated she could not remember the exact time they picked Resident #1 up off the floor, but it could not have been more than 15 minutes that she had been on the floor. CNA A stated Resident #1 wiggled herself out of the bed. CNA A stated 10 minutes later, Resident #1 had wiggled out of the bed again. CNA A stated the first time, Resident #1 was on the floormat. CNA A stated the second time Resident #1 was halfway off the fall mat. CNA A stated due to not being able to use restraints, they brought Resident #1 to the nurse's station. CNA A stated Resident #1 had a fall mat on both sides of the bed. CNA A stated when Resident #1 was not in bed, they folded the fall mats up and placed them in the corner. CNA A stated when Resident #1 was in the bed, the fall mats were placed on the floor. CNA A stated Resident #1 was unable to walk nor transfer herself.<BR/>During an interview with the ADON on 03/13/2025 at 2:25 pm, he stated himself and the DON called RN A and asked her if she knew how long Resident #1 had been on the floor and RN A stated, No, but it was not a long time because she had taken the roommate's vital signs around 9:20 am and then went to chart. The ADON stated RN A said she returned to the room around 9:30 am to see if the roommate was dressed for dialysis and that was when she observed Resident #1 laying on her fall mat. The ADON stated the incident was categorized as a fall with no injuries. <BR/>During an interview with RN A on 03/14/2025 at 11:10 am, she stated she saw Resident #1 on the fall mat and immediately reached out to CNA A for assistance. RN A stated each time she went to check on Resident #1, she was back on the fall mat again. RN A stated she and CNA A assisted Resident #1 back in bed each time. RN A stated she changed Resident #1's diaper herself to make sure that was not why Resident #1 kept having the behavior. Resident #1 stated she continued to check on Resident #1 and administered her medications. RN A stated to the best of her knowledge that was what happened. RN A stated Resident #1 had not sustained any injuries. RN A stated Resident #1 was on the fall mat both times. RN A stated she assessed Resident #1 each time but failed to complete any assessments or enter any documentation into the EMR due to there being no injuries. RN A stated when she saw Resident #1 on the floor again she was confused as to why Resident #1 kept doing it. RN A stated per policy, whenever a resident was found on the floor, they would be assessed. RN A stated the nurse was required to complete all appropriate assessments that needed to be done. RN A stated she did not do any of these things because Resident #1 was on the fall mat with no injuries.<BR/>During an interview with the ADON on 03/14/2025 at 11:40 am, he stated due to Resident #1 not being in her bed and observed on her fall mat, the incident would be categorized as an unwitnessed fall. The ADON stated RN A had not charted anything. The ADON stated RN A informed him and the DON that she had not believed it was a fall because Resident #1 was on the fall mat. The ADON stated regardless, if it was a fall or not, the DON informed RN A even if she thought it was a behavior, the least she could had done was documented it as a behavior. The ADON stated the incident occurred on Saturday (3/8/2025) but he did not learn of it until Monday (3/10/2025). The ADON stated he entered a Progress Note and created an Incident Report on Wednesday (3/13/2025) because RN A had not completed these tasks. The ADON stated the Care Plan should be updated to reflect all falls to ensure residents received the most effective care. The ADON stated the Charge Nurse said she completed an assessment including a pain assessment but failed to document anything.<BR/>During an interview with the ADM on 03/14/2025 at 12:10 pm, he stated Resident #1 had not sustained any injuries and was okay. The ADM stated Resident #1 used a wheelchair and was unable to get up on her own. The ADM stated they preferred fall mats to be off the floor if the resident was not in bed to prevent a tripping hazard. The ADM stated no one was perfect, and they try their best to find the best fit for each resident. The ADM stated staff should assess to ensure it was safe to transfer the resident to bed from the floor pending the nurse's discretion. The ADM stated an assessment and documentation should had been completed timely. The ADM stated he expected all staff to follow the facility's policies.<BR/>A record review of the facility's Fall Management System policy, with a revision/reviewed date of January 2022, reflected Policy: It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.<BR/>3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record.<BR/>c. A Fall Risk Evaluation will be completed post fall incident.<BR/>A record review of the facility's Significant Change of Condition, Response policy, with a revision/reviewed date of December 2023, reflected It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care.<BR/>Procedure<BR/>1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): .<BR/>-Change in behavior or increased problems that may cause injuries or incidents to self or others .<BR/>-Fall or other related incident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's main kitchen and the sub-kitchen, located in the skilled nursing area, reviewed for labeling and dating, and kitchen sanitation. <BR/>The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines and in a sanitary manner.<BR/>The facility failed to ensure expired food was disgarded. <BR/>The facility failed to ensure that the refrigerator, in the sub-kitchen was clean, sanitized, and did not contain staff foods. <BR/>The facility failed to ensure the kitchen equipment in the main kitchen and sub-kitchen was clean and sanitized.<BR/>These failures could place residents at risk for cross contamination and other air-borne illnesses.<BR/>Findings included: <BR/>Observations on 12/19/23 from 08:40 AM to 08:55 AM in the facility's only kitchen revealed:<BR/>o <BR/>One gallon container of sweet relish, located in the walk-in refrigerator, in the main kitchen was dated 3/23 use by 9/23.<BR/>o <BR/>Three large white bins containing sugar, flour, and thickener, located in the main kitchen area had dried up food particles and blackish stains on the outside of the bins and between the opening and the lid of the bins. <BR/>In an observation on 12/19/23 at 8:48 AM of the kitchen substation on the skilled Nursing floor, revealed the counters to be stained with dried brown liquids. There were dried brown stains in a drip pattern on the walls. The refrigerator had dried liquid stains inside on the bottom and on other shelves, as well as in the freezer. There was pint-sized carton of a supplement drink, which was undated, on the door of the refrigerator. The door of the refrigerator would not close.<BR/>In an interview on 12/19/23 at 9:00 AM with CNA/Staffing Coordinator Y, she stated the kitchen substation was used to store snacks and supplemental drinks for the residents. <BR/>Observations on 12/20/23 at 08:32 AM in the sub-kitchen revealed a refrigerator, that was identified by CNA/Staffing Coordinator Y, for the residents in the kitchen area. The refrigerator contained a large blue lunch bag, a medium container of watermelon, which was undated, and medium container containing grapes, honey [NAME], and cantaloupes, which was undated, and two plastic bags of foods that contained miscellaneous food items. The bottom of the refrigerator included two trays that were located on the bottom, had large dark brownish stains in one corner of the area and the other areas had reddish and brownish stains. The shelves in the door had brownish and reddish stains. The freezer section of the refrigerator had reddish and brownish stains and the freezer shelf on the door had reddish and brownish stains. There was a 16-ounce bottle of green tea (verified belonging to staff) in the freezer. The Ice Machine had dark black and white dirt stains along the inside door of the machine and along the inside walls of the machine. The lid of the ice machine hinges had rust and brownish dirt [NAME] in the springs of the door hinges.<BR/>In an Interview on 12/21/23 at 08:05 AM with the Dietary Manager, she stated she managed the main kitchen in the facility but not the substation on the nursing side. She was advised of the food that appeared expired based on the dating, and she stated that the item was not dated correctly, and the use by date should have been 03/24 instead of 03/23. She stated one of the kitchen staff dated it incorrectly and it was corrected. She stated the large bins containing flour, sugar, and thickener, were dirty and she had to remind her staff to clean it daily because of its location being under the preparation table. She stated she had in-serviced staff to clean the outside of the bins daily. She stated they usually wait until the bins were empty before cleaning the inside of the bin. She stated that she constantly had to remind her staff and she was considering moving the bins to an area where there was less traffic to avoid it from getting dirty so easily. She stated the risk of the concerns not being addressed could result in food-borne illnesses.<BR/>In an interview on 12/21/23 09:26 AM with CNA/Staffing Coordinator Y, she stated housekeeping was responsible for keeping the countertops, walls, floors, and sinks clean. She stated she thought the dietary department was responsible for keeping the refrigerator clean, but she was not for sure. She stated she was not sure who was responsible for keeping the rolling carts clean; however, whenever she would see something, she would wipe it down herself. <BR/>In an interview on 12/21/23 at 12:54 AM with LVN N, she stated if nursing staff open a container in the refrigerator, they should either write the date they opened it, or they should pour the rest of the contents down the drain. She stated the dietary department staff were responsible to keeping the refrigerators, microwaves, and dietary carts clean. She stated if the refrigerator and microwave were not clean, it could cause cross contamination and make the residents sick. She stated she had previously kept the ice chest next to the nurses station and had recently moved the refrigerator over, to make room for the cart which held the ice chest, inside the Nourishment room. She stated she did that, so residents and visitors had to request ice from staff, in order to control risk of contamination. She stated if she saw residents or visitors accessing the ice chest, she would dump the ice and disinfect the chest before filling it with fresh ice.<BR/>In an interview on 12/21/23 at 02:02 PM with the Housekeeping Supervisor, she stated they were responsible for sweeping, mopping, counters, cabinets, cabinet doors, outside of the refrigerators and microwaves in the sub-kitchen. She stated she does do audit checks of rooms and areas, but she doesn't get to do it often because she was also overseeing maintenance issues and has other responsibilities, so she can't get to it as often or as regularly as she would like. She stated the condition of the rooms, after seeing photos the concerns in each area, was unacceptable. She stated she had new staff, and they were still learning, but that was no excuse for the condition of the areas. She stated she was going to get with [NAME] about who would be doing what and scheduling. <BR/>In an interview on 12/21/23 at 12/21/23 at 03:18 PM with the Administrator, he stated they have hired a person to solely be responsible for nourishment snacks for diabetic residents, as well as snacks for other residents. The staff person was also responsible for cleaning the refrigerators and microwaves of the sub-kitchens in the other buildings. He acknowledged they have areas to be addressed. He would not say what the impact to the residents could be, as a result of living in an unclean environment.<BR/>Record Review of the Facility's policy on Food Storage and Supplies dated 2012, revealed All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened. <BR/>Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under &sect; 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #99) of 5 residents reviewed for dignity.<BR/>The facility failed to treat Resident #99 with dignity and promote enhancement of her quality of life when the resident was not provided a privacy bag for her catheter bag.<BR/>This failure placed residents at risk of not having their right to a dignified existence maintained and a decline in their quality of life.<BR/>Findings included: <BR/>Review of Resident #99's Face Sheet dated 12/19/2023 reflected resident was an [AGE] year-old female admitted on [DATE]. One of her diagnoses was encounter for fitting and adjustment of urinary device.<BR/>Review of Resident #99's Quarterly MDS assessment dated [DATE] reflected Resident #99 was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated resident had an indwelling catheter.<BR/>Review of Resident #99's Comprehensive Care Plan dated 12/07/2023 reflected Resident #99 had an indwelling catheter and one of the interventions was provide catheter care every shift.<BR/>Review of Resident #99's Physician Order dated 12/02/2023 indicated, POSITION PRIVACY BAG & TUBING BELOW THE LEVEL OF THE BLADDER.<BR/>Observation on 12/19/2023 at 2:51 PM revealed Resident #99 was on her wheelchair resting. Resident #99 had a catheter bag hanging under the wheelchair seat. The catheter bag was observed visible upon entrance to the room. The catheter bag did not have a privacy bag.<BR/>Interview with LVN A on 11/20/2023 at 11:16 AM, LVN A acknowledged Resident #99's catheter bag did not have a privacy bag. LVN A said she changed the catheter bag and placed it inside a privacy bag. She said without the privacy bag, the resident might be embarrassed. She said she reminded the CNA assigned on the hall to make sure to place a privacy bag when the resident was transferred to the wheelchair. <BR/>Interview with CNA O on 12/20/2023 at 11:25 AM, CNA O stated she hung the catheter bag under the wheelchair and forgot to put a privacy bag on the catheter bag. She said there should be a privacy bag whether the resident was inside the room or outside the room to prevent embarrassment.<BR/>Interview with the DON on 12/21/2023 at 8:25 AM, the DON stated the catheter bag should have been placed inside a privacy bag to avoid awkwardness. The DON said all the staff, including her, were responsible in providing dignity to the residents with catheter. The DON said the expectation was for the staff to make sure the catheter bag had a privacy bag when the resident was on the bed or in the wheelchair. She concluded that she would continually remind the staff the importance of catheter care through an in-service.<BR/>Interview with the Administrator on 12/21/2023 at 8:49 AM, the Administrator stated he was not familiar with the procedure for catheter care but would expect the staff to do what was ordered and what was the best practice to prevent embarrassment because the catheter bag was exposed.<BR/>Review of facility policy, Indwelling Urinary Catheter Care, Policy and Procedure rev. 01.2022 revealed Policy: It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed (PRN) for soiling . Purpose: To promote hygiene, comfort, and decrease the risk of infection for a resident with an indwelling urinary catheter . Procedure . 14. Cover the drainage bag with a privacy bag to maintain dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Residents #1, #2, and #3) of 9 residents reviewed for call lights in reach. <BR/>Resident #1's call pad was on the floor, under his bed, and not within reach, while he was in bed. <BR/>Resident #2's call button was on the floor, under his bed, and not within reach, while he was in bed. <BR/>Resident #3's call button was clipped to his pillow, and not within reach, while he was in his wheelchair at the foot of his bed. <BR/>These failures could place residents at risk of not having their needs and preferences met and a decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet, 06/14/2024, reflected he was, and [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included acute cystitis without hematuria (bladder infection), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), lack of coordination, and dysphasia (speaks slowly with great difficulty). <BR/>Record review of Resident #1s MDS Assessment, dated 05/28/2024, revealed Resident #1's BIMS was 3, which indicated severe cognitive impairment. He was dependent for toileting, showers, dressing, personal hygiene and eating. He required extensive assistance in transferring and bed mobility. <BR/>Record review of Resident #1's Comprehensive Care Plan, dated 06/10/2024, revealed, Focus: At risk for a communication problem r/t Hearing Impairment, Dementia. Interventions: Anticipate and meet needs. Focus: ADL Self Care Performance Deficit r/t weakness and confusion. Intervention: Encourage to use bell to call for assistance. Focus: At risk for falls r/t weakness, dementia, bowel/bladder incontinence. Intervention: Be sure the call light is within reach and encourage to use it to call for assistance as needed. <BR/>Record review of Resident #2's Face Sheet, 06/14/2024, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of prostate (cancerous tumor), type 2 diabetes (problem in the way the body regulates and uses sugar as fuel), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and hypertension (pressure in blood vessels is too high). <BR/>Record review of Resident #2s MDS Assessment, dated 06/14/2024, revealed no record of Resident #2's BIMS. His cognitive skills were severely impaired, He had an indwelling catheter and was always incontinent of bladder and frequently incontinent of bowel. <BR/>Record review of Resident #2's Comprehensive Care Plan, dated 06/10/2024, revealed, Focus: ADL Self Care Performance Deficit r/t bed bound, seizures, stroke, brain tumor, dementia. At risk for falls r/t history of recent falls,<BR/>seizures, stroke, dementia, history of brain tumor. Intervention: Be sure the call light is within reach and encourage to use it to call for assistance as needed. Bed in lowest position.<BR/>Record review of Resident #3's Face Sheet, 06/14/2024, reflected he was an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included lack of coordination, and dysphasia (speaks slowly with great difficulty), muscle wasting and atrophy (thinning of muscle mass), chronic kidney disease (kidneys cannot filter blood the way they should), and unsteadiness on feet. <BR/>Record review of Resident #3s MDS Assessment, dated 06/08/2024, revealed Resident #3's BIMS was 10, which indicated a mild cognitive impairment. He was totally dependent for toileting, showers, dressing and personal hygiene. He was dependent for sit to stand and bed to chair transfers. <BR/>Record review of Resident #3's Comprehensive Care Plan, dated 06/06/2024, revealed, Focus: At risk for falls r/t weakness, dementia. Interventions: Be sure the call light is within reach and encourage to use it to call for assistance as needed. Keep needed items, water, etc. in reach.<BR/>An observation on 06/14/2024 at 9:16 AM revealed Resident #1's call pad on the floor under his bed. Resident #1's roommate, Resident #2's call button was on the floor, under the bed and against the wall. Resident #2 was sleeping. <BR/>In an interview on 06/14/2024 at 9:18 AM, Resident #1 said he did use his call light and it was usually on his bed beside him but could not find it at the moment. He stated he needed assistance to get out of bed and did use the call light to call for assistant when he needed it. <BR/>An observation and interview on 06/14/2024 at 9:33 AM revealed Resident #3's call button clipped to the pillow at the head of his bed. The button was under the pillow. Resident #3 was in his wheelchair at the foot of his bed. Resident #3 said he was cold and wanted a blanket. When asked if he used his call light, he said he did but could not find it. <BR/>In an interview on 06/14/2024 at 9:36 AM, the Administrator in Training (AIT) said call lights should be place so residents could reach them. He said residents had a right to use call lights to ensure they can call for assistance when they needed it. <BR/>In an interview on 06/14/2024 at 9:42 AM, LVN A stated Resident #1 could not get out of bed on his own and needed the call pad to call for assistance as needed. He said Resident #2 was recently admitted to the facility and should have the call button within his reach at all times. He stated Resident #3 required total assistance and should also have his call light accessible to him at all times. He said residents had a right to be able to call for assistance when they needed it. He said if residents did not have access to their call lights, they could try to get up and fall. <BR/>In an interview on 06/14/2024 at 9:56 AM, CNA B stated all residents should have access to their call light. She stated she checked for call lights when she did rounds but may have forgotten to place some. She said she had not noticed that Reisidents #1, #2, and #3's call lights were not wihtin thier reach. She said all staff were responsible to ensure call lights were answered and placed in reach of residents. She said if the call lights were not in reach, residents could try to get up and fall resulting in an injury. <BR/>In an interview on 06/14/2024 at 10:41 AM, ADON C stated residents had a right to have call lights in their reach. She stated they need to be able to call for assistance when they require it. She said when resident was not able to call for assistance they often try to meet their own needs and they could fall and hurt themselves. She stated all staff were responsible to ensure call lights were within reach of each resident. She said nurse managers monitor this by rounding. <BR/>In an interview on 06/14/2024 at 12:43 PM, the DON stated all staff should ensure call lights were placed in reach of residents. She stated not doing this was a safety concern as resident could get up to help themselves and fall. She said she expected staff to watch for any safety issues when they are rounding throughout the day. <BR/>In an interview on 06/14/2024 at 1:10 PM, ADON D stated call lights should be accessible to all residents no matter their ability to use them or not. He said it was a resident right to be able to call for assistance as needed. <BR/>In an interview on 06/14/2024 at 2:24 PM, the administrator stated he expected all staff to follow the facility policies. He said resident had a right to have their call lights accessible to them to ensure their needs were met. <BR/>Record review of the facility's policy titled, Call Light/Bell dated 05/2020, reflected, . 5. Leave the resident comfortable. Place the call device within resident's reach before leaving room. If the call light/bell is defective, immediately report this information to the unit supervisor. <BR/>Record review of the facility's policy titled, Safety/Resident revised 07/2013, reflected, .1. Place call light within reach of the resident. 7.Conduct room checks routinely by staff members to promote quality of life and ensure safety of residents residing in the facility. Room checks include but not limited to resident observation (wearing appropriate clothing, oral hygiene, assistive devices, etc.) and bedside observation (call lights within reach, no unauthorized medications, ointments, lotions at bedside, infection control, etc.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #2) of one resident reviewed for gastrostomy tube management.<BR/>The facility failed to ensure Resident #2 had a continuous feeding through a G-tube (A tube directly inserted through the skin to the stomach to deliver nutrition) as per ordered.<BR/>The facility failed to ensure LVN M had the enteral feeding supplies needed to change the feeding formmula of Resident #2.<BR/>The facility failed to ensure Resident #2 had a clear and complete order for the downtime. <BR/>These failures could place residents who receive enteral feedings by G-tube at risk for infection, underfeeding or overfeeding.<BR/>Findings include:<BR/>Review of Resident #2's Face Sheet dated 12/19/2023 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included gastrostomy, and dysphagia.<BR/>Review of Resident #2's Comprehensive MDS assessment dated [DATE] reflected Resident #2 was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated one of Resident #2's primary medical conditions was malnutrition or risk for malnutrition.<BR/>Review of Resident #2's Care Plan dated 11/08/2023 reflected resident had a swallowing problem related to holding food in mouth/choking during meals.<BR/>Review of Resident #2's Physician Order dated 12/14/2023 indicated, every shift FORMULA: JEVITY 1.5 @ 45 ML/HR X 22 HOURS. WATER FLUSH @ 30 ML/HR X 22 HRS.<BR/>Observation on 12/19/2023 at 9:04 AM revealed Resident #2 was on her bed sleeping. Resident had a feeding tube connected to a feeding formula bag. The feeding tube was also connected to the feeding port of the resident. The feeding formula was empty, and the feeding pump was off. <BR/>Observation and interview with LVN M on 12/19/2023 starting at 9:28 AM, LVN M stated the order for the resident's feeding tube was continuous. LVN M said she turned off the feeding pump at around 6:30 AM and said she have not changed the feeding formula because she was waiting for the tubing she needed for the feeding formula. LVN M said she already called central supply for the tubing. LVN M acknowledged there was a three hour gap from the last bag of feeding formula. LVN M said the risk for the feeding gap was underfeeding and malnourishment. She said if the order was continuous, there should have been no gap except for the downtime. LVN M added the order specified to administer the feeding formula for 22 hours but there was no mention about the downtime. LVN M checked the system and confirmed there was no order for the downtime. LVN M asked the DON what was the downtime, the DON replied whatever was written in the order would be the downtime for the feeding tube. LVN M said the risk for no order for downtime could be confusion because the nurses would not know when to stop the feeding and when to continue the feeding. She said another risk would be overfeeding, aspiration, and fluid overload. She added some nurse might do it on the morning or some would do it in the afternoon. LVN M called MD to request an order for the downtime. <BR/>Review of Resident #2's Physician Order dated 12/19/2023 indicated, Jevity 1.5 at 45 ml/hr via g-tube continuous feeding via pump 22 hrs/day. Off at 6:30 am, On at 8:30 am.<BR/>Interview with the DON on 12/21/2023 at 8:25 AM, the DON stated if the order was continuous, there should be no gap on the feeding except during the downtime. The DON said there should be an order for the downtime so there would be consistency on when to stop the feeding and when to continue the feeding. She said if there was a gap more than the downtime, it could cause underfeeding and undernourishment. The DON said she was responsible in monitoring if the resident with G-tube had a n order for downtime. She said the expectation was to follow the order diligently, if the order said continuous, there should be no gaps except for the downtime and the order should specifically say what time was the downtime. The DON said she would continually remind the staff to follow the order and procedure of tube feeding.<BR/>Interview with the Administrator on 12/21/2023 at 8:49 AM, the Administrator stated he would let the clinician answer about the questions regarding tube feeding. The Administrator said whatever was right should be done to be sure to give the best care. Moving forward would coordinate with the clinicians to make sure the adequate time required for tube feeding was given and make sure it was clear when to stop the feeding and when to start it again.<BR/>Record review of facility's policy Gastrostomy Tube Care and Management, Policy/Procedure revealed Policy: It is the policy of this facility to provide proper care . gastrostomy tubes.<BR/>Record review of facility's policy Physician Orders, Pharmacy Services/Nursing Services rev. 07/2022 revealed Policy . It is the policy of this facility to accurately implement orders . 7. Orders . must include . B. Quantity or specific duration of therapy . C. Dosage and frequency .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for five (Resident #2, #23, #34, #41, and #99) of eight residents reviewed for respiratory care.<BR/>The facility failed to ensure Resident #2 and #99's nebulizer mask was properly stored.<BR/>The facility failed to ensure Resident #34 had a clear order for O2 administration.<BR/>The facility failed to ensure Resident #23, and #41's tubing for their oxygen concentrators were changed weekly as scheduled. <BR/>These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.<BR/>Findings included: <BR/>Resident #2<BR/>Review of Resident #2's Face Sheet dated 12/19/2023 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included acute respiratory failure with hypoxia and asthma.<BR/>Review of Resident #2's Comprehensive MDS assessment dated [DATE] reflected Resident #2 was unable to complete the interview to determine the BIMS score. Resident #2's primary medical conditions were asthma and respiratory failure. <BR/>Review of Resident #2's Care Plan dated 11/08/2023 reflected resident had asthma and one of the interventions was give nebulizer treatments and oxygen therapy as ordered.<BR/>Review of Resident #2's Physician order dated 12/14/2023 reflected, Budesonide 0. 5 MG/2ML Suspension. Give 2 ml by mouth two times a day related to acute respiratory failure with hypoxia; unspecified asthma. Nebulize and inhale 2 ml (0.5mg) 2 times a day.<BR/>Review of Resident #2's Physician order dated 12/11/2023 reflected, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 4 hours as needed for SOB or Wheezing via nebulizer.<BR/>Budesonide 0. 5 MG/2ML Suspension. Give 2 ml by mouth two times a day related to acute respiratory failure with hypoxia; unspecified asthma.<BR/>Observation on 12/19/2023 at 9:04 AM revealed Resident #2 was on her bed, awake. Resident #2's nebulizer mask was noted inside the drawer and on top of an incontinent brief. The nebulizer mask was not bagged.<BR/>Interview with LVN M on 12/20/2023 at 11:38 AM, LVN M stated the breathing mask should have not been exposed nor touching anything because it could cause infections. LVN M said the mask should have been bagged when not in use. The breathing mask should have been cleaned and then placed in a storage bag to make sure it would be clean when the resident used it. LVN M said she already changed the mask and placed it on plastic bag.<BR/>Resident #34<BR/>Review of Resident #34's Face Sheet dated 12/19/2023 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included acute respiratory failure with hypoxia, shortness of breath and pneumonitis due to inhalation of food and vomit.<BR/>Review of Resident #34's Comprehensive MDS assessment dated [DATE] reflected Resident #34 had a moderate impairment in cognition with a BIMS score of 8. Resident #34's primary medical conditions were pneumonia and respiratory failure. <BR/>Review of Resident #34's Care Plan dated 11/02/2023 reflected resident had oxygen therapy related to SOB and one of the interventions was to give medications as ordered by physician.<BR/>Review of Resident #34's Physician Order dated 10/04/2023 reflected, O2 at _ L/MIN VIA _ every 12 hours as needed for SOB, RESPIRATORY DISTRESS, CYANOSIS, LABORED BREATHING.<BR/>Review of Resident #34's Physician Order dated 10/04/2023 reflected, O2 AT _ L/MIN CONTINUOUS PER every shift for o2 saturation above 90%.<BR/>Observation and interview with LVN A on 10/11/2023 starting at 11:21 AM, LVN A confirmed Resident #34 was utilizing oxygen supplement as needed. LVN A said resident had been on as needed basis for oxygen supplement for quite some time. LVNA was asked what the order for Resident #34 was for oxygen administration. LVN A said for Resident #34, it was on as needed basis. She turned on her laptop and saw the orders for continuous oxygen and as needed oxygen. She also acknowledged she overlooked the orders were incomplete. The orders did not specify rate of the oxygen administration and the route of the oxygen administration. LVN A said she would confirm the order and remedy the mistake about the order for Resident #34's oxygen supplement. LVN A said it was important to have an order for anything and it was equally important that the order was complete. If the order was not compete, it could result to confusion and the respiratory needs of the resident would not be met. LVN A said she would discontinue the incomplete orders and would place a proper as needed order for oxygen supplement.<BR/>Resident #99<BR/>Review of Resident #99's Face Sheet dated 12/19/2023 reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included acute respiratory failure with hypoxia, pneumonitis due to inhalation of food and vomit, and chronic obstructive pulmonary disease with exacerbation.<BR/>Review of Resident #99's Quarterly MDS assessment dated [DATE] reflected Resident #99 was cognitively intact with a BIMS score of 15. <BR/>Review of Resident #99's Comprehensive Care Plan dated 12/07/2023 reflected resident had COPD and one of the interventions was give nebulizer treatments and oxygen therapy as ordered.<BR/>Review of Resident #99's Physician Order dated 12/03/2023 indicated, Albuterol Sulfate (2.5 MG/3ML) 0.083% Nebulization solution. 0.083% mg inhale orally via nebulizer 2 times a day.<BR/>Observation and interview with Resident #99 on 12/19/2023 at 2:51 PM. Resident #99 was on her wheelchair resting. Resident #99 stated she was on breathing treatment because of her respiratory issues. Resident #99 said she usually had her treatment in the morning and in the afternoon. She said the nurse would place a liquid solution on the nebulizer cup attached to mask. The mask would be placed on her face covering her nose and mouth. Resident #99 continued the nurse would take it off and would usually place the nebulizer machine and the nebulizer mask on the drawer of her side table. The nebulizer mask was noted inside the drawer of the side table. The mask was not bagged and was touching the top of the nebulizer machine.<BR/>Interview with LVN A on 12/20/2023 at 11:16 AM, LVN A stated the mask being used for the breathing treatment must be always clean. A dirty breathing mask could cause infections and various respiratory issues. She said she already changed the mask and placed it in a plastic bag to keep it clean.<BR/>Resident #23<BR/>Record review of Resident #23's face sheet dated 12/19/23 revealed the resident was a [AGE] year-old female that was admitted on [DATE]. Her relevant diagnosis included chronic obstructive pulmonary disease (lung disease), and asthma (trouble breathing). <BR/>Record review of Resident #23's Quarterly MDS dated [DATE] revealed the resident had a BIM score of 4 (severe cognitive impairment).<BR/>Record review of Resident #23's Orders dated 12/19/23 revealed Physician orders for Oxygen 2-4 LPM via nasal cannula to keep O2 greater than 90% as needed.<BR/>Record review of Resident #23's Care Plan revised on 10/23/23 revealed 'Oxygen Settings: (2-4) O2 via nasal prongs/mask @ (Specify) L continuously.<BR/>Observation on 12/19/23 at 11:22 AM of Resident #23's tubing on the oxygen concentrator revealed it was dated 12/7 and 12/10.<BR/>Resident #41<BR/>Record review of Resident #41's face sheet dated 12/19/23 revealed the resident was an [AGE] year-old female that was admitted on [DATE]. Her relevant diagnosis included chronic obstructive pulmonary disease (lung disease), shortness of breath, and heart failure. <BR/>Record review of Resident #41's Quarterly MDS dated [DATE] revealed the resident had a BIM score of 00 (severe cognitive impairment).<BR/>Record review of Resident #41's Orders dated 12/19/23 revealed Physician orders for Change oxygen tubing (and humidifier) every night shift every Sunday.<BR/>Observation on 12/19/23 at 11:42 AM of Resident #41's tubing on the oxygen concentrator revealed it was dated 12/05.<BR/>In an Interview and Observation on 12/19/23 at 02:30 PM with LVN N, she stated she was the evening nurse for the hall of Resident #23 and Resident #41. She stated that both residents used oxygen concentrators and the tubing and humidifier are changed out every Sunday evening by the night nurse. She stated that nurses were required to check to ensure that this had been completed anytime they checked on the resident. She was shown the dates for Resident #23 tubing date of 12/7 and 12/10, and Resident #41's tube dated 12/05/23. She stated that both tubing should have been changed and she did not know why it was not observed prior to today. She stated the risk of the residents tubing not getting changed it infection control.<BR/>Interview with the DON on 12/21/2023 at 8:25 AM, the DON stated the breathing mask and the nasal cannula should be bagged when not in use. The DON said it was the proper way to store the breathing mask and the nasal cannula. She said if those breathing apparatus were not bagged, exposed, or touching surfaces that were not sure clean, the oxygen administration could be compromised. The DON said, the orders should be complete, it should had specified what to administer, the duration, the dosage, the route, and the rationale for the said treatment. If the order was not complete, the staff would not be able to know how much to administer, when it should be administered, and how it should be administered. The DON said the staff, including her, were responsible in monitoring that the equipment used in oxygen therapy were bagged when not in use. She said the expectation was the breathing mask and the nasal cannula would be stored properly and the orders for oxygen administration was complete. She stated the tubing and the fluid in the humidifier should be changed weekly on Sunday nights by the night shift nurse. The DON said she would continually remind the staff to be diligent in making sure the procedures for respiratory care were followed.<BR/>Interview with the Administrator on 12/21/2023 at 8:49 AM, the Administrator stated that in general, the breathing masks and the nasal cannula should be stored properly to prevent respiratory issues. The Administrator said the orders should be complete to give the staff a clear overview of what should be done in terms of oxygen administration. The Administrator said the expectation is for the staff to be diligent in order to provide the highest level of care.<BR/>Record review of facility's policy, Oxygen Administration, Policy/Procedure - Nursing Services rev. 07/2022 revealed POLICY: It is the policy of this facility that oxygen therapy is administered by licensed nurse as ordered by the physician . <BR/>PURPOSE: The purpose of the oxygen therapy is to provide sufficient oxygen . will include: 1. That oxygen is to be administered; 2. When and how often oxygen is to be administered; 3. The type of oxygen device to use (i.e., mask, nasal).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practice for one (Resident #99) of 5 residents reviewed for pressure ulcers.<BR/>The facility failed to document wound care treatments and pain assessment during wound care treatments.<BR/>This failure could place resident at risks for incomplete medical records.<BR/>Findings included: <BR/>Resident #99<BR/>Review of Resident #99's Face Sheet dated 12/19/2023 reflected resident was an [AGE] year-old female admitted on [DATE]. One of her diagnoses was pressure ulcer of sacral region with unspecified stage.<BR/>Review of Resident #99's Quarterly MDS assessment dated [DATE] reflected Resident #99 was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment also indicated resident had a pressure ulcer on the sacral region.<BR/>Review of Resident #99's Comprehensive Care Plan dated 12/07/2023 reflected Resident #99 had pressure ulcer development to right buttock related to decreased physical activity and the goals was to show signs of healing and remain free from infection.<BR/>Review of Resident #99's Physician Order dated 12/01/2023 indicated, Cleanse sacrum area with normal saline, apply calcium alginate and cover with dry dressing daily until resolved one time a day for wound healing.<BR/>Review of Resident #99's Administrative Record Report dated 12/19/2023 reflected treatment to pressure ulcer to sacrum was not documented on 12/11/2023 and 12/18/2023.<BR/>Review of Resident #99's Administrative Record Report dated 12/19/2023 reflected pressure ulcer to sacrum was not assessed for pain before wound treatment on 12/11/2023 and 12/18/2023.<BR/>Review of Resident #99's Administrative Record Report dated 12/19/2023 reflected pressure ulcer to sacrum was not assessed for pain during wound treatment on 12/11/2023 and 12/18/2023.<BR/>Review of Resident #99's Administrative Record Report dated 12/19/2023 reflected pressure ulcer to sacrum was not assessed for pain after wound treatment on 12/11/2023 and 12/18/2023.<BR/>Interview and observation with LVN A on 12/20/2023 at 11:16 AM, LVN A stated Resident #99 had a pressure ulcer to right sacrum that was being treated daily with calcium alginate and covered with dry dressing. LVN A said whoever would do the wound care documented it on the system by placing their initials. LVN A pulled Resident #99's administration record and acknowledge there were no treatments done on 12/11/2023 and 12/18/2023. LVN A said she was not aware the treatments were not done on the said dates. LVN A added the facility had a wound care nurse that would do the wound care. LVN said if the wound care was done during those days it should have been documented on the system. If the treatments were not documented on the system, it meant the treatments were not done. LVN A said if the pressure ulcer were not treated, it could result to exacerbation of the wound, longer healing time, or development of infection.<BR/>Interview with the DON on 12/21/2023 at 8:25 AM, the DON stated any wound with an order of daily treatment should have been treated every day. The DON said daily treatment could help the wound to heal appropriately. The DON said if the pressure ulcer was not treated as ordered, it could result to worsening of the pressure ulcer which was no good for the resident. The DON the order for wound care was placed on the system so the staff would know what, when, and how to treat the wound. She said whoever would do the treatment must put their initial on the system as proof that treatments were done. If there were no initials for those days, it would reflect the wound care was not done. The DON said the expectation was to do the wound care as ordered. She said she would ensure the staff were doing the wound care as ordered.<BR/>Interview with the Administrator on 12/21/2023 at 8:49 AM, the Administrator stated he was not familiar with the procedure for wound care but would expect the staff to do what was ordered and what was the best practice so the wound would heal.<BR/>Review of facility's policy Wound Care, Policy/Procedure - Nursing Clinical rev. 05/2022 revealed Procedure . Document treatment given . as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #42, Resident #45, and Resident #58) of eight residents reviewed for Infection Control. <BR/>1. <BR/>The facility failed to ensure CNA B performed hand hygiene, changed her gloves, and did not put the gloves on her pocket while providing incontinent care to Resident #58 on 02/04/2025.<BR/>2. <BR/>The facility failed to ensure CNA B and CNA C changed their gloves and performed hand hygiene while providing incontinent care to Resident #45 on 02/04/2025.<BR/>3. <BR/>The facility failed to ensure CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #42 on 02/05/2025.<BR/>These failures could place residents at risk of cross-contamination and development of infections.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #58's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with urinary tract infection.<BR/>Record review of Resident #58's Quarterly MDS Assessment, dated 10/28/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated the resident was always incontinent for bowel and bladder.<BR/>Record review of Resident #58's Comprehensive Care Plan, dated 01/29/2025, reflected the resident had bowel/bladder incontinence and one of the interventions was to provide pericare after each incontinent episode.<BR/>Observation on 02/04/2025 at 9:46 AM revealed CNA B was about to do Resident #58's incontinent care. CNA B washed her hands and put on a pair of gloves. She prepared some wipes, a brief, and a plastic bag and put them on the resident's overbed table. She lowered the head of the bed and raised the bed. She unfastened the brief and pushed it between the resident's thighs. She removed her gloves, threw them on the plastic bag placed on the overbed table, and put on a new pair of gloves that she took from the left pocket of her scrub suit's top. She did not sanitize her hands before pulling the gloves from her pocket. She pulled some wipes and cleaned the resident perineal area (area between the thighs) using the front to back technique. She did it three times. After cleaning the perineal area, she assisted the resident to roll towards the left side and cleaned the resident's bottom. After cleaning the resident's bottom, CNA B took the new brief from the overbed table, put it under the resident, and fixed it. She did not change her gloves after cleaning the bottom of the resident and before touching the new brief. After fixing the brief, CNA B assisted the resident to roll back and fastened the brief on both sides. CNA B took off her gloves, threw them in the trash bag, and washed her hands.<BR/>2. <BR/>Record review of Resident #45's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and need for assistance with personal care.<BR/>Record review of Resident #45's Comprehensive MDS Assessment, dated 11/01/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 02. Comprehensive MDS Assessment indicated the resident was always incontinent for bowel and bladder.<BR/>Record review of Resident #45's Comprehensive Care Plan, dated 01/13/2025, reflected the resident had bowel/bladder incontinence and one of the interventions was provide pericare (cleaning the private areas of the resident) after each incontinent episode.<BR/>Observation on 02/04/2025 at 1:22 PM revealed CNA B and CNA C were about to do Resident #45's incontinent care. Both staff washed their hands and put on a pair of gloves. CNA B went to the resident's left side, while CNA C went to the resident's right side. CNA B unfastened the brief and pushed it between the resident's thighs. CNA B removed her gloves, pulled some gloves from her scrub suits' left pocket, and put on the gloves. CNA B pulled some wipes placed on the resident's side and cleaned the resident's perineal area. CNA B removed her gloves, pulled some gloves from her left pocket, and put on the gloves. After CNA B cleaned the perineal area, both CNAs assisted the resident to roll to his right side and CNA B cleaned the resident's bottom. After cleaning the resident's bottom, CNA B pulled the brief and threw it on the trash can. After CNA B threw the soiled brief, it was observed that the resident was still having a bowel movement. CNA B continued to clean the resident's bottom and placed the used wipes on the padding. After cleaning the resident's bottom, again, CNA B removed her gloves, went to the bathroom, took a box of gloves, placed some gloves in her pocket, and put on a pair of gloves. CNA B instructed CNA C to get the resident's brief on top of the resident's drawer. CNA C gave the brief to CNA B. CNA B placed a new padding on top of the rolled soiled padding, put the new brief on top of the new padding, and fixed them. Both CNAs rolled the resident to the other side. CNA C took the soiled padding with soiled wipes in it, put it on a plastic bag, and helped in fixing the brief. They rolled back the resident and fastened the brief. CNA C did not change her gloves after putting the soiled padding on a plastic bag.<BR/>In an interview with CNA B on 02/04/2025 at 1:42 PM, CNA B stated she did change her gloves when she did Resident #58 and Resident # 45's incontinent care but did not sanitize in between changing of gloves. She said hand hygiene should be done after removing the gloves to make sure the hands were not soiled before touching the new gloves. She said gloves should also be changed before touching the new brief to prevent the new brief from being soiled. She said gloves should not be placed in the pockets because she used her pockets for something else, like for her cellphone, her car keys, and others. She said she would be mindful next time not to put the gloves in her pocket, to change gloves after cleaning the residents' bottom, and to do hand hygiene when she changed her gloves. She said not sanitizing the hands when the gloves were changed and not changing the gloves could cause infection. She said putting the gloves in the packet could also indirectly cause infection.<BR/>In an interview with CNA C on 02/06/2025 at 9:47 AM, CNA C stated she realized she did not change her gloves after pulling the soiled padding that had soiled wipes in it. She said she should have changed her gloves, sanitized her hands, and put on a new pair of gloves. She said her gloves were basically soiled when she assisted in fixing the brief. She said not changing the gloves could cause infection like urinary tract infection.<BR/>3. <BR/>Review of Resident #42's Face Sheet, dated 02/05/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with acute kidney failure.<BR/>Review of Resident #42's Comprehensive MDS Assessment, dated 01/22/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated Resident #42 was always incontinent for bladder and bowel.<BR/>Review of Resident #42's Comprehensive Care Plan, dated 01/27/2025, reflected the resident had bowel/bladder incontinence r/t: impaired mobility and one of the interventions was check as required for incontinence, wash, rinse, and dry perineum.<BR/>Observation on 02/05/2025 at 9:02 AM revealed CNA D was about to transfer Resident #42's to her wheelchair through sit-to-stand. She said before she transfered the resident to her wheelchair, the resident would go to the restroom first for a bowel movement. She assisted the resident to a sitting position at the side of the resident's bed, put the sit-to-stand sling around the resident's torso, secured the sling to the sit-to-stand machine, and raised the resident to a standing position. CNA D rolled the resident to the restroom, pulled down the brief, and lowered the resident to the toilet seat. CNA D removed the sling and said she would wait for the resident. While she was waiting for the resident to be done, she removed her gloves, washed her hands, and put on a pair gloves. She put some paper towel on the sink and put some wipes and a brief on the paper towels. When the resident was done with the bowel movement, CNA D put back the sling around the resident, hooked it to the sit-to-stand machine, and raised the resident. She cleaned the bottom of the resident first. After cleaning the resident's bottom, she removed her gloves and put on a new pair of gloves. She did not sanitize her hands when she changed her gloves. CNA D then cleaned the perineal area. After cleaning the perineal area, she pulled the resident's brief and pants back up, rolled the sit-to-stand machine out of the restroom, and lowered the resident to her wheelchair. She did not change her gloves after cleaning the resident's perineal area and before pulling up the brief.<BR/>In an interview with CNA D on 02/05/2025 at 9:29 AM revealed CNA D stated hands should be washed or sanitized when changing the gloves. She said gloves should be clean when touching the brief to prevent infection. She said the gloves should be changed after she cleaned the resident's perineal area and before touching the brief because the gloves that she used to clean the resident's perineal area were already soiled. She said she would be mindful the next time she does incontinent care to wash her hands and change her gloves during incontinent care. She said she had trainings for pericare but did not know why she forgot to wash her hands and change her gloves.<BR/>In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and any kind of infection. She said the expectation was for the staff to sanitize their hands in between changing of gloves and change their gloves after touching anything soiled. She said, another expectation was for the staff to get their gloves from the boxes and not put them in their pockets. She said the pockets might be dirty that would render the gloves also dirty. She said she would do and in-service about hand hygiene, incontinent care, and not putting the gloves in their pockets. She said she would personally monitor the staff doing direct care. <BR/>In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated putting the gloves in the pocket was a bad habit. He said the gloves, when placed in the pockets, could be considered soiled because the dirt from the pockets might cling to the gloves. He said hands should be sanitized every time the gloves were removed, and gloves should be changed after touching something soiled to prevent cross contamination and development of infection. He said they would he would remind the staff to change their gloves from dirty to clen, sanitize in between changing of gloves, and not to put their gloves in their pockets. He said they would also do an in-service about hand hygiene, pericare, and not to put the gloves in the pockets of their scrub suits.<BR/>In an interview with the Administrator on 02/026/2025 at 10:07 AM, the Administrator stated the staff should change their gloves and sanitize their hands to prevent infection. He said they should not put the gloves in their pockets. He said the expectation was for the staff to follow the policy and procedures pertaining to incontinent care and infection control. He said he would coordinate with the DON on how to handle the issue about infection control and hand hygiene.<BR/>Record review of facility policy, Perineal Care Policy/Procedure - Nursing Clinical revised 07/2021 revealed Policy . 3. Prevent irritation or infection.<BR/>Record review of facility policy, Hand Hygiene Infection Prevention and Control Program 2009 revealed Policy: This facility considers hand hygiene the primary means to prevent the spread of infections . 4. Use an alcohol-based hand rub . f. Before donning sterile gloves . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . k. After handling used dressings, contaminated equipment, etc. m. After removing gloves . Applying and removing gloves . 1. Perform hand hygiene before and after applying non-sterile gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #42, Resident #45, and Resident #58) of eight residents reviewed for Infection Control. <BR/>1. <BR/>The facility failed to ensure CNA B performed hand hygiene, changed her gloves, and did not put the gloves on her pocket while providing incontinent care to Resident #58 on 02/04/2025.<BR/>2. <BR/>The facility failed to ensure CNA B and CNA C changed their gloves and performed hand hygiene while providing incontinent care to Resident #45 on 02/04/2025.<BR/>3. <BR/>The facility failed to ensure CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #42 on 02/05/2025.<BR/>These failures could place residents at risk of cross-contamination and development of infections.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #58's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with urinary tract infection.<BR/>Record review of Resident #58's Quarterly MDS Assessment, dated 10/28/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated the resident was always incontinent for bowel and bladder.<BR/>Record review of Resident #58's Comprehensive Care Plan, dated 01/29/2025, reflected the resident had bowel/bladder incontinence and one of the interventions was to provide pericare after each incontinent episode.<BR/>Observation on 02/04/2025 at 9:46 AM revealed CNA B was about to do Resident #58's incontinent care. CNA B washed her hands and put on a pair of gloves. She prepared some wipes, a brief, and a plastic bag and put them on the resident's overbed table. She lowered the head of the bed and raised the bed. She unfastened the brief and pushed it between the resident's thighs. She removed her gloves, threw them on the plastic bag placed on the overbed table, and put on a new pair of gloves that she took from the left pocket of her scrub suit's top. She did not sanitize her hands before pulling the gloves from her pocket. She pulled some wipes and cleaned the resident perineal area (area between the thighs) using the front to back technique. She did it three times. After cleaning the perineal area, she assisted the resident to roll towards the left side and cleaned the resident's bottom. After cleaning the resident's bottom, CNA B took the new brief from the overbed table, put it under the resident, and fixed it. She did not change her gloves after cleaning the bottom of the resident and before touching the new brief. After fixing the brief, CNA B assisted the resident to roll back and fastened the brief on both sides. CNA B took off her gloves, threw them in the trash bag, and washed her hands.<BR/>2. <BR/>Record review of Resident #45's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and need for assistance with personal care.<BR/>Record review of Resident #45's Comprehensive MDS Assessment, dated 11/01/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 02. Comprehensive MDS Assessment indicated the resident was always incontinent for bowel and bladder.<BR/>Record review of Resident #45's Comprehensive Care Plan, dated 01/13/2025, reflected the resident had bowel/bladder incontinence and one of the interventions was provide pericare (cleaning the private areas of the resident) after each incontinent episode.<BR/>Observation on 02/04/2025 at 1:22 PM revealed CNA B and CNA C were about to do Resident #45's incontinent care. Both staff washed their hands and put on a pair of gloves. CNA B went to the resident's left side, while CNA C went to the resident's right side. CNA B unfastened the brief and pushed it between the resident's thighs. CNA B removed her gloves, pulled some gloves from her scrub suits' left pocket, and put on the gloves. CNA B pulled some wipes placed on the resident's side and cleaned the resident's perineal area. CNA B removed her gloves, pulled some gloves from her left pocket, and put on the gloves. After CNA B cleaned the perineal area, both CNAs assisted the resident to roll to his right side and CNA B cleaned the resident's bottom. After cleaning the resident's bottom, CNA B pulled the brief and threw it on the trash can. After CNA B threw the soiled brief, it was observed that the resident was still having a bowel movement. CNA B continued to clean the resident's bottom and placed the used wipes on the padding. After cleaning the resident's bottom, again, CNA B removed her gloves, went to the bathroom, took a box of gloves, placed some gloves in her pocket, and put on a pair of gloves. CNA B instructed CNA C to get the resident's brief on top of the resident's drawer. CNA C gave the brief to CNA B. CNA B placed a new padding on top of the rolled soiled padding, put the new brief on top of the new padding, and fixed them. Both CNAs rolled the resident to the other side. CNA C took the soiled padding with soiled wipes in it, put it on a plastic bag, and helped in fixing the brief. They rolled back the resident and fastened the brief. CNA C did not change her gloves after putting the soiled padding on a plastic bag.<BR/>In an interview with CNA B on 02/04/2025 at 1:42 PM, CNA B stated she did change her gloves when she did Resident #58 and Resident # 45's incontinent care but did not sanitize in between changing of gloves. She said hand hygiene should be done after removing the gloves to make sure the hands were not soiled before touching the new gloves. She said gloves should also be changed before touching the new brief to prevent the new brief from being soiled. She said gloves should not be placed in the pockets because she used her pockets for something else, like for her cellphone, her car keys, and others. She said she would be mindful next time not to put the gloves in her pocket, to change gloves after cleaning the residents' bottom, and to do hand hygiene when she changed her gloves. She said not sanitizing the hands when the gloves were changed and not changing the gloves could cause infection. She said putting the gloves in the packet could also indirectly cause infection.<BR/>In an interview with CNA C on 02/06/2025 at 9:47 AM, CNA C stated she realized she did not change her gloves after pulling the soiled padding that had soiled wipes in it. She said she should have changed her gloves, sanitized her hands, and put on a new pair of gloves. She said her gloves were basically soiled when she assisted in fixing the brief. She said not changing the gloves could cause infection like urinary tract infection.<BR/>3. <BR/>Review of Resident #42's Face Sheet, dated 02/05/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with acute kidney failure.<BR/>Review of Resident #42's Comprehensive MDS Assessment, dated 01/22/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated Resident #42 was always incontinent for bladder and bowel.<BR/>Review of Resident #42's Comprehensive Care Plan, dated 01/27/2025, reflected the resident had bowel/bladder incontinence r/t: impaired mobility and one of the interventions was check as required for incontinence, wash, rinse, and dry perineum.<BR/>Observation on 02/05/2025 at 9:02 AM revealed CNA D was about to transfer Resident #42's to her wheelchair through sit-to-stand. She said before she transfered the resident to her wheelchair, the resident would go to the restroom first for a bowel movement. She assisted the resident to a sitting position at the side of the resident's bed, put the sit-to-stand sling around the resident's torso, secured the sling to the sit-to-stand machine, and raised the resident to a standing position. CNA D rolled the resident to the restroom, pulled down the brief, and lowered the resident to the toilet seat. CNA D removed the sling and said she would wait for the resident. While she was waiting for the resident to be done, she removed her gloves, washed her hands, and put on a pair gloves. She put some paper towel on the sink and put some wipes and a brief on the paper towels. When the resident was done with the bowel movement, CNA D put back the sling around the resident, hooked it to the sit-to-stand machine, and raised the resident. She cleaned the bottom of the resident first. After cleaning the resident's bottom, she removed her gloves and put on a new pair of gloves. She did not sanitize her hands when she changed her gloves. CNA D then cleaned the perineal area. After cleaning the perineal area, she pulled the resident's brief and pants back up, rolled the sit-to-stand machine out of the restroom, and lowered the resident to her wheelchair. She did not change her gloves after cleaning the resident's perineal area and before pulling up the brief.<BR/>In an interview with CNA D on 02/05/2025 at 9:29 AM revealed CNA D stated hands should be washed or sanitized when changing the gloves. She said gloves should be clean when touching the brief to prevent infection. She said the gloves should be changed after she cleaned the resident's perineal area and before touching the brief because the gloves that she used to clean the resident's perineal area were already soiled. She said she would be mindful the next time she does incontinent care to wash her hands and change her gloves during incontinent care. She said she had trainings for pericare but did not know why she forgot to wash her hands and change her gloves.<BR/>In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and any kind of infection. She said the expectation was for the staff to sanitize their hands in between changing of gloves and change their gloves after touching anything soiled. She said, another expectation was for the staff to get their gloves from the boxes and not put them in their pockets. She said the pockets might be dirty that would render the gloves also dirty. She said she would do and in-service about hand hygiene, incontinent care, and not putting the gloves in their pockets. She said she would personally monitor the staff doing direct care. <BR/>In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated putting the gloves in the pocket was a bad habit. He said the gloves, when placed in the pockets, could be considered soiled because the dirt from the pockets might cling to the gloves. He said hands should be sanitized every time the gloves were removed, and gloves should be changed after touching something soiled to prevent cross contamination and development of infection. He said they would he would remind the staff to change their gloves from dirty to clen, sanitize in between changing of gloves, and not to put their gloves in their pockets. He said they would also do an in-service about hand hygiene, pericare, and not to put the gloves in the pockets of their scrub suits.<BR/>In an interview with the Administrator on 02/026/2025 at 10:07 AM, the Administrator stated the staff should change their gloves and sanitize their hands to prevent infection. He said they should not put the gloves in their pockets. He said the expectation was for the staff to follow the policy and procedures pertaining to incontinent care and infection control. He said he would coordinate with the DON on how to handle the issue about infection control and hand hygiene.<BR/>Record review of facility policy, Perineal Care Policy/Procedure - Nursing Clinical revised 07/2021 revealed Policy . 3. Prevent irritation or infection.<BR/>Record review of facility policy, Hand Hygiene Infection Prevention and Control Program 2009 revealed Policy: This facility considers hand hygiene the primary means to prevent the spread of infections . 4. Use an alcohol-based hand rub . f. Before donning sterile gloves . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . k. After handling used dressings, contaminated equipment, etc. m. After removing gloves . Applying and removing gloves . 1. Perform hand hygiene before and after applying non-sterile gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #42, Resident #45, and Resident #58) of eight residents reviewed for Infection Control. <BR/>1. <BR/>The facility failed to ensure CNA B performed hand hygiene, changed her gloves, and did not put the gloves on her pocket while providing incontinent care to Resident #58 on 02/04/2025.<BR/>2. <BR/>The facility failed to ensure CNA B and CNA C changed their gloves and performed hand hygiene while providing incontinent care to Resident #45 on 02/04/2025.<BR/>3. <BR/>The facility failed to ensure CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #42 on 02/05/2025.<BR/>These failures could place residents at risk of cross-contamination and development of infections.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #58's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with urinary tract infection.<BR/>Record review of Resident #58's Quarterly MDS Assessment, dated 10/28/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated the resident was always incontinent for bowel and bladder.<BR/>Record review of Resident #58's Comprehensive Care Plan, dated 01/29/2025, reflected the resident had bowel/bladder incontinence and one of the interventions was to provide pericare after each incontinent episode.<BR/>Observation on 02/04/2025 at 9:46 AM revealed CNA B was about to do Resident #58's incontinent care. CNA B washed her hands and put on a pair of gloves. She prepared some wipes, a brief, and a plastic bag and put them on the resident's overbed table. She lowered the head of the bed and raised the bed. She unfastened the brief and pushed it between the resident's thighs. She removed her gloves, threw them on the plastic bag placed on the overbed table, and put on a new pair of gloves that she took from the left pocket of her scrub suit's top. She did not sanitize her hands before pulling the gloves from her pocket. She pulled some wipes and cleaned the resident perineal area (area between the thighs) using the front to back technique. She did it three times. After cleaning the perineal area, she assisted the resident to roll towards the left side and cleaned the resident's bottom. After cleaning the resident's bottom, CNA B took the new brief from the overbed table, put it under the resident, and fixed it. She did not change her gloves after cleaning the bottom of the resident and before touching the new brief. After fixing the brief, CNA B assisted the resident to roll back and fastened the brief on both sides. CNA B took off her gloves, threw them in the trash bag, and washed her hands.<BR/>2. <BR/>Record review of Resident #45's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and need for assistance with personal care.<BR/>Record review of Resident #45's Comprehensive MDS Assessment, dated 11/01/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 02. Comprehensive MDS Assessment indicated the resident was always incontinent for bowel and bladder.<BR/>Record review of Resident #45's Comprehensive Care Plan, dated 01/13/2025, reflected the resident had bowel/bladder incontinence and one of the interventions was provide pericare (cleaning the private areas of the resident) after each incontinent episode.<BR/>Observation on 02/04/2025 at 1:22 PM revealed CNA B and CNA C were about to do Resident #45's incontinent care. Both staff washed their hands and put on a pair of gloves. CNA B went to the resident's left side, while CNA C went to the resident's right side. CNA B unfastened the brief and pushed it between the resident's thighs. CNA B removed her gloves, pulled some gloves from her scrub suits' left pocket, and put on the gloves. CNA B pulled some wipes placed on the resident's side and cleaned the resident's perineal area. CNA B removed her gloves, pulled some gloves from her left pocket, and put on the gloves. After CNA B cleaned the perineal area, both CNAs assisted the resident to roll to his right side and CNA B cleaned the resident's bottom. After cleaning the resident's bottom, CNA B pulled the brief and threw it on the trash can. After CNA B threw the soiled brief, it was observed that the resident was still having a bowel movement. CNA B continued to clean the resident's bottom and placed the used wipes on the padding. After cleaning the resident's bottom, again, CNA B removed her gloves, went to the bathroom, took a box of gloves, placed some gloves in her pocket, and put on a pair of gloves. CNA B instructed CNA C to get the resident's brief on top of the resident's drawer. CNA C gave the brief to CNA B. CNA B placed a new padding on top of the rolled soiled padding, put the new brief on top of the new padding, and fixed them. Both CNAs rolled the resident to the other side. CNA C took the soiled padding with soiled wipes in it, put it on a plastic bag, and helped in fixing the brief. They rolled back the resident and fastened the brief. CNA C did not change her gloves after putting the soiled padding on a plastic bag.<BR/>In an interview with CNA B on 02/04/2025 at 1:42 PM, CNA B stated she did change her gloves when she did Resident #58 and Resident # 45's incontinent care but did not sanitize in between changing of gloves. She said hand hygiene should be done after removing the gloves to make sure the hands were not soiled before touching the new gloves. She said gloves should also be changed before touching the new brief to prevent the new brief from being soiled. She said gloves should not be placed in the pockets because she used her pockets for something else, like for her cellphone, her car keys, and others. She said she would be mindful next time not to put the gloves in her pocket, to change gloves after cleaning the residents' bottom, and to do hand hygiene when she changed her gloves. She said not sanitizing the hands when the gloves were changed and not changing the gloves could cause infection. She said putting the gloves in the packet could also indirectly cause infection.<BR/>In an interview with CNA C on 02/06/2025 at 9:47 AM, CNA C stated she realized she did not change her gloves after pulling the soiled padding that had soiled wipes in it. She said she should have changed her gloves, sanitized her hands, and put on a new pair of gloves. She said her gloves were basically soiled when she assisted in fixing the brief. She said not changing the gloves could cause infection like urinary tract infection.<BR/>3. <BR/>Review of Resident #42's Face Sheet, dated 02/05/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with acute kidney failure.<BR/>Review of Resident #42's Comprehensive MDS Assessment, dated 01/22/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated Resident #42 was always incontinent for bladder and bowel.<BR/>Review of Resident #42's Comprehensive Care Plan, dated 01/27/2025, reflected the resident had bowel/bladder incontinence r/t: impaired mobility and one of the interventions was check as required for incontinence, wash, rinse, and dry perineum.<BR/>Observation on 02/05/2025 at 9:02 AM revealed CNA D was about to transfer Resident #42's to her wheelchair through sit-to-stand. She said before she transfered the resident to her wheelchair, the resident would go to the restroom first for a bowel movement. She assisted the resident to a sitting position at the side of the resident's bed, put the sit-to-stand sling around the resident's torso, secured the sling to the sit-to-stand machine, and raised the resident to a standing position. CNA D rolled the resident to the restroom, pulled down the brief, and lowered the resident to the toilet seat. CNA D removed the sling and said she would wait for the resident. While she was waiting for the resident to be done, she removed her gloves, washed her hands, and put on a pair gloves. She put some paper towel on the sink and put some wipes and a brief on the paper towels. When the resident was done with the bowel movement, CNA D put back the sling around the resident, hooked it to the sit-to-stand machine, and raised the resident. She cleaned the bottom of the resident first. After cleaning the resident's bottom, she removed her gloves and put on a new pair of gloves. She did not sanitize her hands when she changed her gloves. CNA D then cleaned the perineal area. After cleaning the perineal area, she pulled the resident's brief and pants back up, rolled the sit-to-stand machine out of the restroom, and lowered the resident to her wheelchair. She did not change her gloves after cleaning the resident's perineal area and before pulling up the brief.<BR/>In an interview with CNA D on 02/05/2025 at 9:29 AM revealed CNA D stated hands should be washed or sanitized when changing the gloves. She said gloves should be clean when touching the brief to prevent infection. She said the gloves should be changed after she cleaned the resident's perineal area and before touching the brief because the gloves that she used to clean the resident's perineal area were already soiled. She said she would be mindful the next time she does incontinent care to wash her hands and change her gloves during incontinent care. She said she had trainings for pericare but did not know why she forgot to wash her hands and change her gloves.<BR/>In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and any kind of infection. She said the expectation was for the staff to sanitize their hands in between changing of gloves and change their gloves after touching anything soiled. She said, another expectation was for the staff to get their gloves from the boxes and not put them in their pockets. She said the pockets might be dirty that would render the gloves also dirty. She said she would do and in-service about hand hygiene, incontinent care, and not putting the gloves in their pockets. She said she would personally monitor the staff doing direct care. <BR/>In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated putting the gloves in the pocket was a bad habit. He said the gloves, when placed in the pockets, could be considered soiled because the dirt from the pockets might cling to the gloves. He said hands should be sanitized every time the gloves were removed, and gloves should be changed after touching something soiled to prevent cross contamination and development of infection. He said they would he would remind the staff to change their gloves from dirty to clen, sanitize in between changing of gloves, and not to put their gloves in their pockets. He said they would also do an in-service about hand hygiene, pericare, and not to put the gloves in the pockets of their scrub suits.<BR/>In an interview with the Administrator on 02/026/2025 at 10:07 AM, the Administrator stated the staff should change their gloves and sanitize their hands to prevent infection. He said they should not put the gloves in their pockets. He said the expectation was for the staff to follow the policy and procedures pertaining to incontinent care and infection control. He said he would coordinate with the DON on how to handle the issue about infection control and hand hygiene.<BR/>Record review of facility policy, Perineal Care Policy/Procedure - Nursing Clinical revised 07/2021 revealed Policy . 3. Prevent irritation or infection.<BR/>Record review of facility policy, Hand Hygiene Infection Prevention and Control Program 2009 revealed Policy: This facility considers hand hygiene the primary means to prevent the spread of infections . 4. Use an alcohol-based hand rub . f. Before donning sterile gloves . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . k. After handling used dressings, contaminated equipment, etc. m. After removing gloves . Applying and removing gloves . 1. Perform hand hygiene before and after applying non-sterile gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #59) of five residents was provided medications and pharmaceutical services, including the accurate administering of all drugs, to meet their needs.<BR/>The facility failed to ensure MA did not leave Resident #59's medications inside the resident's room and failed to monitor the administration of the medications on 02/04/2025. <BR/>This failure could place the residents at risk of chocking or not receiving medications as ordered by the physician.<BR/>Findings included: <BR/>Record review of Resident #59's Face Sheet, dated 02/05/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure), gastro-esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach), cerebral infarction (insufficient oxygen in the brain causing stroke).<BR/>Record review of Resident #59's Quarterly MDS Assessment, dated 12/16/2024, reflected resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment also indicated the resident had cerebral infarction, hypertension, and gastro-esophageal reflux disease.<BR/>Record review of Resident #59's Comprehensive Care Plan, dated 11/07/2024, reflected the resident had gastro-esophageal reflux disease, cerebral vascular disease, and hypertension and the interventions for the three medical issues were to give medications as ordered.<BR/>Review of Resident #59's Clinical Assessment on 02/04/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage her own medications.<BR/>Review of Resident #59's Physician Order, dated 04/04/2023, reflected Aspirin EC Tablet Delayed Release 81 MG (Aspirin). Give 1 tablet by mouth one time a day for CVA (cerebrovascular accident: stroke).<BR/>Review of Resident #59's Physician Order, dated 04/04/2023, reflected Famotidine Oral Tablet 20 MG (Famotidine) Give 1 tablet by Mouth one time a day for GERD (gastro-esophageal reflux disease: stomach acid repeatedly flows back into the tube connecting your mouth and stomach).<BR/>Review of Resident #59's Physician Order, dated 04/04/2023, reflected Nifedipine ER Oral Tablet Extended Release 24 Hour 30 MG (Nifedipine) Give 1 tablet by mouth one time a day for HTN DO NOT CRUSH Hold for SBP&lt;110 DBP&lt;60 HR&lt;60,<BR/>Observation on 02/04/2025 at 10:38 AM revealed MA was observed exiting Resident #59's room and closing the door.<BR/>Observation and interview with Resident #59 on 02/04/2025 at 10:40 AM revealed the resident was sitting on a chair beside her bed. In front of the resident was her overbed table with a small plastic cup on top of it. Inside the plastic cup was a white, round pill. The resident she was going to take the medication in a minute. She said she already taken two out of three pills that was left by the staff. She said the staff would leave her medications with her and she would take. She said she told her what the medications were, but she could not remember them and all she could remember was how many.<BR/>In an interview with the MA on 02/04/2025 at 10:48 AM, the MA stated she did leave Resident #59's medication with her because the resident wanted to take the medication every five minutes. She said should have returned to the room and checked on the resident or stayed with the resident until the resident had taken all the medications. She said the pills should not be left with the resident because the resident might not take them, throw them, or choke while taking them and no one would know. She said she left three pills with the resident, her aspirin, famotidine, and her blood pressure medication.<BR/>In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated staff should never leave the medications with the resident for the residents to take later. She said the staff must wait for the residents to be done with their medications before leaving the room. She said the resident might choke while taking the medications and no one would know. She said the resident might not take the medications or hide the pills to avoid taking them. She said the residents could also hoard the medications and take them altogether that could cause an overdose. The DON said the expectation was for the staff not to leave the room until the residents were done taking the medications or if the residents were still not ready to take the medication, just take the medications with them and come back later. She said she would do an in-service pertaining to not leaving the medications with a resident.<BR/>In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated medications were not left with the residents. He said the staff administering the medications should stay with the resident until the resident was done taking the medications. He said the resident might not take them or someone else might, like another resident or a visitor. He said the resident might aspirate while taking the medications and nobody was with him. He said he would coordinate with the DON to do an in-service about not leaving the medications with the residents.<BR/>In an interview with the Administrator on 02/026/2025 at 10:07 AM, the Administrator stated staff should not leave medications unattended because of the risk of the resident not taking them or the pills not taken on time. He said he would coordinate with the DON on how to go forward to prevent untoward outcomes of leaving the medications with a resident.<BR/>Record review of facility policy, Medication Administration Policy/Procedure - Nursing Services revised 07/2020 revealed POLICY: It is the policy of this facility that medications shall be administered as prescribed by the attending physician . PROCEDURES . 4. Identification of the resident must be made prior to administering medication to the resident . 5. Medications may not be set up in advance and scheduled medications must be administered within facility time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in a resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either, life-threatening conditions or clinical complications) for one (Resident #1) of five residents reviewed for changes in condition.<BR/>RN A failed to notify the physician when Resident #1 complained of numbness to the left side of the face on 01/27/23. RN A notified the NP via text message of the change in condition instead of the physician and when the nurse did not receive a response from the NP the resident remained in the facility without the physician being notified. Three days later (01/30/23), Resident #1 was assessed with numbness to the face, slurred speech, and drooling. Resident #1 was transferred to the hospital on [DATE] and admitted with diagnoses of acute stroke (A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts and can cause parts of the brain to die off). <BR/>An Immediate Jeopardy (IJ) was identified on 02/16/ at 4:13 p.m. and the facility was provided the IJ template on 02/16/23 at 4:28 p.m. While the IJ was removed on 02/17/23, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal.<BR/>These failures could place residents at risk for preventing the physician an opportunity to intervene on their behalf, delays in medical treatments and care which could result in clinical complications, disability, and/or death.<BR/>Findings included: <BR/>Review of Resident #1's undated admission record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] and discharged on 01/31/23. Physician's active order summary dated from 12/29/22 to 01/27/23 reflected diagnoses included cerebral infarction (A cerebral infarction-stroke occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction and hypertension (high blood pressure). <BR/>Review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1 was always incontinent of bowel/bladder, required extensive physical assistance of two or more persons for bed mobility and transfers. The assessment reflected the resident used a wheelchair for mobility, required extensive physical assistance of one person for dressing/personal hygiene and had functional limitations in range of motion in the upper and lower extremities on one side of the body. <BR/>Review of Resident #1's change in condition form dated 01/30/23 and authored by RN A revealed the resident was assessed with increased weakness and numbness on the left side. The form further reflected the change in condition was first noted during the afternoon of 01/27/23 at 12:43 p.m. and the NP had been notified on 01/27/23. The form did not reflect the physician had been notified.<BR/>Interview with the DON on 02/14/23 at 11:18 a.m., in the presence of the Administrator, revealed she stated she had provided in-service training to all nurses related to always obtaining a response when they called the physician or NP and to call the physician/NP back or send the resident out if necessary and administration would take care of it later as far as an order was concerned because if a resident was experiencing a change in condition, they should be sent out to the hospital immediately.<BR/>Interview with RN A on 02/14/23 at 12:25 p.m. revealed she was the charge nurse providing care for Resident #1 during the day and evening shifts (6:00 a.m. to 10:00 p.m.) on 01/27/23, 01/28/23 and 01/29/23. She stated during the afternoon on Friday 01/27/23, Resident #1 complained of numbness to the left side of his face. RN A stated she texted the NP that Resident #1 was complaining of numbness to his face but never received a response/call back from the NP. RN A further stated she made no further attempts to contact the NP and did not notify the physician. RN A provided no explanation as to why she did not follow-up with the NP or physician regarding Resident #1's change in condition. When asked why, she stated the resident was stable.<BR/>Review of progress notes dated 01/30/23 reflected the NP assessed Resident #1 on 01/30/23 (Monday) with slurred speech and facial drooping. The notes reflected the NP ordered the resident be sent to the hospital for neurological workup on 01/30/23.<BR/>Review of Resident #1's hospital records dated 01/30/23 revealed the resident was admitted on [DATE] with a diagnosis of acute stoke. The resident's neurological assessment in the ER on [DATE] reflected drool in left corner of the mouth, no facial droop and sensation on the left side was decreased. The resident was treated with an anticoagulant (decreases the blood's ability to clot) and discharged to another facility on 02/14/23.<BR/>Interview with the DON on 02/14/23 at 11:18 a.m. revealed expectations were for nursing staff to send residents out to the hospital if necessary because if a resident was experiencing a change in condition, they should be sent out to the hospital immediately.<BR/>Review of the in-service training records provided by the DON on 02/14/23 and dated 01/31/23 related to changes in condition, physician notification and S/S of stroke reveled RN A was listed as having received the training, but RN B was not listed.<BR/>Interview with the NP on 02/15/23 at 10:46 a.m. revealed she received a text message from RN A on the afternoon of 01/27/23. The NP stated the text message reflected Resident #1 had mild drooling, facial numbness and a blood pressure that was a little elevated. The NP stated she recalled responding to the text and ordered Resident #1 be sent out to the hospital for evaluation. She stated she does not know why RN A did not receive the text message response and was not sure if she had pressed send after typing in her response. The NP stated when she arrived at the facility on Monday (01/30/23) she was surprised to find Resident #1 still in the facility as she thought the nurse had received her text to send the resident out on Friday (01/27/23). She stated her expectation was for facility nurses to call the 24-hour answering services and not send text messages. The NP further stated if the nurse's assessment determined a resident needed to go to the hospital or if they did not receive a call back within 10 to 15 minutes, she and the physician expected facility nurses to send residents to the hospital and not wait for a response/call back. Additionally, the NP stated it was important for Resident #1 to go to the hospital on [DATE] because better and acute care could be provided in the hospital, diagnostics and labs were more readily available in the hospital and there was a four-hour window to use a clot buster medication if needed. The NP stated Resident #1's symptoms on 01/27/23 could have indicated a new onset stroke.<BR/>Interview with RN B on 02/15/22 at 6:25 p.m. she stated she provided care for Resident #1 during the night shifts (10:00 p.m. to 6:00 a.m.) on Friday 01/27/23, Saturday 01/28/23 and Sunday 01/29/23. RN B stated RN A told her something about Resident #1 drooling. RN B stated she did not contact the physician because RN A told her the physician was aware. RN B further stated she did not notice any changes in Resident #1 as the resident slept throughout the night shift.<BR/>Interview with DON on 02/16/23 at 10:39 a.m. revealed in-service training related to changes in condition, physician notification and S/S of stroke had not been completed for all facility nurses. The DON stated the facility used agency nurses and she had planned to in-service agency nurses before they worked in the facility again.<BR/>The facility's P/P entitled Significant Change in Condition, Response, dated revised 01/2022 and identified as current by the DON. The P/P reflected in part: 5. The nurse shall use his/her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event the Attending Physician or on-call Physician cannot be reached. <BR/>The Administrator and the DON were notified on 02/16/22 at 4:13 p.m. that an Immediate Jeopardy (IJ) was identified. The IJ template was provided 02/16/23 at 4:28 p.m. and the facility was asked to provide a Plan of Removal to address the immediate Jeopardy.<BR/>The Facility's Plan of Removal was accepted on 02/17/23 at 12:39 p.m. and reflected the following:<BR/>The facility failed to notify the physician of the resident's change in condition on 1/27/23 or at any time prior to 1/30/23. An in-service was initiated on 1/30/23, however, all facility nurses had not received the in-service training prior to 2/14/23, upon the surveyor's entrance.<BR/>Immediate Action<BR/>1. The Medical Director, [Medical Director's name] was notified of IJ on 2/16/2023 at 4:47 p.m.<BR/>2. Education was initiated with Nurses on 2/16/2023 at 5:00 p.m. and will be completed on<BR/>2/16/2023 at 10:30 p.m. by the DON, ADON and Clinical Resource. The training included Nurse Assessment, Signs and symptoms of a stroke, Change in Condition Process / Policy, vital sign documentation, documentation of the change in condition, notification to the physician, reviewing the resident's health condition with the attending physician, and when to reach out to the Medical Director if the assigned physician is not available. The DON, ADONs and Clinical Resource used facility policy on change in condition, facility procedures on head-to-toe assessment, signs and symptoms of a stroke and clinical examples to ascertain understanding of the material and a knowledge check form was created.<BR/>3. A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses 2/16/2023 and will be completed for all nurses either in-person or via telephone on 2/16/2023. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse.<BR/>4. This education and knowledge check will be completed with facility nurses on 2/16/2023 and 2/17/2023, all nurses will complete education prior to start of their next shift. This reeducation may be in-person or over the phone with the DON, ADONs or Clinical Resource. This education will also be included in the new hire orientation and will be included for agency/ PRN staff.<BR/>5. An ad hoc meeting regarding items in IJ template will be completed on 2/16/2023 at 6:00pm. Attendees included Administrator, DON, Medical Director, and Clinical Resource. The Plan of removal items and interventions were developed, reviewed, and agreed upon.<BR/>Identification others Affected<BR/>6. Currently there are 113 residents residing in the facility. All residents could have been affected by the deficient practice.<BR/>Systemic Change to Prevent Re-occurrence<BR/>7. Education was initiated with Nurses on 2/16/2023 at 5:00 p.m. and will be completed on<BR/>2/16/2023 at 10:30 p.m. by the DON, ADON and Clinical Resource which included Nurse Assessment, Signs and symptoms of a stroke, Change in Condition Process / Policy, vital sign documentation, documentation of the change in condition, notification to the physician, reviewing the resident's health condition with the attending physician; and when to reach out to the Medical Director if the assigned physician is not available. The DON, ADONs and Clinical Resource used facility policy on change in condition, facility procedures on head to toe assessment, signs and symptoms of a stroke and clinical examples to ascertain understanding of the material and a knowledge check form was created.<BR/>8. A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses 2/16/2023 and will be completed for all nurses either in-person or via telephone on 2/16/2023. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse.<BR/>9. The DON and ADON initiated a monitoring form on 2/16/2023 to track all changes in condition daily on weekdays and weekends via review the electronic 24-hour reports found on PCC, new orders, new medication orders, hospital transfers and nursing documentation of a change in condition and notification to family and physician. Follow up on interventions and updates to the plan of care will be completed by the DON and ADON. The daily monitoring by the DON and ADON began 2/16/2023 and will be ongoing.<BR/>10. Changes in condition will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions. The Administrator, DON, ADON, MDS and/or designees to attend weekly clinical meetings to include review of residents with change in conditions, hospital transfers and update of care plan interventions, notifications of Resident Responsible Parties, and Physicians.<BR/>Monitoring<BR/>11. Knowledge checks were initiated on 2/16/2023 will be completed on all nurses by 2/17/23 either by phone or one on one conversations by the DON, ADONs or Clinical Resource. These knowledge checks will be ongoing throughout the Quality Assurance process, reported weekly to the QAPI committee meeting for 4 weeks or until substantial compliance is established and then monthly for 90 days.<BR/>12. This knowledge check will be completed for 5 random nurses weekly by the DON, ADONs or Clinical Resource. The knowledge check questions include: o If a resident has a change of condition the nurse should?<BR/>o <BR/>Get a full set of vital signs<BR/>o <BR/>Notify the attending physician Notify Family<BR/>o <BR/>Notify nurse management<BR/>o <BR/>Follow the facility policy<BR/>o <BR/>All of the above <BR/>o If a resident develops a change of condition the nurse must document for 72 hours or longer if necessary.<BR/>o <BR/>True<BR/>o <BR/>False <BR/>o Signs and Symptoms of a stroke include: <BR/>o <BR/>Facial droop, weakness on one side, slurred speech<BR/>o <BR/>Bilateral leg weakness, pain in legs<BR/>o <BR/>Abdominal pain, foul smelling urine, sediment in urine <BR/>o If the resident develops signs of a stroke and has abnormal vital signs, it is best to call:<BR/>o <BR/>The physician<BR/>o <BR/>Calf 911 for medical emergency<BR/>o <BR/>The family to come talk to them <BR/>o If a resident has a change of condition the care plan must be updated with the interventions.<BR/>o <BR/>True<BR/>o The nurse should document the change of condition using the e-lnteract change of condition form?<BR/>o <BR/>True <BR/>o <BR/>False <BR/>If the attending physician is unavailable who do you contact <BR/>o <BR/>Nobody<BR/>o <BR/>Medical Director <BR/>o <BR/>Another Nurse<BR/>13. <BR/>Daily review of all changes in condition daily via review of 24-hour report, new orders, new medication orders, change in condition assessments, hospital transfers and nursing documentation by the DON and ADONs. This information will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance is established, then monthly for 90 days.<BR/>14. Weekly clinical meetings to discuss changes in condition and hospital transfers. Meeting attendees will include the Clinical IDT; DON, ADON, Administrator, MDS, Dietary Manager, Activities Director, Social Services, and Rehab Director. Meeting minutes will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance.<BR/>15. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. QAPI meetings content will include changes in condition, hospital transfers and residents requiring antiseizure medications.<BR/>16. Follow up on IJ Plan of Removal and monitoring will be verified by the DON and the Administrator by review of change on condition documentation through the weekly clinical meeting, review of nurse knowledge check obtained throughout the week, hospital transfer logs, and the weekly QAPI meeting.<BR/>The following interviews, and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following:<BR/>Interviews were conducted with 11 licensed nurses (LVN G, RN D, LVN E, LVN F, RN G, LVN H, LVN I, LVN J, RN K and LVN L) across multiple shifts on 02/17/23 from 12:42 p.m. to 1:50 p.m. and from 3:00 p.m. to 3:10 p.m. The nurses were able to verbalize comprehension of the in-service training provided. They stated they had been in-serviced on S/S of a stroke, completing a full assessment to include obtaining a full set of vital signs for residents with changes in condition, contacting the primary physician, and contacting the Medical Director if they were unable to reach the primary physician.<BR/>Review of the in-service training records dated 02/16/23 revealed licensed nurses staff received training related to completing head-to-toe assessments, who to notify when residents experienced changes in condition, S/S of a stroke, completing a full assessment to include obtaining a full set of vital signs for residents with changes in condition, contacting the primary physician, summoning 911 if changes in condition were emergent and contacting the Medical Director if they were unable to reach the primary physician.<BR/>The Administrator was notified on 02/17/23 at 4:00 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 02/17/23, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of four residents reviewed for quality of care. <BR/>Facility staff failed to recognize and respond when Resident #1 complained of numbness to one side of the face on 01/27/23. RN A notified the NP of a change in condition on 01/27/23 at 12:43 p.m. via text message. When RN A did not receive a response to her text message, she did not follow-up for orders, instructions or monitor the resident's condition. Resident #1 was noted three days later on 01/30/23 with numbness to the face, slurred speech, and drooling. Resident #1 was transferred to the hospital on [DATE] and admitted with diagnoses of acute stroke (A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts and can cause parts of the brain to die off). <BR/>An Immediate Jeopardy (IJ) was identified on 02/16/23 at 4:13 p.m. and the facility was provided the IJ template on 02/16/23 at 4:28 p.m. While the IJ was removed on 02/17/23, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal.<BR/>These failures could place residents at risk for delays in medical treatments and care which could result in clinical complications, disability, and/or death.<BR/>Findings included: <BR/>Review of Resident #1's undated admission record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] and discharged [DATE]. Physician's active order summary dated from 12/29/22 to 01/27/23 reflected diagnoses included cerebral infarction (A stroke). <BR/>Review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1 was always incontinent of bowel/bladder, required extensive physical assistance of two or more persons for bed mobility and transfers. The assessment reflected the resident used a wheelchair for mobility, required extensive physical assistance of one person for dressing/personal hygiene and had functional limitations in range of motion in the upper and lower extremities on one side of the body. <BR/>Review of Resident #1's change in condition form dated 01/30/23 and authored by RN A revealed the resident was assessed with increased weakness and numbness on the left side. The form further reflected the change in condition was first noted during the afternoon of 01/27/23 at 12:43 p.m. and the NP had been notified on 01/27/23. The form reflected no interventions were implemented on 01/27/23 and the RN had been awaiting a response from the NP. Record reviews of nurses' notes, progress notes, reflected no documentation of a change in condition, neurological checks, or assessments of Resident #1 after his complaint on 01/27/23, 01/28/23 or 01/29/23. <BR/>Review of progress notes dated 01/30/23 reflected the NP assessed Resident #1 on 01/30/23 (Monday) with slurred speech and facial drooping. The notes reflected the NP ordered the resident be sent to the hospital for neurological workup on 01/30/23.<BR/>Review of Resident #1's hospital records dated 01/30/23 revealed the resident was admitted on [DATE] with a diagnosis of acute stoke. The resident's neurological assessment in the ER on [DATE] reflected drool in left corner of the mouth, no facial droop and sensation on the left side was decreased. The resident was treated with an anticoagulant (decreases the blood's ability to clot) and discharged to another facility on 02/14/23.<BR/>Interview with the NP on 02/15/23 at 10:46 a.m. revealed she provided her phone for review that reflected she received a text message from RN A on the afternoon of 01/27/23. The text message reflected Resident #1 had mild drooling, facial numbness and a blood pressure that was a little elevated. The NP stated she recalled responding to the text and ordered Resident #1 be sent out to the hospital for evaluation. She stated she does not know why RN A did not receive the text message response and was not sure if she had pressed send after typing in her response. The NP stated RN A did not provide any blood pressure or vital sign results and due to Resident #1's symptoms she did not need blood pressure or vital signs results to make the decision to send the resident to the hospital. The NP stated when she arrived at the facility on Monday (01/30/23) she was surprised to find Resident #1 still in the facility as she thought the nurse had received her text to send the resident out on Friday (01/27/23). She stated her expectation was for facility nurses to call the 24-hour answering services and not send text messages. The NP further stated if the nurse's assessment determined a resident needed to go to the hospital or if they did not receive a call back within 10 to 15 minutes, she and the physician expected facility nurses to send residents to the hospital and not wait for a response/call back. Additionally, the NP stated it was important for Resident #1 to go to the hospital on [DATE] because better and acute care could be provided in the hospital, diagnostics and labs were more readily available in the hospital and there was a four-hour window to use a clot buster medication if needed as the medication could not be used past four hours and other methods of treatment would need to be considered. The NP stated Resident #1's symptoms on 01/27/23 could have indicated a new onset stroke.<BR/>Interview with RN B on 02/15/22 at 6:25 p.m. she stated she provided care for Resident #1 during the night shifts (10:00 p.m. to 6:00 a.m.) on Friday 01/27/23, Saturday 01/28/23 and Sunday 01/29/23. RN B stated RN A told her something about Resident #1 drooling. RN B stated she did not contact the physician or NP because RN A told her the physician was aware. RN B further stated she did not notice any changes in Resident #1 and provided no additional monitoring other than her normal rounds every two-hours.<BR/>Interview with DON on 02/16/23 at 10:39 a.m. revealed in-service training related to changes in condition, physician notification and S/S of stroke had not been completed for all facility nurses. The DON stated the facility used agency nurses and she had planned to in-service agency nurses before they worked in the facility again.<BR/>Review of the in-service training records provided by the DON on 02/14/23 and dated 01/31/23 related to changes in condition, physician notification and S/S of stroke reveled RN A was listed as having received the training, but RN B was not listed.<BR/>Interview with the DON on 02/14/23 at 11:18 a.m. revealed expectations were for nursing staff to send residents out to the hospital if necessary because if a resident was experiencing a change in condition, they should be sent out to the hospital immediately.<BR/>Interview with the DON on 02/15/23 at 4:30 p.m. revealed she was unable to locate any assessments, neurological checks or change in condition forms prior to 01/30/23 to address Resident #1's change in condition exhibited on 01/27/23.<BR/>On 02/16/23 at 12:00 p.m. the facility's 24-hour nursing report dated from 01/27/23 through 01/30/23 was requested from the DON. The DON stated Resident #1 was not listed on the report and she was not sure why. She stated that it was possibly due to the resident being discharged . She stated the way the electronic system worked the 24-hour report would just be a duplicate ot the resident's nurse's notes.<BR/>Interview with Resident #1's physician on 02/16/23 at 12:15 p.m. he stated the NP made the correct decision to send Resident #1 out to the hospital on [DATE] (Friday). He stated it was better for the resident to have been evaluated at the hospital out of an abundance of caution. The physician stated strokes could potentially be fatal due to complications and timely evaluation and treatment was essential because if you don't go you don't know. He stated complications of a stroke included lasting neurological damage and/or increased cranial hemorrhage. He further stated complications of a stroke could lead to death. <BR/>Interview with RN A on 02/17/23 at 12:55 p.m. she stated she did not obtain a measurement of Resident #1's blood pressure or vital signs on Friday during the time the resident complained of numbness. She stated the blood pressure she was referring to in the text message to the NP was obtained during the morning hours around 7:00 a.m. before the resident's change in condition. RN A stated she did not know she needed to perform a full assessment on 01/27/23 that included vital signs as she did not associate the resident symptoms with a need to obtain vital signs.<BR/>The facility's P/P entitled Significant Change in Condition, Response, dated revised 01/2022 and identified as current by the DON. The P/P reflected in part: 1. If at any time, it is recognized by any one (sic) of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. 2. The Nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. (SBAR-situation, background, assessment, and recommendation is a tool used to aid in facilitating and strengthening communication between nurses and prescribers-change in condition form). 5. The nurse shall use his/her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event the Attending Physician or on-call Physician cannot be reached. The P/P did not reflect a specific method to use when contacting the physician.<BR/>The Administrator and the DON were notified on 02/16/22 at 4:13 p.m. that an Immediate Jeopardy (IJ) was identified. The IJ template was provided 02/16/23 at 4:28 p.m. and the facility was asked to provide a Plan of Removal to address the immediate Jeopardy.<BR/>The Facility's Plan of Removal was accepted on 02/17/23 at 12:39 p.m. and reflected the following:<BR/>The facility failed to notify the physician of the resident's change in condition on 1/27/23 or at any time prior to 1/30/23. An in-service was initiated on 1/30/23, however, all facility nurses had not received the in-service training prior to 2/14/23, upon the surveyor's entrance.<BR/>Immediate Action<BR/>1. The Medical Director [Medical Director's name] was notified of IJ on 2/16/2023 at 4:47pm.<BR/>2. Education was initiated with Nurses on 2/16/2023 at 5:00pm and will be completed on<BR/>2/16/2023 at 10:30pm by the DON, ADON and Clinical Resource. The training included Nurse Assessment, Signs and symptoms of a stroke, Change in Condition Process / Policy, vital sign documentation, documentation of the change in condition, notification to the physician, reviewing the resident's health condition with the attending physician, and when to reach out to the Medical Director if the assigned physician is not available. The DON, ADONs and Clinical Resource used facility policy on change in condition, facility procedures on head-to-toe assessment, signs and symptoms of a stroke and clinical examples to ascertain understanding of the material and a knowledge check form was created.<BR/>3. A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses 2/16/2023 and will be completed for all nurses either in-person or via telephone on 2/16/2023. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse.<BR/>4. This education and knowledge check will be completed with facility nurses on 2/16/2023 and 2/17/2023, all nurses will complete education prior to start of their next shift. This reeducation may be in-person or over the phone with the DON, ADONs or Clinical Resource. This education will also be included in the new hire orientation and will be included for agency/ PRN staff.<BR/>5. An ad hoc meeting regarding items in IJ template will be completed on 2/16/2023 at 6:00pm. Attendees included Administrator, DON, Medical Director, and Clinical Resource. The Plan of removal items and interventions were developed, reviewed, and agreed upon.<BR/>Identification others Affected<BR/>6. Currently there are 113 residents residing in the facility. All residents could have been affected by the deficient practice.<BR/>Systemic Change to Prevent Re-occurrence<BR/>7. Education was initiated with Nurses on 2/16/2023 at 5:00pm and will be completed on<BR/>2/16/2023 at 10:30pm by the DON, ADON and Clinical Resource which included Nurse Assessment, Signs and symptoms of a stroke, Change in Condition Process / Policy, vital sign documentation, documentation of the change in condition, notification to the physician, reviewing the resident's health condition with the attending physician; and when to reach out to the<BR/>Medical Director if the assigned physician is not available. The DON, ADONs and Clinical Resource used facility policy on change in condition, facility procedures on head to toe assessment, signs and symptoms of a stroke and clinical examples to ascertain understanding of the material and a knowledge check form was created.<BR/>8. A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses 2/16/2023 and will be completed for all nurses either in-person or via telephone on 2/16/2023. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse.<BR/>9. The DON and ADON initiated a monitoring form on 2/16/2023 to track all changes in condition daily on weekdays and weekends via review the electronic 24-hour reports found on PCC, new orders, new medication orders, hospital transfers and nursing documentation of a change in condition and notification to family and physician. Follow up on interventions and updates to the plan of care will be completed by the DON and ADON. The daily monitoring by the DON and ADON began 2/16/2023 and will be ongoing.<BR/>10. Changes in condition will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions. The Administrator, DON, ADON, MDS and/or designees to attend weekly clinical meetings to include review of residents with change in conditions, hospital transfers and update of care plan interventions, notifications of Resident Responsible Parties, and Physicians.<BR/>Monitoring<BR/>11. Knowledge checks were initiated on 2/16/2023 will be completed on all nurses by 2/17/23 either by phone or one on one conversations by the DON, ADONs or Clinical Resource. These knowledge checks will be ongoing throughout the Quality Assurance process, reported weekly to the QAPI committee meeting for 4 weeks or until substantial compliance is established and then monthly for 90 days.<BR/>12. This knowledge check will be completed for 5 random nurses weekly by the DON, ADONs or Clinical Resource. The knowledge check questions include: o If a resident has a change of condition the nurse should?<BR/>o <BR/>Get a full set of vital signs<BR/>o <BR/>Notify the attending physician Notify Family<BR/>o <BR/>Notify nurse management<BR/>o <BR/>Follow the facility policy<BR/>o <BR/>All of the above <BR/>o If a resident develops a change of condition the nurse must document for 72 hours or longer if necessary.<BR/>o <BR/>True<BR/>o <BR/>False <BR/>o Signs and Symptoms of a stroke include: <BR/>o <BR/>Facial droop, weakness on one side, slurred speech<BR/>o <BR/>Bilateral leg weakness, pain in legs<BR/>o <BR/>Abdominal pain, foul smelling urine, sediment in urine <BR/>o If the resident develops signs of a stroke and has abnormal vital signs, it is best to call:<BR/>o <BR/>The physician<BR/>o <BR/>Calf 911 for medical emergency<BR/>o <BR/>The family to come talk to them <BR/>o If a resident has a change of condition the care plan must be updated with the interventions.<BR/> o True<BR/>o The nurse should document the change of condition using the e-lnteract change of condition form?<BR/>o <BR/>True <BR/>o <BR/>False <BR/>If the attending physician is unavailable who do you contact <BR/>o <BR/>Nobody<BR/>o <BR/>Medical Director <BR/>o <BR/>Another Nurse<BR/>13. Daily review of all changes in condition daily via review of 24-hour report, new orders, new medication orders, change in condition assessments, hospital transfers and nursing documentation by the DON and ADONs. This information will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance is established, then monthly for 90 days.<BR/>14. Weekly clinical meetings to discuss changes in condition and hospital transfers. Meeting attendees will include the Clinical IDT; DON, ADON, Administrator, MDS, Dietary Manager, Activities Director, Social Services, and Rehab Director. Meeting minutes will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance.<BR/>15. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. QAPI meetings content will include changes in condition, hospital transfers and residents requiring antiseizure medications.<BR/>16. Follow up on IJ Plan of Removal and monitoring will be verified by the DON and the Administrator by review of change on condition documentation through the weekly clinical meeting, review of nurse knowledge check obtained throughout the week, hospital transfer logs, and the weekly QAPI meeting.<BR/>The following interviews, and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following:<BR/>Interview with RN A on 02/14/23 at 12:25 p.m. revealed she was the charge nurse providing care for Resident #1 during the day and evening shifts (6:00 a.m. to 10:00 p.m.) on 01/27/23, 01/28/23 and 01/29/23. She stated during the afternoon on Friday 01/27/23, Resident #1 complained of numbness to the left side of his face. RN A stated she rubbed a toothpick alone the side of Resident #1's face and the resident told her he was able to feel it. She stated she did not perform a complete neurological assessment to include assessing the resident's hand grips. She stated the resident's blood pressure was ok but was not able to recall the results. RN A further stated she texted the NP that Resident #1 was complaining of numbness to his face but never received a response/call back from the NP. Additionally, RN A stated she checked on the resident frequently throughout the weekend and the resident was stable, vital signs including blood pressure readings were stable and the resident voiced no further complaints. RN A stated she expected some type of response from the NP even if it was just an ok to acknowledge the message was received. RN A stated she made no further attempts to contact the NP or physician. RN A provided no explanation as to why she did not follow-up with the NP or physician regarding Resident #1's change in condition. When asked why, she stated the resident was stable. RN A stated on Monday 01/30/23 Resident #1 complained of numbness to his forehead and to his face. The NP was in the facility on 01/30/23 and ordered the resident to be transferred to the ER. RN A stated she did not recognize Resident #1's signs/symptoms could have been related to the resident having another stroke. She further stated she had received training after the resident was transferred to the hospital on signs and symptoms of stroke and if she did not receive a response after contacting the physician or NP, she should call again within 30 minutes. RN A was able to verbalize she was now aware that signs and symptoms included numbness/weakness, on one side of the body, headache, change in mental status, facial drooping, or problems with speech.<BR/>Review of the in-service training records dated 02/16/23 revealed licensed nurses staff received training related to completing head-to-toe assessments, who to notify when residents experienced changes in condition, S/S of a stroke, completing a full assessment to include obtaining a full set of vital signs for residents with changes in condition, contacting the primary physician, summoning 911 if changes in condition were emergent and contacting the Medical Director if they were unable to reach the primary physician. Review of knowledged check tests reveled all nursing staff had completed and passed the knowledge check. <BR/>Interviews were conducted with 11 licensed nurses (LVN G, RN D, LVN E, LVN F, RN G, LVN H, LVN I, LVN J, RN K and LVN L) across multiple shifts on 02/17/23 from 12:42 p.m. to 1:50 p.m. and from 3:00 p.m. to 3:10 p.m. The nurses were able to verbalize comprehension of the in-service training provided. They stated they had been in-serviced on S/S of a stroke, completing a full assessment to include obtaining a full set of vital signs for residents with changes in condition, contacting the primary physician, and contacting the Medical Director if they were unable to reach the primary physician.<BR/>The Administrator was notified on 02/17/23 at 4:00 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 02/17/23, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #59) of five residents was provided medications and pharmaceutical services, including the accurate administering of all drugs, to meet their needs.<BR/>The facility failed to ensure MA did not leave Resident #59's medications inside the resident's room and failed to monitor the administration of the medications on 02/04/2025. <BR/>This failure could place the residents at risk of chocking or not receiving medications as ordered by the physician.<BR/>Findings included: <BR/>Record review of Resident #59's Face Sheet, dated 02/05/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure), gastro-esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach), cerebral infarction (insufficient oxygen in the brain causing stroke).<BR/>Record review of Resident #59's Quarterly MDS Assessment, dated 12/16/2024, reflected resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment also indicated the resident had cerebral infarction, hypertension, and gastro-esophageal reflux disease.<BR/>Record review of Resident #59's Comprehensive Care Plan, dated 11/07/2024, reflected the resident had gastro-esophageal reflux disease, cerebral vascular disease, and hypertension and the interventions for the three medical issues were to give medications as ordered.<BR/>Review of Resident #59's Clinical Assessment on 02/04/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage her own medications.<BR/>Review of Resident #59's Physician Order, dated 04/04/2023, reflected Aspirin EC Tablet Delayed Release 81 MG (Aspirin). Give 1 tablet by mouth one time a day for CVA (cerebrovascular accident: stroke).<BR/>Review of Resident #59's Physician Order, dated 04/04/2023, reflected Famotidine Oral Tablet 20 MG (Famotidine) Give 1 tablet by Mouth one time a day for GERD (gastro-esophageal reflux disease: stomach acid repeatedly flows back into the tube connecting your mouth and stomach).<BR/>Review of Resident #59's Physician Order, dated 04/04/2023, reflected Nifedipine ER Oral Tablet Extended Release 24 Hour 30 MG (Nifedipine) Give 1 tablet by mouth one time a day for HTN DO NOT CRUSH Hold for SBP&lt;110 DBP&lt;60 HR&lt;60,<BR/>Observation on 02/04/2025 at 10:38 AM revealed MA was observed exiting Resident #59's room and closing the door.<BR/>Observation and interview with Resident #59 on 02/04/2025 at 10:40 AM revealed the resident was sitting on a chair beside her bed. In front of the resident was her overbed table with a small plastic cup on top of it. Inside the plastic cup was a white, round pill. The resident she was going to take the medication in a minute. She said she already taken two out of three pills that was left by the staff. She said the staff would leave her medications with her and she would take. She said she told her what the medications were, but she could not remember them and all she could remember was how many.<BR/>In an interview with the MA on 02/04/2025 at 10:48 AM, the MA stated she did leave Resident #59's medication with her because the resident wanted to take the medication every five minutes. She said should have returned to the room and checked on the resident or stayed with the resident until the resident had taken all the medications. She said the pills should not be left with the resident because the resident might not take them, throw them, or choke while taking them and no one would know. She said she left three pills with the resident, her aspirin, famotidine, and her blood pressure medication.<BR/>In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated staff should never leave the medications with the resident for the residents to take later. She said the staff must wait for the residents to be done with their medications before leaving the room. She said the resident might choke while taking the medications and no one would know. She said the resident might not take the medications or hide the pills to avoid taking them. She said the residents could also hoard the medications and take them altogether that could cause an overdose. The DON said the expectation was for the staff not to leave the room until the residents were done taking the medications or if the residents were still not ready to take the medication, just take the medications with them and come back later. She said she would do an in-service pertaining to not leaving the medications with a resident.<BR/>In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated medications were not left with the residents. He said the staff administering the medications should stay with the resident until the resident was done taking the medications. He said the resident might not take them or someone else might, like another resident or a visitor. He said the resident might aspirate while taking the medications and nobody was with him. He said he would coordinate with the DON to do an in-service about not leaving the medications with the residents.<BR/>In an interview with the Administrator on 02/026/2025 at 10:07 AM, the Administrator stated staff should not leave medications unattended because of the risk of the resident not taking them or the pills not taken on time. He said he would coordinate with the DON on how to go forward to prevent untoward outcomes of leaving the medications with a resident.<BR/>Record review of facility policy, Medication Administration Policy/Procedure - Nursing Services revised 07/2020 revealed POLICY: It is the policy of this facility that medications shall be administered as prescribed by the attending physician . PROCEDURES . 4. Identification of the resident must be made prior to administering medication to the resident . 5. Medications may not be set up in advance and scheduled medications must be administered within facility time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to accommodate residents' food preferences for 1 of 2 residents (Resident #1) reviewed for preference.<BR/>The facility failed to honor Resident #1's food dislikes. <BR/>This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. <BR/>Findings included:<BR/>Record review of the electronic face sheet undated revealed an 81 year- old- female admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of acute and chronic respiratory failure (shortness of breath), Oropharyngeal dysphagia (swallowing problems occurring in the mouth and/or the throat).<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 15 which indicated intact cognition. Section GG regarding eating indicated setup or cleanup assistance needed.<BR/>Record review of the care plan dated revised 10/11/23 indicated Resident#1 had potential for nutritional problems. Interventions included diet as ordered by physician, regular consistency, and thin liquids, if eat less then 50% offer meal replacement.<BR/>Review of the Resident #1 food and beverage preference undated revealed special food request for each meal, no rice.<BR/>Interview and Observation on 10/17/23 at 12:50PM with Resident#1 revealed she continued to receive rice during meals although she had informed the kitchen staff that she did not want rice on the plate several times. Resident # 1 stated when she was served rice, she would not eat her meal and did not receive a meal replacement. Resident#1 stated each time rice is on the menu she is continually served rice. Observation of the resident revealed rice on her plate for lunch.<BR/>Interview on 10/17/23 at 3:00PM with the Dietary Manager revealed she completed a food and beverage preference sheet with residents upon admission. She stated she had recently updated all resident preference sheets. The Dietary Manager reviewed the preference sheet and confirmed that Resident #1 had a preference of no rice. The Dietary Manager stated the cook overlooked the preference sheet however she would in -service all kitchen staff today (10/17/23) regarding ensuring resident food preferences are followed. <BR/>Interview on 10/17/23 at 4:15 PM with the Administrator revealed he was informed by the Dietary Manager regarding food preferences not being followed. The Administrator stated with staff turn overs there was an opportunity to in- services new staff which the Dietary Manager had completed. The Administrator stated there was no policy regarding dietary preferences.

Based interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 5 days of the 6-month review period, reviewed for RN coverage. <BR/>The facility failed to ensure the facility maintained the services of a registered nurse for at least 8 consecutive hours a day on Saturdays and Sundays for 5 days of the four months (July 2023 - December 2023) reviewed. <BR/>This failure placed residents at risk of receiving higher levels of patient care. <BR/>Findings included:<BR/>Review of the facility provided time sheets for Registered Nurses (RN) for the review period from July 2023 to December 2023, revealed the facility did not have the required Registered Nurses coverage of at least 8 consecutive hours a day, for the following dates:<BR/>11/04/23: 3.4 hours recorded<BR/>11/25/23: 1.15 hours recorded<BR/>12/02/23: 1.18 hours recorded<BR/>12/09/23: 1.63 hours recorded<BR/>12/16/23: 2.47 hours recorded<BR/>In an interview on 12/21/23 at 09:21 AM with the DON, she stated she that they had a CNA that created the Registered Nurses schedules for the weekend coverage. She stated she was not aware of any missed RN hours for the past year. She stated any time they appeared to have a shortage in RN coverage, she would come in and cover for them. She stated she had the dates she had covered for staff and would provide the dates. The DON later returned with the dates she had worked and none of them were the dates mentioned previously. She stated she thought they had sufficient coverage and she helped when needed so she was unsure of why days were short of RN coverage. She stated the risk of there being no RN coverage was not good because it was required.<BR/> In an interview on 12/21/23 at 09:21 AM with CNA/Staffing Coordinator Y, she stated she had been doing this for 8 years. She stated she created the Registered Nurses schedules for the weekend coverage. She stated she had never had any concerns of RN coverage for the past year. She stated that whenever an RN calls out and there was no coverage, she contacts the DON who usually covers. She stated she had the dates the DON covered. The CNA never returned with the dates the DON had worked. <BR/>Interview on 12/21/23 at 01:15 PM with the Administrator, he stated he was unaware of any lapse in RN coverage on the weekends. He stated he did not have any shortage in registered nurse. He stated he would have to follow up with the DON to see what happened. He stated the risk of not having RN coverage on the weekend was that he only knew that it was a requirement. <BR/>Review of the facility's policy on RN Coverage, undated, revealed Facilities are responsible for ensuring they have an RN providing services at least 8 consecutive hours a day, 7 days a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #42) of three residents observed for Incontinent Care.<BR/>The facility failed to ensure that CNA D did not wipe Resident #42's perineal (area between the legs) area from back to front while providing incontinent care on 02/05/2025. <BR/>This failure could place the residents at risk of cross-contamination and development of urinary tract infections.<BR/>Findings included:<BR/>Review of Resident #42's Face Sheet, dated 02/05/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with acute kidney failure.<BR/>Review of Resident #42's Comprehensive MDS Assessment, dated 01/22/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated Resident #42 was always incontinent for bladder and bowel.<BR/>Review of Resident #42's Comprehensive Care Plan, dated 01/27/2025, reflected the resident had bowel/bladder incontinence r/t: impaired mobility and one of the interventions was check as required for incontinence, wash, rinse, and dry perineum.<BR/>Observation on 02/05/2025 at 9:02 AM revealed CNA D was about to transfer Resident #42 to her wheelchair through sit-to-stand. She said before she transfered the resident to her wheelchair, the resident would go to the restroom first for a bowel movement. She assisted the resident to a sitting position at the side of the resident's bed, put the sit-to-stand sling around the resident's torso, secured the sling to the sit-to-stand machine, and raised the resident to a standing position. CNA D rolled the resident to the restroom, pulled down the brief, and lowered the resident to the toilet seat. CNA D removed the sling and said she would wait for the resident. While she was waiting for the resident to be done, she removed her gloves, washed her hands, pulled a pair of gloves from the left pocket of her scrub top, and put on the gloves. She prepared some wipes on the sink covered with paper towels. When the resident was done with the <BR/>bowel movement, CNA D put back the sling and raised the resident. She cleaned the bottom of the resident. After cleaning the resident's bottom, she removed her gloves, and put on a new pair of gloves. CNA D then cleaned the perineal area from back to front. She did it three times. After cleaning the perineal area, she pulled the resident's brief and pants back up, rolled the sit-to-stand machine out of the restroom, and lowered the resident to her wheelchair.<BR/>Observation and interview with CNA D on 02/05/2025 at 9:29 AM revealed CNA D demonstrated the manner she cleaned Resident #42's perineal area. She said she started on the sides and then the middle. When asked how she cleaned the middle of the perineal area, she demonstrated wiping the middle from back to front. She said it was because of the position of the resident that was why she cleaned the resident's perineal area that way. She said she still should had cleaned the resident's front part from front to back regardless of the position of the resident. She said the wiping should always be from front to back to prevent urinary tract infection. She said she should be mindful of how she does incontinent care because the resident would be at risk for infection.<BR/>In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated the cleaning the perineal area should be from front to back to prevent cross contamination and probable infection. She said the procedure did not change with regards to the position of the resident. She said cleaning the perineal area was front to back whether the resident was in the bed, sitting in the toilet seat, sitting in a commode, or standing up. She said the gloves should not be placed in their pockets because, basically, we did not know how dirty their pockets were and then they would use the gloves from the pockets to clean the residents. She said the expectation was for the staff to focus on the prevention of infection and not their convenience. She said she would do an in-service about incontinent care and said the expectation was for them to practice the right procedure of incontinent care. <BR/>In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated the proper way of cleaning the resident's perineal area would be always front to back to avoid transfer of germs from the bottom to the front part of the resident. He said the purpose of which was to prevent infection. He said the expectation was for the staff to do incontinent care the right way which was cleaning the front part from front to back. He said they would do an in-service pertaining to incontinent care focusing on proper cleaning of the front part of the residents.<BR/>In an interview with the Administrator on 02/06/2025 at 10:07 AM, the Administrator stated improper incontinent care could cause infection and the expectation was for the staff to do the right procedure. He said he would collaborate with the DON on how to deal with the issue.<BR/>Record review of facility policy, Perineal Care Policy/Procedure - Nursing Clinical revised 07/2021 revealed Policy . 3. Prevent irritation or infection . Procedures . NOTE: The basic infection control-concept for pericare is to wash from the cleanest area to the dirtiest area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to obtain laboratory services to meet the needs of residents for one (Resident #1) of five residents reviewed for laboratory services.<BR/>The facility failed to ensure the TXN obtained laboratory services for Resident #1 as ordered on 01/02/03 by the PCP-MedDir.<BR/>This failure risk residents' needs being met regarding the quality and/or timeliness of laboratory services and reporting laboratory results.<BR/>Findings included: <BR/>Record review indicated Resident #1 was a 74 y/o male initially admitted to the SNF 10/14/2014. Resident #1 had a history of recurrent hospitalizations for hypernatremia {a common electrolyte problem defined as a rise in serum sodium concentration to a value exceeding 145 mmol/L} and aspiration PNA {Inflammation of the lungs, usually due to infection with bacteria, viruses, or other pathogens}. Resident #1 had diagnoses of Dysphagia {swallowing difficulties}, a G-tube {a tube inserted through the belly that brings nutrition directly to the stomach}, CVA {a loss of blood flow caused by blood clots and broken blood vessels, which damages brain tissue in the brain}, PAD {a common condition in which narrowed arteries reduce blood flow to the arms or legs}, Dementia {impaired ability to remember, think, or make decisions that interferes with doing everyday activities}, Aphasia {loss of ability to understand or express speech}, and a Stage 4 PU {the most severe form of a pressure ulcer} to left ankle.<BR/>A record review of Resident #1's Re-entry Comprehensive MDS assessment dated [DATE] revealed Resident #1 readmitted to the SNF on 01/18/23 following hospitalization, 01/11/23 to 01/18/23 for an admitting dx of severe sepsis, hypernatremia {a common electrolyte problem defined as a rise in serum sodium concentration to a value exceeding 145 mmol/L}, and dehydration. The final dx included sepsis, severe protein-calorie malnutrition, and Pneumonitis {inflammation of lung tissue} due to inhalation of food and vomit. The Re-entry Comprehensive MDS assessment did not reflect a BIMS Summary Score. Resident #1's cognitive skills were severely impaired per staff assessment. Resident #1's functional status was total dependence. Record review indicated Resident #1 admitted to Hospice Services on 01/31/23.<BR/>A review of Resident #1's clinical physician orders reflected:<BR/>Order date 01/02/23: Blood Tests - ESR (Erythrocyte sedimentation rate), CRP (C-reactive protein), and CBC (complete blood count) one time a day for two days<BR/>Order date: 01/11/23 at 3:03 PM: Resident sent to the ER for evaluation.<BR/>Review of Resident #1's progress notes reflected:<BR/>An orders note dated 01/02/23, entered by the TXN indicated an ESR, CRP, CBC order one time a day for two days.<BR/>Review of Resident #1's January 2023 TAR reflected LVN A's initials on January 2nd and January 3rd acknowledging the ESR, CRP, CBC order. On 01/04/23 the order reflected a completed status.<BR/>A review of the hospital medical records for inpatient stay 01/11/23 - 01/18/23 indicated Resident #1 presented to the ED 01/11/23 at 4:08 PM via EMS from SNF for evaluation of tachycardia. Patient [Resident #1] required 8LPM O2 via NC on route, to maintain O2 sat at 90%. Patient [Resident #1] was minimally responsive to pain and hypoxic {having too little oxygen} upon arrival. Patient [Resident #1] was admitted [DATE] at 4:17 PM. A review of the hospital laboratory and diagnostic results reflected:<BR/>01/11/23: Sodium 173 mmol/L (range 135-147 mmol/L) {Sodium results higher than normal may be a sign of dehydration}<BR/>Resident #1 discharged back to SNF on 01/18/23.<BR/>A review of Resident #1's medical record revealed no evidence ESR, CRP, CBC labs were collected following the order on 01/02/23.<BR/>During an interview on 04/03/23 at 10:30 AM, the WMD said that he expected nurses to follow an order through to obtain labs and report results immediately upon receipt.<BR/>During an interview on 04/03/23 at 1:22 PM, LVN A indicated she was the primary nurse for Resident #1 on 01/02/23 and 01/03/23 from 6 AM to 2 PM. LVN A said that she initialed the TAR acknowledging the lab order but did not check to see if the order was entered via the laboratory service provider portal or that the lab had been collected or resulted. <BR/>During an interview on 04/03/23 at 3:27 PM, the TXN said that she received the order (on 01/02/23) from the WMD to have an ESR, CRP, CBC lab collected from Resident #1. The TXN stated she entered the order into PCC on 01/02/23 but did not enter the order in the laboratory services portal to arrange laboratory services as ordered. The ESR, CRP, and CBC was not collected as ordered. The TXN stated that the procedure is to confirm the order the physician entered in PCC (or enter the order received from the physician in PCC), log on to the laboratory service provider's portal to request lab collection, print the request, communicate with the charge nurse, and follow up that the request was completed. The TXN said that she did not enter the request in the laboratory portal. The TXN stated if nursing staff did not ensure that lab services were requested and collected, they [nursing staff] failed to meet a resident's need and may not receive treatment needed due to abnormal lab values.<BR/>During an interview on 04/03/23 at 5:33 PM, the DON said that she was responsible for oversight and training. The DON said that she conducted in-services on change in condition and head-to-toe assessments, but not specifically about laboratory services within the last three months. The DON said that a nurse should request laboratory services through the laboratory provider portal, communicate with nurses in the shift report to follow through until results are received and notify the physician.<BR/>During an interview on 04/04/23 at 12:47 PM, the NP said she expected the nurse(s) to follow through with lab orders and report results to the MD/NP once received. The NP stated that if the labs were obtained as ordered, treatment could have been implemented to manage or prevent the high sodium levels reported during Resident #1's hospital stay.<BR/>Record review of the facility's policy and procedure Laboratory Services revised 10/2022, reflected, a physician's order is required for laboratory services. A licensed nurse will arrange laboratory and radiology services as ordered. The nurse will report the laboratory, radiological, and diagnostic test results to the ordering physician. Notification of test results will be documented in the resident's clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 6 (room [ROOM NUMBER], #2, #3, #4, #5, and #6) of 10 resident rooms reviewed for cleanliness and sanitization.<BR/>The facility failed to ensure that Resident Rooms #1, #2, #3, #4, #5, and #6 were thoroughly cleaned and sanitized.<BR/>This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. <BR/>Findings included:<BR/>An observation on 09/24/24 at 12:57 PM of Resident room [ROOM NUMBER] reflected the bathroom floor had built up dirt particles along the walls. The base that the toilet sat on, had thick brownish stains along the front and sides. The air condition unit in the resident's room had dirt stains along the top of the unit and thick black dirt between the vents. The mini fridge in the room had a thick orange stain along the inside bottom. <BR/>An observation on 09/24/24 at 12:59 PM of Resident room [ROOM NUMBER] reflected the base that the toilet sat on, had thick brownish stains along the front and sides. The air condition unit in the resident's room had dirt stains along the top of the unit and thick black dirt between the vents. The mini fridge in the room had a thick white dust along the top.<BR/>An observation on 09/24/24 at 01:01 PM of Resident room [ROOM NUMBER] reflected the bathroom floor had built up dirt particles along the walls. The base that the toilet sat on, had thick brownish stains along the front and sides. The air condition unit in the resident's room had dirt stains along the top of the unit and thick black dirt between the vents. <BR/>An observation on 09/24/24 at 01:03 PM of Resident room [ROOM NUMBER] reflected the bathroom floor had built up dirt particles along the walls. The base that the toilet sat on, had thick brownish stains along the front and sides. The air condition unit in the resident's room had dirt stains along the top of the unit and thick black dirt between the vents.<BR/>An observation on 09/24/24 at 01:05 PM of Resident room [ROOM NUMBER] reflected the air condition unit had dirt stains along the top of the unit and thick black dirt between the vents.<BR/>An observation on 09/24/24 at 01:07 PM of Resident room [ROOM NUMBER] reflected the air condition unit had dirt stains along the top of the unit and thick black dirt between the vents. The mini fridge in the room had a brownish stain along the inside bottom. <BR/>In an interview on 09/25/24 at 09:41 AM, Housekeeping S stated she had been at the facility for 3 years. She stated they are supposed to clean all parts of the room, including the bathrooms and the air condition unit. She stated they are also supposed to dust, mop, and empty trash. She was shown pictures of the concerns observed in the resident rooms and she stated they were supposed to clean the air condition units, but she stated they did not have a good brush to clean the vents. She stated she tried cleaning the base of the toilets, but it was rust. She stated the risk to the residents was that the concerns observed was a hazard and could cause breathing issues.<BR/>In an interview on 09/25/24 at 10:22 AM, the Housekeeping Supervisor stated she had been at the facility for 12 years and in her current position for 4 years. She stated housekeeping staff was supposed to clean bathrooms, floor, windowsills, air condition units. She stated the filter was cleaned once a week at the beginning of the month. She stated housekeeping did not clean out the mini fridges in the resident rooms unless they are very dirty. She stated the family member, or the CNAs clean the mini fridges out. She was shown pictures of the concerns observed in the resident rooms and she stated that there was no excuse and she had completed in services on 09/18/24 about properly deep cleaning the rooms. She stated the resident rooms are scheduled to be deep cleaned once a week. She stated the concerns observed could cause health problems for the resident.<BR/>In an interview on 09/25/24 at 10:35 AM, the Administrator stated he had spoken with the housekeeping supervisor about the concerns observed in the resident rooms. He was also shown pictures of the concerns observed. He stated housekeeping was to clean all the areas of concern, including cleaning the inside of the resident's mini fridge. He stated the housekeeping supervisor takes her role very seriously and she will ensure that the concerns were corrected. He stated the concerns observed in the resident rooms could cause health problems for the resident.<BR/>Review of the facility's policy on Cleaning and Disinfection of Environmental Surfaces (08/2019) reflected Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard.<BR/>Review of the facility's policy on Environmental Services (November 2021) revealed To provide a clean, attractive, and safe environment for residents, visitors, and staff. <BR/> High Dust Wall Articles:<BR/>Damp Dust the Doors and Wall the tops of items along the resident's room and restroom walls (door frames, picture frames, clocks, over bed lighting, door closures, etc.) that are at or above your shoulder height.<BR/>Clean and Disinfect the Room Furnishings:<BR/>A.<BR/>Clean all furnishings in the resident's room including the bed rails, IV poles, doorknobs, wheelchairs, walkers, and all other high contact surfaces.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident was free from physical restraints not required to treat the residents' medical symptoms as was possible for one of five residents (Resident #4) reviewed for physical restraints. The facility failed to ensure Resident #4 had physician orders for the bolster mattress on her bed. This failure could place residents at risk of not having an environment that was free of restraints which could result in injury. Findings include: Record review of Resident #4's face sheet, dated 09/09/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4's relevant diagnoses included unsteadiness on feet and repeated falls. Record review of Resident #4's Quarterly MDS assessment, dated 08/18/25, reflected she had a BIMS score of 99 (unable to complete the interview). For ADL care, it reflected the resident required extensive assistance. Record review of Resident #4's Comprehensive Care Plan, dated 05/22/25, reflected the resident was a fall risk and an intervention included the use of a bolster mattress for safety. Record review of Resident #4's physician orders, dated 09/09/25, reflected no physician orders for the bolster mattress. Record review of the facility's incident report for May 2025, June 2025, July 2025, and August 2025, revealed no falls or unknown injuries for Resident #4. In an observation on 08/12/25 at 10:10 AM, Resident #4 was observed lying in bed. The resident's bed had padding on the sides of the bed that measured approximately six inches in height and six inches in thickness. In an interview on 09/09/25 at 11:19 AM, the DON was advised that Resident #4 was observed with a bolster mattress and no physician orders was observed on file. She stated the resident was provided the equipment because she was a fall risk. She stated she had shown the bolster mattress to Resident #4's Responsible Party and they agreed that it would be a good device for the resident. She stated she added it to the resident's care plan, but she forgot to get the physician orders for it. She stated it was her sole responsibility. She stated the resident required physician orders for the equipment because it was needed. The facility's policy RESTRAINTS (06/17) reflected It is the policy of the facility to refuse to restrain residents for any cause. Should a resident have cause for need of a restraint, the physician will be notified immediately, and Texas state regulations will be followed

Based on observation, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1one of 1 (3000 Medication Carts) medication carts reviewed for medication storage.<BR/>The facility failed to ensure the 3000-medication cart was locked when unattended.<BR/>This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. <BR/>Findings include:<BR/>In an observation and interview on 10/17/23 at 11:21 AM Medication Aide A passed medication to residents and left the 3000-medication cart unlocked and unattended while entering the resident room and closing the door behind her. There was no staff or residents observed on the hall near the 3000-medication cart. Interview with Medication Aide A stated she had worked in the facility PRN for one year. Medication Aide A stated she would typically lock the medication cart each time she left it unattended however she was nervous and forgot. Medication Aide A stated the risk of leaving the Medication Cart unlocked would be someone would have access to the medication. The medication cart was observed to have routine medication, eye drops and nasal sprays.<BR/>Interview on 10/17/23 at 2:06 PM with the Director of Nursing revealed the medication aides were aware of the expectation to lock the medication carts when they were not within eyesight. The Director of Nursing stated she had in serviced the medication aides on the floor after she was informed about the medication cart being unlocked. The Director of Nursing stated the risk of leaving the medication cart unlocked would be staff or residents would have access to the medication. <BR/>Record review of the facility's policy titled, Medication access and storage/ drug destruction, policy dated July/2023 revealed, It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication.